Rx Shelf Life

I’ve made it to middle age taking almost no medication. True, I consume the occasional NSAID or antibiotic for time-limited purposes, but I don’t get up each morning and gulp a handful of pills as do many of my colleagues of even younger age.

Thus, with the exception of one – Synthroid (levothyroxine sodium 0.15 mg tablets) for hypothyroidism – I do not personally support Big Pharma’s bottom line.

Actually, I’ve tried not to even support Abbott Labs (the original maker of Synthroid) over these past 25 years. One of the perks of being a physician – there are still a few left – is having access to samples. I’m not talking about controlled substances, mind you, but instead those agents that fall into the ‘maintenance Rx’ category, such as Synthroid.

Back in 2003, I contacted the Abbott rep who covered my territory. I said that I was taking Synthroid and did he have any samples he could leave for me? I was hoping that I might be provided a few months’ worth that would save me, for a short while, the effort and (minor) expense of going to the drug store every four weeks for a refill. Plus I figured I’d make his acquaintance for purposes of future invitations to pharmaceutical events, as we were still allowed by the Ethics Police back then to attend such gatherings.

The rep – I don’t even remember his name as he left the company shortly thereafter – came around to my office the following week, saying that he had “a few samples he could leave with me.”

He wasn’t kidding.

He hauled a huge box around which he could barely wrap his arms. Putting it down on the floor, he said “they’re going to expire before long, but maybe you can get some use out of them until then.”

At 150 mcg per day, it was well over a decade’s worth of Rx in that box. But the contents were stamped with a ‘use by’ date in 2005, then still two years in the future.

This morning, 29 April 2014, I took the very last dose from that original supply, nine years after expiration. And that milestone spurred me to write today of expiration dates in general.

Most of what is known about drug shelf life comes from a study conducted by the Food and Drug Administration at the request of the military back in the 1970s. With a large and expensive stockpile of drugs, the military faced tossing out and replacing its drugs every few years. What they found from the study is that 90% of the more than 100 drugs analyzed, both prescription and over-the-counter, were perfectly good to use even 15 years after expiry.

Granted, this doesn’t apply to every active moiety; tetracycline arguably has a much shorter shelf life, as do nitroglycerin, insulin, and most chemo agents and other liquid preparations.

So the expiration date doesn’t really indicate a point after which a medication has ‘gone bad.’ Medical authorities state that most expired drugs are safe to take, even those that expired years ago. It’s true that the efficacy of a drug may decrease over time, but much of the original potency still remains even a decade after expiry, especially if kept in cool dry storage.

In case you’re wondering, my family doc tests my thyroid panel regularly, and it has always been in the normal range, thanks to these long-expired pills.

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Modern Carnevale

One of my cousins lives in Ottawa and is a flight attendant for Air Canada. As such, she gets to visit some pretty cool places, and she has agreed to periodically guest blog when she has an interesting story. Here is her first, in part, from a recent trip to Italy…

Carnevale in Venice is something like New Orleans’ Mardi Gras, only with class. Costumes (and there are many) are mostly 18th century in style. For those of you who remember Heath Ledger’s movie Casanova, that is a very accurate portrayal of the flavor of Carnevale, at least what I observed. In addition to exploring the city, my friends and I one evening attended Verdi’s La Traviata, performed in a 16th century palazzo on the Grand Canal (the building happens to be for sale, for only $9,000,000 for those of you who might be interested). And though I’ve been to Venice several times before, we did all the usual touristy things, like having our pictures taken on Rialto Bridge, buying souvenir masks, and taking a gondola ride during our lay-over.

About that gondola, it was pretty amusing, but not for the reasons you might expect. We caught a gondolier on his way home at 9:00 p.m., and he agreed to give us a cut-rate ride (probably because it was on his way home anyway and he figured, “what the heck, I’ll make some extra money for doing almost nothing.”) I didn’t know about chartering a gondola after dark, but it was great! Three of us piled in, and before long we were gliding along deserted canals. The only sounds were the gentle lapping of the boat’s wake against building walls, and the occasional call from the gondolier as we rounded blind corners to make certain we didn’t run into another near-silent gondola coming from the other direction. Remember that there are no headlights on these black-lacquered missiles, nor are there streetlights over canals. It was totally peaceful and quiet. No one was talking. We were just basking in the calm and silence. And it was dark. Really dark.

All of a sudden, there was a jarring noise that pierced the night like a siren. Just as happens when your clock’s alarm goes off early in the morning, you vaguely recognize the sound in your brainstem, but it takes a few seconds for your mind to wake up to the point that you can process and identify it. My brain immediately recognized this blast, but for a few seconds, I couldn’t place it in context. And then it hit me – it was the gondolier’s cellphone! He was guiding us down silent 16th century canals in the dark, and now was talking to his girlfriend about groceries, her day, what to bring home, &c.!

"can you hear me now?"

“can you hear me now?”

I had to laugh, because even in Venice at night on the canals, the 21st century intrudes in very unexpected ways.

Think of that the next time you see someone cruising down the QEW gabbing on the phone and driving with one hand. The gondolier was doing the same thing, just 75 kph slower, on water, and without rear view mirrors!

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Death Takes A Holiday (VIII)

to wit, a middle-aged peripatetic shrink undertakes the Great American Cross-Country Road Trip with help from little leaguers, German bikers, the King of Rock ‘n Roll, porn stars and an abandoned brothel, a flock of domesticated ducks, the Department of Homeland Security and the West Memphis police, a decommissioned atomic warhead, some dodgy motels… and a strange rider in the back of a 2013 Ford Fusion.

It was a long drive past Wickenburg, Phoenix, and Casa Grande before reaching Marana, where was located our Holiday Inn Express for the night. Pulling into Marana, I stopped at a 24-hr McDonald’s to get something to drink, and saw the first saguaro of the trip – a tall and majestic cactus with its sweeping arms, symbol of the West, towering over me on the median strip of a common strip mall parking lot.

It just didn’t seem right (but more on that magnificent flora later).

Suitably hydrated and arriving at the hotel very late, it was tempting to leave Boney-Dude in the trunk. As had been the case in Vegas, though, I didn’t want to lose him to a random break-in after all we’d experienced together. So I dutifully lugged him upstairs in his pool filter box and quickly fell into a deep sleep.

A sleep, unfortunately, that wasn’t nearly as long as I would have liked. Morning came quickly. Boneman and I still had many miles to go and much to see. We couldn’t lounge in bed (or box).

On the way out of the hotel, I was pushing a luggage cart with my suitcase and the pool filter box when I encountered a gaggle of Little Leaguers swarming around me in the lobby. They were in town for some playoff games, and the group was wound tight on adrenaline and sugar as are only parentless 11 and 12 years olds on an extended road trip. The chaperone was distracted. One of the wee terrorists slammed into my luggage cart while trying to escape from his friends. He turned and looked at me and my box. “Hey mister, what’cha got in there? A body?” By now, several of the other ne’er do wells had caught up with him, laughing and punching and poking, and heard his question. Several more immediately chimed in. “He’s got a body in there!” “Let’s see the body!”

Their attention span disintegrating, they ran off.

It all happened so quickly, but I have never been so tempted in my life.

Once back in the car, my late colleague and I proceeded through Tucson and past the San Xavier Reservation and Mission. The terrain by now was that of a flat dry valley with cacti and other scrub growth, rimmed by mountains in the distance.

And then we came to Green Valley AZ, 15 miles south of Tucson, and its Dr Strangelovian time capsule.

For those of you too young to remember, Dr Strangelove, or How I Learned to Stop Worrying and Love the Bomb, was a 1964 black-comedy satirizing the atomic military-industrial complex and the Red Scare of the era. It was directed, produced, and co-written by none other than Stanley Kubrick, the disturbed cinematographic mind who also brought us A Clockwork Orange, The Shining, and Full Metal Jacket.

[sidebar: the Dr Strangelove character, a presidential advisor in the film, is said to have been a composite of three men: Henry Kissinger, Edward Teller, and Wernher von Braun]

At a time when ‘duck and cover’ exercises were commonplace in American schools, silos filled with intercontinental atomic weapons dotted the heartland; Titan II missiles were located not only south of Tucson, but also at McConnell AFB near Wichita and Little Rock AFB in Arkansas. The Titan II Missile Museum at Green Valley – more officially known as ‘USAF Facility Missile Site 8’ or ‘ICBM Site 571-7 of the 390th Strategic Missile Wing’ – was activated in 1963 and fully operational until 1982; it is the only remaining missile silo and complex of that era. As such, it was designated a National Historic Landmark in 1994.

The Titan II – an instrument of war only Dr Strangelove could love – was the largest and most powerful intercontinental ballistic missile ever fielded by the United States. It had a single warhead with yield of 9 megatons, or more than 500 times the explosive blast of the bomb which leveled Hiroshima in 1945.

Not much of USAF Facility Missile Site 8 can be seen from the road – only a tall barbed wire fence, a few small outbuildings and vehicles, and the modern visitors’ center with gift shop and book store are visible. However, once inside the perimeter, one discerns the presence of a much larger world underfoot. Locked stairs lead downward. The silo complex consists of a three-level launch control center as well as the eight story tall missile (103’) with its requisite diesel generators, air filters, antennae, and miles of buried cable, tunnels, pipes, and tubes. The complex was built of steel-reinforced concrete with walls as much as 8’ thick in places, as well as doors resembling those of bank vaults that weigh up to 3 tons each. And the whole subterranean catacomb is situated on massive steel springs to absorb shocks from (those anticipated and hopeful) near-miss enemy explosions up top.

Titan II

Titan II

The extant missile, as you might expect, is now inert, its uranium removed, and the nose with a large hole drilled in the side to allow verification that the cone is, in fact, empty. The silo cover is also permanently fixed half-open and cannot move, a stipulation of the strategic arms treaties with the former USSR to ensure compliance with disarmament.

What is far more interesting than the missile itself is the control and command apparatuses still in place. The original consoles, chairs, telephones, teletypes, intercoms, maps, desks, and computer mainframes have never been replaced. When technology advanced to the point that vacuum tubes and early transistors just didn’t cut it anymore, new computer hardware was installed inside the original metal cabinetry. To walk inside the launch room (1963) is to take a step back to an era before the first hand-held calculator (1967) or computer mouse (1968). When the Titan II went live, the floppy disc, the VCR, Atari’s ‘Pong,’ the disposable Bic lighter, the post-it note, and the Sony Walkman hadn’t been invented. Everyone still used rotary dials, music was on vinyl LPs, and businessmen presented with Kodak slide carousels in lieu of Microsoft’s Powerpoint. It is sobering to think that with technology that pre-dated the 8-track tape (1964), the lives of millions rested.

launch room computers I

launch room computers I

launch room computers II

launch room computers II

computers and console

computers and console

When active, USAF Facility Missile Site 8 could attack one of three pre-determined targets, all of which were unknown and unknowable to the crew. To change the target, all the silo commander had to do was push a different button on the console, almost like changing the speed on one’s blender – thermonuclear technology coupled with primitive consumer electronics! At the time of its deactivation in 1982, the missile’s computer was programmed to fire against Target #2. We still don’t know what was Target #2, as all ICBM targets remain top secret to this day, even though the missiles are long gone and the adversary, by its former name, no longer exists. All we know for certain is that Target #2 was programmed to be a ground impact blast (as opposed to an air blast), meaning that it was almost certainly a hardened underground military facility.

Of note, the highest state of alert ever ordered at USAF Facility Missile Site 8 was on 22 November 1963, only months after it became operational – and the day of President Kennedy’s assassination. At that time, not knowing if the murder in Dallas was the opening salvo of a Soviet strike, orders were issued by SAC to remove the launch keys from their protective cases and keep them at the ready on the consoles. The keys were not, however, ever inserted into the launch switches. Or so we’re told.

Once back up top, what better souvenir to take home… than an original 1960s can of government emergency drinking water from the silo complex’s survival stockpile?

emergency water

emergency water

Water can in hand, I returned to Boney in the parking lot. We had to make it to a nearby brothel before it closed.

[to be continued…]

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[Copyright 2013 @ The Alienist’s Compendium]

The Dogs of Titanic

Today, April 15th, marks exactly 102 years since the sinking of RMS Titanic in the cold waters of the North Atlantic. Over 1500 souls were lost that night.

Much has been written of the human tragedy. Less discussed are the animals which were lost. There were a dozen dogs on the ship during that voyage, and only three of them survived.

Kitty Astor

Kitty Astor

Those fortunate canines were all of very small breeds – two Pomeranians and a Pekinese. They were also all traveling with wealthy owners, as only First-Class passengers were allowed to have dogs on the ship.

One of the Pomeranians, Lady, was purchased in Paris by passenger Margaret Hayes just prior to embarkation. The other Pomeranian, name unknown, was owned by the Rothschilds.

As for the Pekinese, Sun Yat-Sen, he was owned by the Harper family (of the New York publishing firm Harper & Row).

These three were small enough to be unobtrusively wrapped in coats and blankets when the order to evacuate was given.

The other dogs – John Jacob Astor’s Airedale named Kitty, Helen Bishop’s Fox Terrier named Dog, Robert Daniel’s French Bulldog named Gamin, several whose names have been lost – were not staying in their masters’ cabins, but instead were in the ship’s kennel, sealing their fates.

One sad story involves Elizabeth Isham and her Great Dane, Rex. When the ship was foundering, Isham went to the kennel to get Rex. Once on deck, she was told that the dog was too large to be allowed on a lifeboat… so Isham got out of the dinghy and stayed onboard with him. When found several days later by the SS Mackay Bennet, the bodies of mistress and dog were found tangled together in Rex’s leash in the icy seas.

And as far as we know, there was only one canine-related insurance claim from the disaster. William Carter’s family brought with them on the voyage a King Charles Spaniel and another Airedale, having insured both dogs for a total of $300 (about $7500 today) given their championship bloodlines. The insurance company later made good on the loss.

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[Copyright 2013 @ The Alienist’s Compendium]

Sigmund and Nose Candy

Above-average intelligence and the ability to ‘think outside the box’ may in some cases be facilitated by recreational drug use. Proponents of substance decriminalization have held this, and while it’s an interesting hypothesis, it is not one without tremendous controversy and public health ramifications. Nevertheless, history illustrates a number of drug users who over their lives forged new and creative paths, whether related to chemical use or not.

One drug dilettante was none other than Sigmund Freud, originator of the concept of the subconscious and, amongst other honorifics, the Father of Psychoanalysis.

Freud was a trailblazer of his day, whether or not you subscribe to his approach to the human psyche. And he was also a big fan of cocaine, and advocated its use for a wide variety of conditions.



In a letter written to his fiancée Martha in 1883, Freud opined, “if all goes well, I will write an essay [on cocaine] and I expect it will win its place in therapeutics by the side of morphine and superior to it…. I take very small doses of it regularly against depression and against indigestion and with the most brilliant of success.”

Freud did in fact publish just such a review:

“Über Coca,” Von Dr. Sigm. Freud, house officer of the General Hospital of Vienna. Centrallblatt für die ges. Therapie. 2, 289-314, July 1884.

He began his treatise with a description of the South American coca plant, erythroxylon coca, which is a bush that grows to a maximum of 6’ height and has ovoid shaped leaves. Though cocaine was chemically isolated by Gardeke only as late as 1855, Freud noted that Andean natives were known to have used coca leaves as early as 600 CE when “faced with a difficult journey, when [attempting to satisfy] a woman, or… whenever strength is more than usually taxed.”

Freud postulated cocaine’s benefits for a host of conditions, including asthma, migraine headaches, indigestion, pain, and as a stimulant in wasting diseases. However, like most physicians of his day, he held that cocaine’s greatest therapeutic effects would be seen in psychiatry, in no small part because of the drug’s ability to control melancholia and sexual dysfunction. Interestingly, Freud’s paper was also one of the first to propose substitution as a therapeutic treatment for addiction. While replacing morphine or alcohol with cocaine is something we now know to be counter-productive to recovery, the concept of substitution persists to this day (think Methadone clinics, and Xanax detox using Klonopin).

It is true, Freud conceded, that there can be ill effects from over-use. Commonly were seen dry mouth, dizziness, elevated pulse, and oddly, eructation. Anorexia was also noted, though Freud hastened to add that survivors of the siege of La Paz in 1781 were those who had taken cocaine in lieu of food when there was nothing to eat. He did describe in some individuals a “moral depravity” that arises when these immoderate users become “complete[ly] apath[etic] toward anything not concerned with coca.”

Freud took cocaine himself about a dozen times, employing 50 mg orally on each occasion. Afterward, he claimed, he had no craving for the substance. As far as psychic effects, he did report exhilaration which was the same as the “normal euphoria of a healthy person.” He felt “more vigorous and capable of work,” but he said the overall feeling was “simply normal” and he found it hard to believe that he was under the influence of a drug at all. He did observe a lack of desire for both food and sleep for several hours after ingesting cocaine. Following several trials, he hypothesized that the psychological benefits of cocaine were not due to stimulating effects, but rather “the disappearance of element in one’s general state… which cause depression.”

Freud did not recognize the addictive potential of cocaine, in large part because it was believed in the 19th century that only depressants – morphine, alcohol, laudanum – were habit-forming. Most clinicians felt that cocaine was then better classified with caffeine.

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[Copyright 2013 @ The Alienist’s Compendium]

Milton Hershey

Later this week – on April 14th and 15th to be exact – 102 years will have passed since the sinking of RMS Titanic in the cold waters of the North Atlantic. Over 1500 souls were lost that night.

Just as there are celebrated cases of individuals on September 11th, 2001, barely missing their subway or commuter van en route to the Twin Towers, or being late for their United Airlines or American Airlines boardings, so there are several stories of those who didn’t make Titanic’s sailing… arguably the most fortuitous tardiness or change-of-plans of their lives.

J. Pierpont Morgan missed the boat when he lost track of time while lounging in a French spa (some have postulated brothel);

Alfred Vanderbilt cancelled at the last minute (though he later perished on RMS Lusitania);

Guglielmo Marconi’s schedule didn’t permit his passage on the maiden voyage, but he accepted a company raincheck for Titanic’s second scheduled crossing;

Nobel Laureate J.R. Mott was likewise offered a free stateroom, but decided against it for reasons unclear.

Milton Hershey

Milton Hershey

The easily recognizable name of yet another lucky individual is that of Milton Hershey, founder of the Hershey Chocolate Company. Fabulously wealthy, in December 1911 he had paid a $300 deposit (almost $8000 today) for a stateroom on Titanic’s westward crossing, as he and the missus were to spend four months in Europe on holiday and would be returning by mid-April.

However, Milton’s wife Kitty was in notoriously poor health, and there were pressing business matters at home, both of which necessitated the Hersheys returning to the States from their extended jaunt earlier than planned. They lost their deposit to the White Star, instead sailing on the Hamburg-America Line’s Amerika several days prior.

Ironically, Amerika passed through the same waters that Titanic would later be sailing, and sent word back that there were a few treacherous-looking icebergs along the way. Obviously, the warning wasn’t heeded.

Even if they had been on board, Hershey and his wife would have enjoyed a better chance of surviving than a majority of passengers. Based on figures later provided by the British Board of Trade, 97% of female first class passengers were saved during the disaster, along with 33% of male first class passengers. That’s in comparison to the 46% of female third class passengers and only 16% of male third class passengers who were saved.

Interestingly, the Hershey archives still retains their founder’s cancelled deposit check, made out to the White Star Line.

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In keeping with our mummy-theme, a few words on adipocere are in order.

With the proper substrate and environment – cold, humid, and lacking oxygen, as might be found in mud or a well-sealed coffin – the fatty tissues in a recently buried corpse will be hydrolyzed by anaerobic bacteria. This hydrolyzation is usually seen in dearly departed who are obese, female, or newborn (i.e., those with extra body fat). Instead of putrefaction, the hydrolyzed soft tissues then form carboxylated sodium salts, with an add’n by-product that we know as glycerin.

In this setting, the glycerin is firm, crumbly, and grey-tan in color – hence its name ‘grave wax’ in the vernacular but ‘adipocere’ in scientific and mortuary circles.

The phenomenon of saponification – the creation of adipocere – was first described in Western print by no less a luminary than Sir Thomas Browne in 1658:

“In a … body ten years buried in a [nearby] church-yard, we met with a fat concretion, where the nitre of the earth, and the salt and lixivious liquor of the body, had coagulated [into] large lumps of fat [which were] the consistency of the hardest castile-soap.”

I therefore give you… the soap mummy.

While it is possible that an entire body will saponify, it is more usual that only parts will undergo this chemical conversion. Sometimes the outer ‘shell’ is preserved, while in other cases the internal organs alone undergo saponification. And those parts that saponify can remain intact for centuries. Soap mummies have been unearthed in which stomach contents can still be clearly identified hundreds of years post-mortem.

And people being as they are, it didn’t take long for sensationalism to take hold. Augustus Bozzi Granville, MD, an early 19th century physician, and the first anatomist to conduct an autopsy of an Egyptian mummy before the Royal Academy in London, made candles from adipocere, and then used them to light the anatomic theatre in which he conducted the scientific demonstration.

Needless to say, the event was sold out.

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‘Mummy Brown,’ also known as ‘Egyptian Brown’ or ‘Mummia,’ is a rich dark earth-tone pigment, somewhere between burnt and raw umber, commonly used by artists starting in the 16th century. And yes, it’s called Mummy Brown for a reason.

It was made from mummies.

The color comes not from the dead body per se, but from the bitumen and asphaltum resin that the ancient Egyptians used in the embalming process. Renaissance artists believed that when pigment from mummified flesh was used in paintings – along with the inevitable bits of ground-up bone – the resulting compound had more solidity and wouldn’t later crack or chip.

finger painting, anyone?

finger painting, anyone?

[this was later shown to be wholly inaccurate… though Mummia had good transparency and could be used successfully for glazes, shadows, and flesh-tones, it did have a tendency to craze, as well as alter other nearby colors because it contained both ammonia and fat]

Entrepreneurs being as they are, when genuine dead Egyptians were not available, hucksters would supply faux-Mummia, made from Egyptian cat mummies (best case) or any old human corpse lying around (worst case). Artists sneeringly referred to such cheap imitations as ‘Mummia Falsa.’ In 1915, one London colourman, touting the quality of the real thing, claimed that he could satisfy the demands of his customers for twenty years from a single genuine Egyptian mummy.

Accept no substitutes.

But once the Edwardians learned of the macabre source, Mummia started its fall from favor. Some artists held (mock?) funerals for their tubes of paint. And yet the need for the shade didn’t go away. As late as 1964, TIME reported that one of London’s best-known art suppliers, C Roberson & Co, had stopped selling Mummy Brown. Geoffrey Roberson-Park, then managing director of C Roberson, is quoted in the article as having said, “we might have a few odd limbs lying around somewhere… but not enough to make any more paint. We sold our last complete mummy [a while back].”

So Mummia Falsa was resurrected; it was false, not in the sense that it was made from dead cats or ordinary corpses in lieu of ancient human ones, but rather because it wasn’t made from dead tissues at all. You can still purchase variations of Mummy Brown in art supply stores, except that it is now composed of kaolin, quartz, goethite, and hematite, and ranges from yellow to dark red (the latter being called ‘Mummy Violet.’)

And it’s not just for art anymore.

Mummia was used as a medicinal preparation – it was for sale in Merck’s pharmaceuticals catalogue as recently as 1908. But more on that later.

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