Dr. Ethan Levine  

This is Dr. Ethan Levine, and welcome to the latest edition of the Mental Wealth Podcast. We’re delighted today to have Dr. Monica Leriger as our guest. She’s a pharmacist, a business person, and an extraordinary individual. Monica, if you would just share a few words about who you are and what you do. 

Dr. Monica Leriger 

Sure, thank you for the opportunity. I am Monica Lorigi and I am a doctor of pharmacy. I’ve been practicing for about 25 years now, in long-term care specifically, and just really driven to promote wellness related to medications and drug interactions. So I really appreciate this opportunity. 

Dr. Ethan Levine  

Thanks. You’re talking about most of your career at this point is with older individuals. What’s unique about pharmaceuticals as it relates to that population? Because we’re all getting older. 

Dr. Monica Leriger 

Absolutely. Well, so we know that all these drug utilization, all the recommendations are based on drug studies, which mostly are healthy, no comorbidities, younger populations. And then, it’s one medication. But then as we get older, we’re taking two or three medications or four or five medications. And now we have this do of medications that all have to go through our body and be absorbed. They all have to be distributed, they all have to be metabolized and then run through our kidneys. So we start compounding that. It’s a science, but there’s an art to understanding how those are going to interact in the body in each individual patient. And so just getting that feel for, okay, what is this patient going through? What is their symptomology right now? So we can determine is this particular medication still beneficial or are we to a point now where this medication could be doing more harm? And so as we age, this is a constant check-in. And I think that’s a miss is we have to constantly check in on these medications. We hear this idea of you’re going to take this cholesterol medication. Well, how long? We’re going to be on it for life. life is a long time, right? So am I going to be 85 years old in a nursing home and still on this medication? Is that still the best use of that medication? I’ll often tell people medications are not crock pots. You know, we don’t just set it and forget it. You know, we have to constantly be checking in on those medications. So I just find it really fascinating and it’s an area that we don’t really, as a society, we don’t address. 

Dr. Ethan Levine  

So when you think about the perspective of the consumer, somebody who’s listening to our podcast saying, yeah, actually I take 15 medicines and I’ve taken them for 10 years. What do you advise them to do? 

Dr. Monica Leriger 

That’s a great question. There’s a quote, Dr., I think it’s Gutweiss, it was like in the 90s, like 94. He’s a gerontologist and this really stuck with me. He said, All new symptoms in an elderly patient should be considered a drug side effect until proven otherwise. So any new symptom that you have, you have a new leg pain, a new symptom that’s coming along that you haven’t had before, well, you really should look at those medications and say, could this be a case in which there’s a change in my body and maybe I’m not metabolizing that particular medication anymore? Maybe we need a dose adjustment. on it, especially in our 40s and 50s and 60s. We really miss those signs that it could be a medication now and we might need to do some dose adjusting. So I’d say really listening to your body, any new changes, and then look, always look critically at your medications. Because you could be on a medication for 10 years and while the medication hasn’t changed, your body has. And so your body is not going to be utilizing that medication the same in 10 years as it did when you first started taking it. 

Dr. Ethan Levine  

What about cognitive changes? Would the same thing apply there? 

Dr. Monica Leriger 

Absolutely, absolutely. And there’s this class of medications, the anticholinergics, and it’s really important to our cognitive function to understand our anticholinergic burden because there are a lot of medications that we take for overactive bladder, for allergies, these medications And there’s a lot of psychotropic medications as well that carry an anticholinergic burden. And if you’re on one medication, it might not really affect you. But you take another medication that has a low anticholinergic burden and then another one that has a moderate burden and all of a sudden you’ve really compounded these medications to the point where they’re going to cause confusion. They’re going to look like dementia. in patients and we can hear patients saying, a little cloudy, a little brain fog. Well, that could be because these medications have been compounded. And even if you haven’t changed those medications, again, as your body ages, our receptors in our body are different places. So you’ve got receptors in your bladder and you’ve got them in your GI and you’ve got them in your brain. And as receptor sites change when we get older, there’s going to be fewer here where you need them and there’s going to be, that drug is now going to go to your brain. and have different effects on you. So it’s really, anticholinergics are something that I really like to talk about because they’re so vast, there’s so many of them that we really need to make sure that we’re evaluating each drug as we age. 

Dr. Ethan Levine  

What I’m hearing you saying, I just want to make sure for people who might be listening, you’re not really separating psychotropic medication from primary care. 

Dr. Monica Leriger 

No, oh, absolutely not. Actually, that becomes dangerous. siloing our medications. This is something that we do see quite a bit is this medication was written by a specialist. Well, then we don’t want to mess with that medication because it was written by a specialist. But if you see two or three different specialists, you really need to have somebody who is monitoring all of those medications to say, This medication interacting with that medication could be causing some other issues. So we don’t want to do that, especially if we’re talking psychotropics. We do not want to assume that any medication that we’re taking for non-psych need is benign and not affecting us. 

Mukund 

Who would do that determination, doctor, in terms of seeing the interactions between the different medicines. 

Dr. Monica Leriger 

So you would hope your primary care would, but more and more, there are a lot of pharmacists who are able to do this. And this is really something that we struggle with now that we don’t have as many corner store pharmacies. You know, you go into the local pharmacy and, oh yeah, why do I have to wait a half an hour for this medication? Like all they do is take a bottle and put a label on it. because that pharmacist is actually looking at that full list of medications that you’re on and determining, this could be an interaction. And they’re picking up the phone and they’re calling the doctor to say there’s an interaction with a different medication they’re taking from a different doctor. And as we are getting more into these mail order pharmacies or these specialty pharmacies, We are losing that central pharmacist that used to do that time-consuming review, but that really helped keep us in check on all the medications we take. There are opportunities. Some friends of mine have started a concierge pharmacy where you can actually bring in all of your medications and they will go through them and take through that. And I think that’s a fantastic thing. I love those services where you can find those? 

Dr. Ethan Levine  

So how would somebody go about finding something like that? 

Dr. Monica Leriger 

So if you are anybody over the age of 50, you can actually search for a senior care pharmacist. So the American Society of Consultant Pharmacists, the ASCP, has a website. You could go to that website and you can search for a senior care pharmacist and they have those resources to help you find that. But you could also do a search for your area and see if there are any pharmacist organizations that would do that consulting. 

Dr. Ethan Levine  

So for people who are out in the community, I think my feeling and experience, they’re more vulnerable because they don’t have the people routinely coming in. You would suggest that there’s somebody they speak with rather than beyond just the physician themselves or physicians, really. 

Dr. Monica Leriger 

Yeah, it’s a great practice to have a primary care, right? Somebody who takes total care of all of your day-to-day symptoms. So if you’ve got a primary care, that’s a great first reach out to ask them, is there a pharmacist that they work with or do they have a drug review in their own office? So it’s great. Most of them don’t, but if you ask the questions, and I’m always a fan of asking the questions, if you ask the questions, it might spark something to get that conversation going and get them to take a look. 

Dr. Ethan Levine  

What’s some of the things that have surprised you as a pharmacist? 

Dr. Monica Leriger 

I’m really old school. And when I started in pharmacy, I didn’t think there would be such a push away from just being a pharmacist. nowadays, pharmacists want, we want to prescribe and we want to give immunizations and all these other things. And just having that, being the drug expert, being that source that is the stopgap to say, Somebody needs to check to see if there’s any interactions on this. I didn’t think that would go away as much as it has. I thought there would always be a need for that. And the fact that it’s kind of gone away has been a little sadly surprising to me. 

Dr. Ethan Levine  

One of the questions that comes to mind for me is the average person, how does that relationship between pharmacists and physicians work these days? 

Dr. Monica Leriger 

It’s getting so much better than it used to be. I don’t know how much you wanted me to go into the backstory of it. So pharmacists aren’t considered healthcare professionals on a federal level. So we can’t bill Medicare and we can’t bill Medicaid unless the state allows it. And if Medicare and Medicaid don’t allow it, third parties don’t usually pay for it. So pharmacists actually don’t get paid for consulting services in many cases. So While a lot of us are wanting to provide that service, it is time consuming. And when you don’t get paid for it, you get paid for the pills you dispense. It really created that whole issue that I was talking about that surprised me where pharmacists aren’t really providing that information because there’s no revenue source for it. And while we’d all love to give services away for free, we also still have to pay bills, and we all need a roof over our head. So There have been changes though to billing codes that have allowed for pharmacists to work with prescribers in order to get paid for those services. So a lot of these accountable care organizations are really pushing that because they’re understanding that there’s a lot of hospitalizations. I say up to 30% of hospitalizations are drug related. So understanding that this is a risk, they need somebody to be monitoring this. There are some changes that are hopefully coming in the pipelines. that are allowing pharmacists to work with prescribers. And there are more and more prescribers now that are seeing that because they’re getting held accountable for those hospitalizations. So there’s been a really great opening for those conversations. 

Dr. Ethan Levine  

One of the areas I’m very curious about is your perspective on herbal medicines. There’s a lot of consumers probably taking herbals of some kind. What’s your advice for people if they’re choosing to go down that road? 

Dr. Monica Leriger 

Yeah, so herbals are really interesting to me. Medicine is fascinating. And whether it comes from a lab or it comes from a forest and a root, it’s still a medicine. It’s still a chemical. And everything has to go through that process in your body of being absorbed, metabolized, eliminated, right? So just because it’s occurring in nature doesn’t mean that it’s not going to affect your liver. It’s not going to affect your kidneys because it has to go through those processes. And there’s kind of this catch-22 and that these really great things that could be out there because there’s no standardization. And I know a lot of people think, well, we overstandardize things and we’ve prevented some of these herbals from getting out there. But those standardizations actually, in some cases, do help keep us safe. So for example, if you’re going to go buy a new medication that is based off of a flower, right, because there are some out there that draw from flowers. Is that bottle that you’re buying off the shelf, was that sourced from the stem of the flower or the root or the petals or the whole thing? Because that’s actually going to affect the concentration of that chemical you’re looking for. So it really does need to be standardized. So if you go buy it off of the shelf from this brand and then you go back and you buy it off of a different brand, you might be getting a different concentration, even though they both say 50 milligrams. So you’re not necessarily getting the same thing. So It can be a little dangerous. You want to make sure that if you take something, you find a consistent source. That source comes from consistency as well. So make sure that they have a good standard of practice. You really want to make sure that you’re looking into what that is. And then whatever you can find about how that medication or that herbal track through your body. And do they have any information on drug interactions? Because again, a lot of these herbals, they’re not required to have any test on them. So we don’t necessarily know. Does that medication go through this enzyme in your liver and it’s going to interact with these different things? We don’t know. And that can be dangerous. So herbals, if you’re not taking anything else and you want to try an herbal, again, just acknowledge that. But if you’re taking other medications before you add on an herbal, you really want to know as much as you possibly can about that. And then you’re just going to have to weigh out your risks and your benefits. if you’re taking the medication because you think it might help with something that’s temporary, can you just deal with the temporary without having to take that medication? 

Dr. Ethan Levine  

How do people find out information if they’re going to go down that path to say, does it interact? Is it safe? How do people find that out? 

Dr. Monica Leriger 

There are some websites that will do the basic search for you. But you can also look in to see if there’s anything on the mechanisms of it. You really have to watch your sources. So if you can see anything that comes from a pharmacy journal, so something that’s Journal of Pharmacokinetics, those are good ones. If it comes from something like JAMA and herbals, but those are always good. If they can find some sort of a study on it, those are great sources. Again, if you’re going to try an herbal, that’s fine. But if you start to notice some changes after you’ve taken that medication, you should really go back to say, I got to look at that herbal and see. There are a lot of medications that we take for like allergies. And how that works is it can affect your immune response. Well, do we want to take a medication that is going to alter our immune response for a long period of time? So it’s something really that we want to make sure everybody is aware of and you add those. Don’t forget when the doctor asks you, what are you taking? add everything. You’re taking vitamin C. Vitamin C is not benign, right? Everything’s all just vitamin C. Vitamin C can actually cause diarrhea. So it’s good to make sure that you list everything. 

Dr. Ethan Levine  

That’s a great example. This leads me to ask the other question that a lot of people have concerns about or are interested in is generics. A generic medication and the one that came from the branded one. 

Dr. Monica Leriger 

Yeah, that is great. I always tell people a generic medication, it’s not like you go into your local grocery store and you see your brand name Fruit Loops next to, Fruito’s or anything like that. In order to get an FDA approval as an AB rated generic, you do have to show that you have the same markers that we talked about. You have to be able to show that you are the same medication. activity-wise in order to be a generic equivalent. I’m a fan of generics for the most part. Now, there are some caveats. If you’re taking a medication that’s a generic and it’s, you know, 500 milligrams of a medication, okay. Now, if you’re talking thyroid medications where it is 50 micrograms, that’s actually different. That’s really difficult to get the same consistency across a couple of generics. So I usually say I’m fine with generic medications. I think it’s great, except in the case of your thyroid medications. If you’re taking a generic by manufacturer A, then you want to stick with manufacturer A every time you go get that medication for that thyroid medicine. And because those amounts are so small, you don’t want to get anything in there that could alter your dosage that you’re actually getting. You don’t want to switch to brand name and you don’t want to switch to a different generic. So it’s really difficult for thyroid medications. But for the most part, other medications, I’m a fan. I think generics are a good cost savings. 

Dr. Ethan Levine  

Is it the inactive that’s different or the actual active medication? 

Dr. Monica Leriger 

The active medication has to be the same. Most of the cases in the generic, the inactive are the same. So a brand name medication comes out and this manufacturer has put all this money into research and development to get this drug out there. And they only have so many years before their patent goes off and they won’t be able to make that brand name money again and recoup the cost. Well, a lot of those manufacturers have started their own generics so that way they can at least have something off of it. So A lot of times when a generic comes out anymore, you’re seeing the drugs that were made in the same labs and are in the same manufacturing complexes as the brand name because it’s the same manufacturer trying to recoup some of their own costs. So if you know who that manufacturer is, and there’s some generic manufacturers that are just crackerjack, like they’ve been doing it for 50 years. They have the process down, like they’re really good at their standardization. 

Dr. Ethan Levine  

Let’s talk about psych meds a little bit. How do you look at psych meds? Are there one category versus another category? What advice would you give people as they’re getting into that arena? 

Dr. Monica Leriger 

So it would depend on what type of psych we’re dealing with. 

Dr. Ethan Levine  

Well, let’s take two main categories, depression, anxiety. 

Dr. Monica Leriger 

All right, good ones. My first thing is, this new? Gives this a new symptom. And is there something that’s bringing that on? And then, especially when it comes to anxiety, like if we’re talking nervous, jitteriness, something that is uncharacteristic that you’ve never experienced before, then we all know that there could be some life events that cause that. But if you’re taking a medication, or you’ve had new medications added in the last couple of months, those medications actually can cause that. So their jitteriness Anxiety, panic actually could be caused by non-psych medications. Like I said, going back to the anticholinergics, you actually could have some side effects from those. So it’s something that I would look into. Same with depression. As we get older, like I said, there’s that blood-brain barrier, right? There is this barrier that prevents just like anything from getting into your brain. But as we age, that barrier becomes leakier. So we don’t block as much. And then like I said, that drug that used to be used on your bladder, you could have fewer receptors for that in your bladder. So you’ve got more drugs circling around and it’s easier to cross into your brain. So you can start having some of these effects from medications that you never took for anything that was psychotropic at all. So anytime you see again, new symptom, new depression, new anxiety, anything, You really need to have somebody take a look at your medications. And again, you could do a search of the most common side effects and the most severe side effects and see if that’s something that could be bubbling to the surface now. 

Dr. Ethan Levine  

And you’re talking about for the primary care meds, make sure that that’s not impacted. 

Dr. Monica Leriger 

Yeah. Yeah. 

Dr. Ethan Levine  

So when somebody starts taking a psych med, let’s stick with those two categories. How quickly should they feel like this is helping or clearly this is not helping? How long do they have to wait? 

Dr. Monica Leriger 

So great question because those are two totally different psych concerns, right? If you’re talking anxiety, most of the medications are depending, but if you’re talking like a benzodiazepine or something that is a quick acting medication, that’s going to be, you’re going to feel that right away, right? Depends on how quickly it gets absorbed, 20, 30 minutes. before you start to feel the effect of an anxiety medication. If you’re looking for something to help prevent it, that can take longer. We always say, you know, four to six weeks before you get steady state on a medication, but you will probably feel something sooner and depression as well. So typically you’re going to see changes in some symptomology on depression before you actually feel the full benefit on the depression itself. And when I say symptomology, I’m talking about some people when they’re depressed, they just lose their appetite. They just can’t eat. And others, when they’re depressed, that’s all they do is eat. You know, sleep. Sleep and eating are two things that are affected in completely. completely opposite ways with depression in two different people, right? Some people, all they want to do is sleep. They don’t want to get out of bed when they’re depressed. And others, they just have this insomnia and they can’t sleep. So choosing the right medication, the medications that can cause insomnia, the medications that do promote sleep, you know, those are, you’re going to want to choose those based on the symptoms that the patient’s having and those you might start to notice. faster, you’re going to probably notice some changes in sleep patterns sooner. But the full depression symptoms are longer. 

Dr. Ethan Levine  

Let me flip it around to the opposite side of that question. Let’s talk about depression in this instance. Two days after it’s been prescribed, they say, I don’t like how this is making me feel. As a pharmacist, what would be your guidance to that person? 

Dr. Monica Leriger 

The first question is, you don’t like how it’s making you feel, how? Like, what are you feeling? Is it that it just makes you feel like you’re just kind of not there, like your skin’s crawling or just a little something? How manageable is it? to where it’s affecting my GI and I’m in the bathroom all day long and it’s affecting my work? Okay, that’s a little more severe, right? It’s really causing me to, you know, have some serious thoughts. So really getting to the specifics of it, you really have to take the time to understand when somebody says, I don’t like the way this makes me feel. That’s a big trigger phrase. Let’s dive into that. What does that mean? And just understanding what you don’t like about it and is there timing on that too? Is this something that you feel all day long or is this something you feel an hour after you take the medication and it goes away? Is it something that you feel like a couple hours after you take the medication, maybe as the medication’s wearing off and you’re starting to feel that? So it’s really important to know what you’re feeling and what the timing is on that and how long it lasts. 

Dr. Ethan Levine  

So when you take antibiotics, some of them it’s recommended to take with food. Can that be true for a psych med as well? 

Dr. Monica Leriger 

Yes, absolutely. So again, because your food has to be absorbed, it has to be metabolized, right? So anything that you eat could affect medications and there’s some medications that are more susceptible to others. So yes, and psych medications as well can cause some pretty severe GI effects. So might affect when you want to eat it with food. Sometimes we want to take those at night. So Again, if this is a medication that just makes you feel a little off an hour after you take it, well then maybe we switch it to taking it at night. So you sleep through that first hour and you don’t notice it. 

Dr. Ethan Levine  

The future of pharmaceuticals, there’s always research going on that’s just incredible new developments every day in primary care and in psych in particular. What are you seeing that’s really exciting to you in pharmacology? 

Dr. Monica Leriger 

Yeah, this whole monoclonal antibodies and our genetic tailoring on our therapies is just amazing. Again, I’m old school pharmacokinetics, pharmacodynamics nerd. I absolutely love the mechanism of action of these medications, the cancer treatments, you know, how we can really pinpoint, like we can kill a cancer cell, like just that cell. It’s amazing the technology that is coming around and I really feel like AI is really going to help us in that mapping out of specific diseases and specific disease states. I think these therapies are going to really boom. I think there’s going to be a lot of opportunities and I think it might also help us with our psychotropic medications where again, we can really tailor the needs of those medications. I don’t think we’re ever going to get to a point where we can say we’ve cured just because there’s so many neurotransmitters and it’s going to be a constant change. So again, just because we find something that helps with something that’s more of a long-term disease, we’re going to have to constantly keep those kinetics in mind. We’re starting to use these drug combinations. And there’s a particular psych medication. We’re using a combination where there is one drug that inhibits the metabolism of another drug. so that drug stays around longer to have more of an effect. And it’s like, who thinks of that? Who’s like, I’m going to use this interaction to actually cause a treatment. That’s pretty exciting. But we also have to be careful because now we are inhibiting an enzyme in the body. And yeah, it’s going to keep that drug around longer, that drug that we want. But if you’re taking any other medications, those drugs are going to stick around longer too. And you might actually put yourself at risk for toxicity on other medications that you weren’t intending. So I think it’s really an exciting time where there’s a lot of opportunity out there, but there’s a lot of risk that’s going to come with that. So we really need to make sure that we’re keeping an eye on this as it goes. 

Dr. Ethan Levine  

Is that something that’s out on the market or it’s still in clinical trial? 

Dr. Monica Leriger 

It’s out on the market. And there’s another one. I talked about the blood-brain barrier. So there’s another medication that is out where we weren’t able to use this medication because it had some pretty significant peripheral effects. So not central acting, not on the brain or that blood-brain barrier, but it would have some pretty severe effects on the rest of the body. So they started giving it with another medication that blocks that in the periphery, but still allows it to cross the blood-brain barrier. And it’s like, again, Who are the nerds that sat around and said, we can treat this with this, and put those combinations together? So it’s really exciting to see drug combinations being used. It gives everybody a broader understanding that, hey, these drugs interact, right? So it’s going to raise awareness. It can raise some risks, but overall raising awareness is a good thing. 

Dr. Ethan Levine  

I read this past week about how somebody’s doing clinical trial on literally putting LSD into a capsule and having people take it because there’s been studies with psychedelics for treatment-resistant depression have phenomenal results. I don’t know if you have any perspective on that kind of thing. 

Dr. Monica Leriger 

This is what I’ve read on it. So they’re putting them into this controlled environment so that they can go back to like those traumatic events and help rewire the memories of those traumatic events to make it again. Who thinks of this? Like, I want to hang out with these people because they can solve all the world’s problems, I think. It’s just, that’s an amazing thought. Obviously, it’s not something that we’re going to use in everybody, and it’s something that has to have a controlled environment. There’s a lot of danger. Like, I don’t know that I would trust anybody to go back into the minds of somebody who’s had this traumatic event to help them rethink their thoughts. That’s kind of, maybe we’re getting a little Orwellian there. But still, what a great, amazing thought for people who have no other options, who are really a potential danger. It’s worth a shot to try something. I’m a fan of right to try on medications. You know, again, cancer medications, if it’s your last shot, you know, you have a right to try this medication if you understand the full consequences of that. And I think that’s just an exciting time. So you’re right. If that’s what they’re going for and they can control that environment, I’m so looking forward to reading the results of that. But do I think that means that we should just go out there and try it on our, oh, you know, we’ve got to be careful. We don’t want to encourage people to, hey, you’ve got a bad memory and you want to erase it. We’ll take some LSD and go sit in your living room and talk it over with your brother and see if you can, that’s not really our intent. So I’m all for it. I’m really about, let’s put some guardrails on things. I’m a big fan of just making sure that we temper our trials. 

Dr. Ethan Levine  

From my perspective, it’s interesting because a lot of people are very pill friendly. And that specific example, EMDR in the psychology arena, goes back to trauma and helps rewire how people think of it. But if I said you could either go through 12 weeks of EMDR or I can give you this pill and you’ll go on a trip and fix it, a lot of people go on a trip. 

Dr. Monica Leriger 

Yes, but I don’t think that’s a bad thing if we can get away from pills. I feel like we have created a society where we want a pill to fix everything. We think that a pill is going to fix everything. First of all, it’s false, right? And even if a pill, like we said, even if a you take this tablet and it works for you and it fixes you for 10 years, it’s not going to be the same. You’re not the same body that you’re putting that pill in 10 years later, right? So if you don’t equip yourself for what’s going to happen in 10 years when that medication is not having the same effect, well, now that’s where depression can really set in, right? Because you put all your hopes and dreams on this pill. Boy, what are we going to do when that doesn’t work, you know? 

Dr. Ethan Levine  

And you were saying previously, too, that as consumers, we should always be aware that something’s changing in us, that we need to be asking the physician, do I need to still take this medicine? Am I on the right dose of this medicine? We added this medicine. Be aware and active in your pharmaceutical treatment. 

Mukund 

You had mentioned vitamin C, like even if someone takes vitamin C to inform if there’s any conflicts or interactions with the other medicines. During the summertime, people drink more orange juice. Does it also contribute equally or is medicine just a separate kind of domain? 

Dr. Monica Leriger 

No, that’s a great, so that’s a fantastic question. No, exactly. What we eat really matters. You know, I’m here in the Midwest. And in the summer, we got a booming farmer’s market. Great, we’re eating our green leafy vegetables. Well, that’s going to produce a lot more vitamin K, you know, and that’s great in some instances, but also, you know, we’re getting some great immune boosts. And there’s really something too, you know, we get colds in the winter. Well, we also decrease our consumption of fruits and vegetables in the wintertime. So, you know, does that contribute to it? So foods, no, foods absolutely do have that. So I actually have a story in a nursing home and this patient was having some really bad diarrhea. And boy, they just could not figure it out what was going on. And come to find out, well, it was summer and it was watermelon season. And his grandson was bringing him in like pieces of watermelon every day for like 2, 3 weeks. And he was eating basically like half of a watermelon. this entire time, and it was only because his blood sugar started to spike a little bit that everybody’s like, there’s something going on here. His blood sugar is spiking. He’s had more in diarrhea. Maybe it’s a medication he’s taking. No, nobody was really paying attention to what he was eating. So absolutely, that is important. Grapefruit juice. And when we’re talking about enzyme inducers, enzyme inhibitors, grapefruit juice is an enzyme inhibitor. So if you really love to eat grapefruit or grapefruit juice, that is absolutely something that your doctor needs to know because it causes a lot of drug interactions. So consistency with your diet is really important and just understanding that as well. That’s a great question. 

Mukund 

What are some common psych medications from a pharmacy point of view, from a prescription point of view, what has been the most common or most prescribed? 

Dr. Monica Leriger 

So there’s a class of medications that we’re really starting to utilize a lot, which has a concern to me, and those are the anticonvulsant medications. So medications that were traditionally seizure medications, but they’re centrally acting medications. So because they were for seizures, they work on nerves. So we might start taking them for mood disorders. We might start taking them for nerve pain. We start taking for all these other nerve related issues because, well, let’s face it, the other medication class, well, we can’t use that because boy, just, you know, society says that’s not a good, like we don’t want to use the antipsychotics, right? Because who wants to take an antipsychotic? So we’re just going to take this anticonvulsant or, you know, that medication for nerve pain is really expensive. and my insurance doesn’t want to pay for it. But I could take this anticonvulsant and it might help with my nerve pain. The problem is that the anticonvulsants, everybody thinks, yeah, well, it’s a safer alternative. But the anticonvulsants actually, traditional, older anticonvulsants have a higher mortality rate than any other drug class. So it’s not necessarily safer. There’s consequences for all medications. So those are medication classes that I see being used quite a bit. And In some cases, they’ve been very helpful. But when we get to a point where it is our primary go-to drug and we don’t go back to say, is it actually helping? okay, we’re using it for nerve pain, but the patient is still complaining of pain and now is taking Tylenol and ibuprofen and now they’re looking at taking a stronger narcotic. Okay, well then let’s take a look and see. We probably don’t need that other medication still, right? But we never take it off. 

Dr. Ethan Levine  

People are making choices based on how much a drug costs. I don’t want this one. I don’t prescribe it. My insurer won’t cover it. What do people do if they’re struggling on the financial end? And how do you handle the doctor offering you something else because it will be covered. 

Dr. Monica Leriger 

Sometimes we have these other medication options as trials because they’re tried and true, right? I can see both sides of this. Again, I kind of like the generics because if it’s a generic on the market, that drug has been around for 20 years. We have some good long-term data on the use of that medication. I feel a little better than necessarily the new bright, shiny object that’s come onto the market just because I remember the days when drugs would get approved. And then within six months, they were being pulled because they caused liver damage or something else, right? So it’s been some years ago. We’ve really tightened up some review since then, but still a little concerning. You don’t necessarily know the long-term effects of these medications. So I was always a little more hesitant on the newer medications. And all that being said, like I said, there’s a lot of really exciting things going on right now. For example, like the GLP-1s have a lot going on for them as far as utilization now. There’s still concerns. There’s always concerns with medications and we don’t know the long-term effects. But in our patients that would like to use them for weight loss and they’re diabetic, there’s some great programs now. The Medicare changes that are going into effect are causing a lot of downstream changes in cost of medications and the assistance programs that are out there. So my first thing is if there’s a drug, and I mentioned the GLP-1 drug class, because there’s actually a bridge for people that can trial those medications and have them covered. So they can trial it, see if it’s something that they want to try, and then they can determine the cost of those medications moving forward to get some assistance programs. There’s a lot out there, and the drug manufacturers have been really good about having some programs on these medications. So the first thing you can do is if you have a local pharmacy that you’re allowed to go to, is check with the pharmacy and see if they have any programs that they know that are available. Is there any sort of a discount or rebate through the manufacturer that can be tried first? 

Mukund 

You had mentioned about the interaction between pharmacists and the general population who come to you for filling their prescription. How much do people still ask for advice from pharmacists? 

Dr. Monica Leriger 

I personally, anecdotally, I don’t work in a dispensing pharmacy, but once people find out that I am a pharmacist, grocery store, soccer game, church event, whatever, usually I will get some questions about, what do you think about this? Or, you know, I’ve been having this, or, you know, how to take, yeah. So people want the access. They’re going to ask the questions. So yeah, it happens quite a bit. It’s very frequent. I personally love it. I’m all for it. Ask me whatever questions you want wherever I am. Let’s at least get you going. If you’ve got a question, let’s make sure you’re okay. And get you at least pointed to the right direction or get you somebody that can spend some time with you. So I think there’s a big desire for it. It’s not going to go away. It’s the access that’s going away. And I think it’s making people feel a little helpless and a little hopeless when it comes to who they can talk to. 

Mukund 

One question I had was naming the medicines. I know there’s a chemical name for it and then there’s the name that common person like me would be aware of. How is it translated? 

Dr. Monica Leriger 

Wow, that is such a fantastic question. So yeah, so the chemical names, so we call the generic name, right? The generic name is the name for the medication. And most of them, those are based on the chemical structure. So for example, the beta blocker medications all end in OLOL, right? So generic names like metoprolol. Atenolol. It’s OLOL. They’re all the same. Your cholesterol medications that are the statin medicate, all end in statin, atorvastatin, you know, resuvastatin. 

Mukund 

Is it a federal rule or is it just industry norm? 

Dr. Monica Leriger 

No, it’s an industry norm, but it also, it’s co-beneficial to know. that this medication is like I talked about the monoclonal antibodies that all end in MAB, right? So that way you understand that when you are just taking a quick look at a medication list, you can also just kind of scroll through and see, bam, there’s the MAB. So we understand kind of what we’re looking at. The rest of it can be picked based on the drug manufacturer, you know, he who finds it, names it, right? So there’s a lot of that when it comes to the generic names. And basically a lot of those names are really hard to pronounce. So they try to pick a brand name. Now, back in the day, you used to pick a brand name that was easy to pronounce. Nowadays, I feel like they’re making them harder to pronounce. I don’t know if it’s a game or what, but the brand names are different. The brand names are all chosen by the manufacturer and there are some amazing stories about what those are, some really great stories about newer ones that come out. Some drug companies have contests for their employees to name their new drug that’s come out, which is, I think is a lot of fun. What a great thing. But there’s also like, I’ll give you an old example. So furosemide, right? It is a loop diuretic, right? So semide is the root, the ending of the name. So torsemide is another. So furosemide is the generic name. So the brand name though is Lasix. right? So LASIX, Lasix got its name because the diuretic effect lasts 6 hours. So they named it Lasix based on that. I’m like, what an amazing, and there was this old medication and I don’t know if it’s available still, but it was available for hot flashes, right? And so the name of it was Amen. So like, Amen, my hot flashes are over. I’m like, you guys. That’s just like you’re really, so the generic names are more based on the chemical structure, but the brand names I think can be fun based on whatever they want to, the manufacturers. 

Dr. Ethan Levine  

Wellbutrin is another one because I was at the company at the time that came out because it’s the well, you know, you’re feeling well. They want to, they would always talk about the brand name reminding you or getting people to think about what the product is doing. people will ask in clinical trials, what’s the name of, because we got involved in some of that, what the name of the medicine is. And until you’re submitting it to the FDA, you don’t need a name. It’s all that chemical name. 

Dr. Monica Leriger 

Yeah. 

Dr. Ethan Levine  

So there is no name. 

Dr. Monica Leriger 

Well, and it also makes it easier, you know, we try to go by just that generic chemical name just because it makes it easier when you’re looking through med lists to have it all succinct in the same method. But then there’s some of them where I’m like, I’m not writing that. Lasix. There we go. Moving along. 

Dr. Ethan Levine  

Well, Dr. Rigi, thank you so much for being generous with your time today. And you’re, as always, absolutely delightful. And anytime you want to come back on, we I would love to have you. 

Dr. Monica Leriger 

I appreciate that. No, thank you for the time. This is really enjoyable. I appreciate it.