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Exuberance Over Exubera: Some Cautionary Notes

We appreciate the over 3000 readers who have requested more information on Exubera. You obviously have an intense interest in finding out the right way to use this exciting new medicine for your patients. Leonard Lipson, M.A. Psychology, LMHC takes a look at some of the psychological challenges that this new medicine could present.

I don’t want to be a downer, to rain on the parade. I’m really pleased that there is an approved inhaled short-acting insulin preparation indicated for the treatment of type 1 and type 2 diabetes. Inhaling is obviously more pleasant than injection. Any treatment that hurts is not a treatment that lends itself to a high level of adherence. This good news leads however, to a couple of interesting questions: 1) If a form of treatment doesn’t hurt, will that significantly increase adherence? Will Exubera really lead to better management? 2) Can it actually be a source of psychological danger for some patients?

A preliminary study, supported by Phizer and published in the February edition of Diabetes Care in the UK, reports that subjects said they would be three times more likely to use insulin therapy if it could be inhaled. What remains to be seen is if people actually do what they say they will and for how long. The variable being tested here is whether adherence will be significantly effected by the elimination of pain. I suspect the answer is: Not as much as we would all hope.

Question 1) If a form of treatment doesn’t hurt, will that significantly increase adherence?

Pain is an easy thing to point to as a reason for not doing something. We accept it in ourselves and don’t feel guilty. We expect others to understand and they usually do. For some however, pain is not the primary cause of non-compliance. Denial, acknowledging being less than perfect, rationalizations, various levels of depression, lack of proper education re consequences or quality management, omnipotence or avoidance based on fear are examples of sources of non-compliance that have nothing to do with avoiding the discomfort of injection.

These other sources of non-adherence may be out of the patients’ awareness. Patients are driven by these underlying issues but have no way of understanding the connection between their underlying issues and non-adherence. They search for a reason for not taking better care of themselves and alight upon pain, the visible, easily understandable element. When they report pain to be the problem, they’re not lying. This is what they believe. This is not deception of themselves or others. To deceive you have to know a truth and then knowingly put forth different information. I have no reason to doubt that the people in the Phizer study believed they would use insulin much more often if it could be inhaled. Those that don’t however, will have the opportunity to learn something about themselves.

These fancier psychological issues are not the only reasons for lowering our expectation of the impact of inhaled insulin. The market over time may diminish the price somewhat but preliminary indications are that the cost of inhaled insulin will be 2-4X that of the injectable form. Basic affordability can effect adherence, as can perceived greater comfort vs. cost. Each individual’s pain tolerance will be measured against financial pain. It will be worth it to some but not to others. There is also some concern as to the efficacy of the inhaled form after 6 months of usage.

Question 2) Can it actually be a source of psychological danger for some patients?

I think we all know patients who regularly use insulin to balance poor eating. When taking insulin is more comfortable, will some people be more encouraged to abuse insulin in this way?

Patients tending to minimization of their disease can see this as a step closer to being able to think of themselves as “normal.” While obviously we don’t want people walking around feeling different/defective, we do want a level of acceptance and awareness sufficient to guide the enactment of a healthy lifestyle. This is true not just for the approximately 5 million already using insulin but also for the approximately 43 million pre-diabetics in this country.

One of the problems with many chronic conditions is that their onset is very gradual. Symptoms, with their pain and threat don’t appear until later. Poor eating, lack of exercise, exposure to toxic conditions or stress can feel normal, even pleasurable in the moment. It feels like there’s no need for alarm. When, to this experience, we add the idea that even if you get diabetes and you need insulin, it’s no big deal because it doesn’t have to hurt, we can have some people at greater risk.

We should use the advent of this new treatment tool as an opportunity for more intensive lifestyle education. The dangers noted above can best be countered by directly discussing them with patients. Information presented in a low-keyed, realistic, respectful manner is most likely to be heard. Time and hopefully carefully gathered data will tell us if any of my concerns are merited. In the meantime, our awareness of the issues and our ability to pass these on appropriately to our patients is the best way to maximize what will hopefully be an aid to the effective management of diabetes.

Leonard Lipson, M.A. L.M.H.C. received his Bachelors degree in Psychology from Adelphi University and his Masters in Psychology from the New School for Social Research. He received four years of post-graduate education from The American Institute for Psychotherapy and Psychoanalysis. He has been in the private practice of psychotherapy for the past 29 years, with offices in Manhattan and Suffern, NY. Mr. Lipson created the Medical Adherence Training program in 1995. The program helps people adhere to what is medically recommended. The program now serves patients throughout the U.S. and is in the process of being put into book form.

Mr. Lipson is a member of the Rockland County Psychological Society, The Society for Behavioral Medicine and The NYS Mental Health Counselors Association