Study, Jan/18:Providing Optimal Care When Inheriting Patients Taking Benzos

The full title of this American study is "Benzodiazepines II: Waking Up on Sedatives: Providing Optimal Care When Inheriting Benzodiazepine Prescriptions in Transfer Patients".

 

Written by the same authors, it is the companion piece to the study called "Benzodiazepines I: Upping the Care on Downers: The Evidence of Risks, Benefits and Alternatives". Like the first one, it is well-written and researched, but this one looks at issues such as continuing prescriptions vs. withdrawing them, tapering, withdrawal, adding psychotherapy and other pharmacological interventions, etc. .

 

I'll be interested to hear others' thoughts on this one. Lots to consider. I will try to post some key quotes from the various sections that may be of most interest to everyone here.

 

This quote is from the section called "Deciding the Recommendation":

 

While the decision to forgo initiating a BZD in favor of evidence-based first- and second-line treatments is easy, it can be very difficult to decide how to manage a patient transferred from another prescriber who was prescribing BZD. BZD dependence is preventable with short-term use (i.e., less than 2–4 weeks) [1], but even more preventable by using other of the various medications for anxiety. Once BZDs are used, patients are often reluctant to change medications or may not find replacement medications as subjectively pleasing. Prescribers have the decision—sometimes mutually agreed-upon and sometimes unilateral—to continue, discontinue, or change BZDs. This decision should be made based on evidence-based indications (conditions and timeframes), risk of adverse effects and misuse, comorbidities, and potential drug-drug interactions.

 

This decision should not be taken lightly. Continuing a harmful treatment violates the primum non nocere principle, but removing a treatment perceived as helpful could risk the therapeutic alliance. Some prescribers may oppose continuing BZDs even when the potential for harm is high even in the absence of adverse effects or misuse, while others argue for vigilant monitoring. Some prescribers may push for unilaterally discontinuing BZDs when contraindications are present but no definitive harm, though others may decide to continue BZDs when patients protest their discontinuation all the while providing psychoeducation and working through the stages of change to move a patient away from BZDs and towards evidence-based treatments. “Unwilling patients should not be forced to withdraw. It is unwise and unkind to compel withdrawal. Enforced withdrawal is usually unsuccessful and leads to unnecessary distress” [5]. Nevertheless, many clinicians do not want to assume the risks and responsibilities associated with continuing to prescribe BZDs.

 

Here's the full study:

 

http://www.mdpi.com/2077-0383/7/2/20/htm

From the section called "Assessing Harms":

 

When patients present with problems, clinicians’ first instinct is to be active—to provide or increase treatment rather than remove or decrease treatment. However, one of the first questions a clinician should always ask themselves is, “what have other providers or I done to potentially cause this” before ruling in or ruling out iatrogenic effects and proceeding with assessment. After all, “first, do no harm.”

 

YES. 

This is an interesting excerpt. Basically, it's about informed consent, which, I believe, few of us gave because we weren't at all "informed". It's from the section called "Monitoring".

 

Some providers find contracts to be helpful tools with patients when using agents with high potential for abuse and addiction such as BZDs. These contracts can specify parameters for both parties and serve to codify expectations in the doctor-patient relationship as they relate to the prescribed medication and other elements of the treatment plan (e.g., attending psychotherapy aimed at addressing anxiety). Prescribers should advise all patients of the risk of dependence, adverse effects, indication(s) for continued use, that the lowest dose for the shortest period of time to achieve the desired outcome will be provided, that they will be monitored closely (e.g., weekly reviews, urine drug screens), that the treatment of anxiety and insomnia should rely largely on nonpharmacological interventions (e.g., psychotherapy, sleep hygiene, relaxation techniques), and that they must obtain all prescriptions from the same provider and pharmacy (and inform the provider of changes) [10]. These agreements should be clearly explained to the patient who signs the agreement, a copy is provided to the patient, and it is clearly documented in the record.

From the section called "Discontinuation":

 

Decreasing and discontinuing BZDs can be terrifying for patients. Approximately one-third of patients have difficulties during managed BZD withdrawal [5], and even more likely have high anticipation anxiety even before starting the discontinuation process. It is difficult to study BZD discontinuation because of high rates of patients refusing to participate in and of dropping out of BZD withdrawal studies [1]. This is a testament to how powerful BZD dependence is. Dropping out of a BZD-tapered discontinuation study is associated with not being married, short-acting BZDs and extraversion. Successful discontinuation is associated with low baseline neuroticism, low behavioral inhibition due to anxiety, higher number of positive life events, and higher level of social support satisfaction. Self-efficacy in coping during the tapering period is associated with decreased relapse. “Psychological differences might explain why some patients do and others do not experience difficulties stopping BZDs” [47]. Even with education, it is often difficult to transition patients from BZDs—which they have potentially been using for years—to evidence-based treatments. Psychotherapeutic interventions and replacement pharmacotherapy to target the symptoms which these patients are most afraid of can be helpful in the transition.

 

While symptom relapse after BZD discontinuation is high only for a brief period of time during acute withdrawal, there is a high risk of relapse—perhaps as high as 50%—on BZDs often with patients seeking the medications from other prescribers and/or illegal sources [8]. Relapse (i.e., resumed use) after BZD discontinuation is associated with abrupt withdrawal (i.e., without taper), insomnia severity, psychological distress (e.g., anxiety, major life changes such as divorce, retirement, or death of a spouse), snoring partner, hospitalization, or surgery and chronic pain [8]. Elderly patients are significantly less likely to stop BZDs than younger patients. Many do not see an advantage to withdrawal and believe BZDs are effective. However, the cognitive advantages to withdrawal and lack of effectiveness of long-term BZDs may be persuasive [7]. To reduce relapse risk, there are several tools to assist in discontinuation: education, handouts, psychotherapeutic interventions, tapering, medications to assist with discontinuation, and alternative medications. The keystones of BZD discontinuation are gradual tapering, psychological support, and judicious individual management [1]. When BZD discontinuation is managed judiciously and individually, success rates can be 70–80% [1,7,48].

From the section called "Withdrawal":

 

When BZDs are suddenly discontinued in tolerant patients, they become exposed to hypoactive inhibition of GABA and hyperactive excitation of glutamate [1,18]. This combination causes withdrawal symptoms, which often leads to the perception that baseline anxiety is worse without BZDs. Most patients who take BZDs long-term will experience clinically significant withdrawal symptoms [15,52]. Even patients who use low doses short-term (even as few as 3 weeks) may experience mild withdrawal [15,18]. There is also evidence to suggest that sporadic, non-continuous BZD use may sensitize patients to future withdrawal [18].

 

There are three types of BZD discontinuation symptoms: recurrence, rebound, and withdrawal.

 

Recurrence symptoms are identical to the symptoms for which BZDs were originally prescribed. It is common for both patients and providers to misinterpret rebound and withdrawal symptoms to be recurrence symptoms, leading patients to mistakenly believe these symptoms make up their permanent baseline condition without BZDs. Other than a few symptoms (e.g., seizures, delirium, paresthesia, hypersensitivity to light or sound), there are few withdrawal symptoms that are distinguishable from common anxiety symptoms [11,18].

 

Rebound symptoms are “the mirror image” of therapeutic effects of BZDs (e.g., worse anxiety, insomnia, and restlessness) [53]. These symptoms occur shortly after discontinuation, including between doses (especially with short half-life BZDs) [50]. This generally causes patients to be acutely aware of their next dose. Such craving is common, and may itself exacerbate symptoms of anxiety [1,52,54,55,56].

 

Withdrawal symptoms are idiosyncratic to drug classes, and are not present before the particular drug was first used. For BZDs, severe symptoms usually occur after abrupt discontinuation (e.g., seizures, arrhythmia, death), but more mild symptoms may also occur with gradual tapering (e.g., anxiety, insomnia, tremors) [53,54]. The course of withdrawal is different depending on half-life, and may be slower with elderly or liver disease patients [11,15,18,54]. Withdrawal symptoms (particularly protracted withdrawal) may be due to individual constitutional and psychological factors in addition to GABA-A receptor changes. “Determining whether symptoms that emerge during [bZD] taper are actually a recurrence of anxiety or are related to a withdrawal syndrome is often difficult” [50].

While most patients taking long-term BZDs experience withdrawal symptoms upon discontinuation, short half-life BZDs can cause earlier and more severe withdrawal [50]. Table 2 summarizes the characteristics of various common BZDs [1,15,39,57]. Short half-life BZD withdrawal usually starts within 6–24 h, peaks in intensity at 1–4 days, and significantly improves by 4–5 days. Long half-life BZD withdrawal usually starts within 1–7 days, peaks in intensity at 5–14 days, and significantly improves by 3–4 weeks. In some patients, mild withdrawal symptoms may last for months to years (i.e., protracted withdrawal syndrome) [48,58]. With gradual reduction (over 2–4 months), the withdrawal of short-term and long-term BZDs are more similar and less severe [50].

 

 

From the section called "Tapering":

 

Withdrawal symptoms can be lessened or avoided entirely with gradual tapering that considers dose, potency, duration of BZD use, duration of taper, rate of taper, frequency/timing of dosing, and psychosocial factors (e.g., lifestyle, personality, stressors, and support). For example, because withdrawal insomnia is a major concern, taking higher doses or the total BZD dose at night can increase discontinuation tolerance [1,5]. A long duration of taper is generally thought to best, with many recommending tapering over at least 2–4 months [24,50]. The whole process of BZD withdrawal may take months. Rapid withdrawal can increase distress and decrease success, but some argue that withdrawing at too slow of a rate may prolong distress. During withdrawal, symptoms commonly wax and wane, varying in severity and type. “Patients need not be discouraged by these wave-like recurrences; typically ‘windows’ of normality, when the patient feels well for hours or days, appear after some weeks, and over time these ‘windows’ enlarge while discomfort slowly regresses” [5].

 

Regarding rate of tapering, there are varying recommendations. Length of time of tapering is unpredictable, ranging from a few weeks to months depending on dose, duration, type of drug, patient’s physical health, and concomitant psychopathology. Usually the rate of discontinuation decreases over time as most withdrawal symptoms occur in the last half of tapering. Patients are usually able to tolerate gradual tapering without withdrawal symptoms until they are at 10–20% of their highest dose [11]. For the most effective and safest (especially in outpatient settings), most recommend tapering no faster than 25% of the total daily dose per week [1,49,59]. Because the end of the taper can often be most difficult, some recommend 25% daily dose reductions per week until (1) there is a 50% reduction in the original total daily dose, after which slow the rate even further [50]; (2) there is a 75% reduction in the original total daily dose, after which decrease the remaining dose one-eighth to one-tenth per week until discontinued; or (3) 4 weeks have passed, after which space out the further reductions for a total discontinuation period of 12 weeks [47]. While tapering one half tablet daily every 2 weeks can be effective for those who have taken BZDs for less than a year, more rapid tapering can be effective for those who have taken BZDs for over a year (e.g., 0.5 mg/week for alprazolam, 1 mg/week for lorazepam) [15]. Ideally, the patient should be in control of the reduction rate with informed consent and support from the provider [1,8]. A useful technique is to offer 2–3 reasonable options for rate/dose/frequency changes (but not an option for no change) and allow the patient to choose.

 

Original dose may influence tapering rates. For those with therapeutic dose dependence, a slow tapering rate of one-eighth to one-tenth of the daily dose every 1–2 weeks with optimal time for withdrawal from 6–8 weeks up to 1 year is helpful. For those taking less than 20 mg of diazepam equivalents daily, patients usually tolerate decreases of 1 mg every 1–2 weeks. For patients taking 20–40 mg, patients usually tolerate decreases of 2 mg every 1–2 weeks until the daily dosage is 4–5 mg, after which decreases of 0.5 mg every 1–2 weeks are better tolerated. Stopping the last 4–5 mg are often particularly difficult for patients (usually because of fears about how they will cope without the medication), but they are generally surprised by how easy it actually is. For patients taking larger doses (some abusers take over 0.5 g of diazepam equivalent dose daily), patients usually tolerate decreases of 10 mg every 2–3 weeks. For those with high-dose BZD dependence in the presence of polysubstance use, Ashton recommends inpatient detoxification for the primary drug and BZD conversion to diazepam with withdrawal over 2–3 weeks [1,5].

From the section called "Substitution or Adjuvant Pharmacotherapy for Withdrawal":

 

Adjuvant medication may be helpful during BZD withdrawal, but no medications have consistently demonstrated relief of general withdrawal. No adjuvant medications have been proven effective in attenuating BZD withdrawal symptoms. Among those medications studied have been antidepressants, beta blockers, buspirone, anticonvulsants (e.g., gabapentin, carbamazepine), flumazenil, captodiamine, and progesterone. Of these, carbamazepine has the strongest—though still relatively weak [5]—evidence of promise for BZD withdrawal [62,63]. While non-BZD GABA receptor agonists (e.g., zolpidem, zaleplon, eszopiclone) have proven to relieve BZD withdrawal symptoms, they are contraindicated due to having the same disadvantages as BZD (i.e., dependence and abuse) [1]. Nevertheless, some occasional adjuvant medications may be helpful during discontinuation [1,5]. Several medications have been used for temporary symptom relief during BZD withdrawal: propranolol, non-BZD hypnotics, TCAs, clonidine, and analgesics. These drugs help control certain symptoms but do not alleviate overall withdrawal [48]. If autonomic hyperactivity is present (e.g., tachycardia), beta blockers (e.g., propranolol) or 2-adrenergic agonists (e.g., clonidine) may be useful adjuncts [11]. Antidepressants can help with dysphoria [48]. Low doses of TCAs may help for anxiety, insomnia, and depression. However, SSRIs may precipitate acute anxiety in some cases. Beta-blockers such as propranolol may help with palpitations, tremors, and muscle twitches but have little effect on overall states. Buspirone, clonidine, nifedipine, and alpidem have demonstrated no benefit, and may sometimes worsen withdrawal symptoms [5].

From the section called "Replacement Pharmacotherapy for Anxiety and/or Insomnia":

 

See Section 3.4 for evidence-based alternatives to sedative-hypnotics. Again, psychotherapy is the gold standard treatment for either anxiety or insomnia. As far as pharmacological agents, serotonergic agents and a variety of non-sedative-hypnotic agents have the strongest evidence for anxiety and insomnia, respectively. When prescribers and patients find the need for fast-acting medication, Table 1 presents several alternatives. However, treatments that enhance patient coping skills and build confidence should always be emphasized and preferable to exogenous means of sedation. While the lack of immediate response/remission can frustrate patients and providers, prescribers should not resort to prescribing ineffective or harmful medications just to satisfy their own feelings of helplessness.

From the section called "Tapering":

 

Withdrawal symptoms can be lessened or avoided entirely with gradual tapering that considers dose, potency, duration of BZD use, duration of taper, rate of taper, frequency/timing of dosing, and psychosocial factors (e.g., lifestyle, personality, stressors, and support). For example, because withdrawal insomnia is a major concern, taking higher doses or the total BZD dose at night can increase discontinuation tolerance [1,5]. A long duration of taper is generally thought to best, with many recommending tapering over at least 2–4 months [24,50]. The whole process of BZD withdrawal may take months. Rapid withdrawal can increase distress and decrease success, but some argue that withdrawing at too slow of a rate may prolong distress. During withdrawal, symptoms commonly wax and wane, varying in severity and type. “Patients need not be discouraged by these wave-like recurrences; typically ‘windows’ of normality, when the patient feels well for hours or days, appear after some weeks, and over time these ‘windows’ enlarge while discomfort slowly regresses” [5].

 

Regarding rate of tapering, there are varying recommendations. Length of time of tapering is unpredictable, ranging from a few weeks to months depending on dose, duration, type of drug, patient’s physical health, and concomitant psychopathology. Usually the rate of discontinuation decreases over time as most withdrawal symptoms occur in the last half of tapering. Patients are usually able to tolerate gradual tapering without withdrawal symptoms until they are at 10–20% of their highest dose [11]. For the most effective and safest (especially in outpatient settings), most recommend tapering no faster than 25% of the total daily dose per week [1,49,59]. Because the end of the taper can often be most difficult, some recommend 25% daily dose reductions per week until (1) there is a 50% reduction in the original total daily dose, after which slow the rate even further [50]; (2) there is a 75% reduction in the original total daily dose, after which decrease the remaining dose one-eighth to one-tenth per week until discontinued; or (3) 4 weeks have passed, after which space out the further reductions for a total discontinuation period of 12 weeks [47]. While tapering one half tablet daily every 2 weeks can be effective for those who have taken BZDs for less than a year, more rapid tapering can be effective for those who have taken BZDs for over a year (e.g., 0.5 mg/week for alprazolam, 1 mg/week for lorazepam) [15]. Ideally, the patient should be in control of the reduction rate with informed consent and support from the provider [1,8]. A useful technique is to offer 2–3 reasonable options for rate/dose/frequency changes (but not an option for no change) and allow the patient to choose.

 

Original dose may influence tapering rates. For those with therapeutic dose dependence, a slow tapering rate of one-eighth to one-tenth of the daily dose every 1–2 weeks with optimal time for withdrawal from 6–8 weeks up to 1 year is helpful. For those taking less than 20 mg of diazepam equivalents daily, patients usually tolerate decreases of 1 mg every 1–2 weeks. For patients taking 20–40 mg, patients usually tolerate decreases of 2 mg every 1–2 weeks until the daily dosage is 4–5 mg, after which decreases of 0.5 mg every 1–2 weeks are better tolerated. Stopping the last 4–5 mg are often particularly difficult for patients (usually because of fears about how they will cope without the medication), but they are generally surprised by how easy it actually is. For patients taking larger doses (some abusers take over 0.5 g of diazepam equivalent dose daily), patients usually tolerate decreases of 10 mg every 2–3 weeks. For those with high-dose BZD dependence in the presence of polysubstance use, Ashton recommends inpatient detoxification for the primary drug and BZD conversion to diazepam with withdrawal over 2–3 weeks [1,5].

 

As usual, this is WAY TOO FAST for some/most? people. That's what I'm concerned about. It seems geared more toward the doctor's impatience (to get it over with) than the patient's comfort. It's the same old tired story...And it's not only that the end of the taper can be bad, it ALL can be bad. Sorry, but I'm not buying this. Why don't they go to the root, like the Benzo Coalition, and ask the good people there who have been ALL THROUGH IT what their thoughts are? I'm sure they'd get an earful.

I believe this info was based completely on whatever studies the authors could find rather than personal experience with patients. Within one of the above quotes, it states that there aren't that many studies of people coming off benzos because people drop out. The authors use Ashton's paper quite often, but again, as we know around here, the lived experience is often different than what's on paper.

 

Actually, this tapering section was the part I found most confusing. What's good is that they do state that patients should be given various options for tapering.

 

Here's the quote about studies that I was referring to:

 

It is difficult to study BZD discontinuation because of high rates of patients refusing to participate in and of dropping out of BZD withdrawal studies [1].

 

Thus far, I haven't heard of any BBs who have participated in studies. I suppose the authors could take a look at BB and try to glean info, but really, I'm not sure most academics would take the time.

Yes, I read that, too, Lapis. At least they acknowledge that they don't have much to go on, and I have to hand it to them for writing something like this in the first place. Finally, people who care about the situation!!

I was thinking, Terry, that these two studies represent an enormous body of work. I find it impressive, however I'm disappointed that there's little information about those of us who experience long and difficult withdrawals. I'm not sure how that info will get out there if there aren't any studies on it, though. It's a Catch-22, it seems.

 

Thank goodness for BB! Our realities are reflected here.

Yes, that is very much a concern, Lapis. We seem to be forgotten by these studies, which is sad, because so many of us have to suffer for years and years. It is VERY DIFFICULT and ought to be acknowledged. If I felt even a morsel of understanding from doctors, I would relax a lot more. But that's not the case.

The problem is, though, that no one wants to participate in the studies. So.....that's why there's a dearth of information. I can see the issue from the researchers' point of view -- no studies, no information, so they rely on the few studies that ARE available, and those studies might not reflect all of the various outcomes of benzodiazepine withdrawal. It's a very challenging situation.

 

I'm very glad, however, that the first part of this study validated many of the things we know about how bad benzos are. It's a good piece of literature to share with any medical professional who prescribes these meds.

Yes, it's excellent information, Lapis!! But as I said before, with this comes the responsibility of employing excellent tapering guidelines.

It seems like there are a number of suggestions for tapering. The authors do give the Ashton method, i.e. switch over to longer-acting form, and go down step by step until you reach zero. That's in the second paragraph, i.e. the one you didn't highlight when you quoted that tapering section. I'm pretty sure that's straight Ashton.

 

They also say that each person is different, and that it can take from a few months up to a year to withdraw. I agree that the first section looks quite different, and I found it rather confusing. Perhaps some might be able to go that fast, but obviously, most BBs couldn't. Bear in mind that we are the minority, not the majority when it comes to these things.

 

I'll have to check the references again to see where those tapering schedules came from.

Hi Terry,

I just went back to check the references for that tapering section that you highlighted, and it seems there are a number of studies by authors other than Ashton, so that would account for the different tapering methods. As far as the literature goes, there is no agreement on exactly how to do it. Personally, I'm glad I eventually used the Ashton method, but I remember distinctly being at a doctor's office and being told to drop my clonazepam dose by 25% per week. I was also given some trazodone and told it would help with sleep during the transition. It lowered my blood pressure so much that I was fainting every morning. I lasted a few days and then begged to stop the whole thing. BRUTAL!

 

Again, I'm pleased that the authors of this study did not seem to be married to any one of the methods. They do state that there are different options and that doctors need to take individual factors into account. I think they're also saying that people need to be assessed regularly by their doctors so that the plans can be adjusted accordingly.

 

Here's a quote:

 

Ideally, the patient should be in control of the reduction rate with informed consent and support from the provider [1,8]. A useful technique is to offer 2–3 reasonable options for rate/dose/frequency changes (but not an option for no change) and allow the patient to choose.

 

 

Of course, I really wish that cases such as ours were reflected in the literature. We're in the minority, but still, our situations are real and extremely debilitating.

 

 

I'm very happy that such a study was even done!! And also that there is a consensus that benzo withdrawal can be very difficult with a lot of pitfalls. I really wish a class were taught to doctors on this, with people from various benzo websites involved. It is a very complicated (naturally, because of the neurotransmitters running through the body) and potentially long-lasting process.

 

In my mind, studies have to be done in order to find out why certain people get off without a scratch when there are others in our situation, lasting years.

 

You must have suffered so, so badly!!! 25% reduction off K and given some Trazodone??? Yes, BRUTAL!!!

I never made it past the first six days of that. The risk of fainting was scary and debilitating. One of trazodone's well-known side effects is "othostatic hypotension", i.e. when you stand up, you faint. My normal blood pressure is 100/70 or 90/60, so any drop is dangerous. I was a basket case!

 

Eventually, I found my way to the Ashton Manual, crossed over to diazepam from clonazepam, and did much better. Max dose 8 mg of diazepam, then 1 mg drops every two weeks. It went fine. I wasn't on BB at the time, so I just followed the Manual and did the best I could on my own.

It's good that you switched over to Valium. I wish I'd done that. I'm glad you made it through okay!!!

It's good that you switched over to Valium. I wish I'd done that. I'm glad you made it through okay!!!

 

Thanks, Terry. I'm sure the crossover thing isn't for everyone, but I just couldn't taper off clonazepam. I got terrible muscle spasms and had panic attacks. The diazepam settled those things right down, and I was pretty confident that I was going to be able to get through the taper just fine.

I had a terrible time on K. I should have switched over to Valium, but I didn't know the difference. A doctor prescribed K. Regret, regret, regret...

Oh Terry, I'm so sorry to hear that! Had you found the Ashton Manual at that point? Did you get off the K/clonazepam because your doctor told you that you had to? Or because you decided you needed to? In my case, I realized that the benzos were causing problems, and I needed to get off them.

No, I hadn't read anything about the Ashton Manual. And where I was (POR or Point of Return) we were told not to look things up on the Internet and go looking around for answers. There weren't enough people on the forum to really get an idea of what I had. I was very ignorant. I just knew that I had to get off the Ativan, though, because suddenly I was hit with intense vertigo while walking that I'd never experienced before. After the second time, I started searching the Internet and found that it was because of the Ativan, and I thought Point of Return would be the best place for me. They had a doctor there to help, and he switched me to Klonopin. Since I was having ugly withdrawal all the way through, I thought it best to stay on the Klonopin. I did call back and found out that Alesandra had a terrible time with Valium, so that's why they were recommending K. Something like that. Wish I could have a do-over!!! But I have to look forward, not back.

Yes, of course, forward we go, Terry! I didn't know your story, though, and I'm so sorry to hear that you had a rough ride. I know we all do that "What if...?" thing, but we know it's not a good idea to do that. I suspect that it could have been even harder to get directly off Ativan, since the half-life is so short. K has a longer half-life. The other key factor is genetics and how we each metabolize the different meds, i.e. the CYP450 enzymes.

 

I hope that one day, there will be an easy and inexpensive genetic test available to all that could help make the decision about this med vs. that med. It could change a lot of lives.