— Should doctors be allowed to give pills to patients they’ve never seen, whose names they don't know, for a disease somebody may or may not have?
Yes, if the suspected disease is chlamydia or another sexually transmitted disease, according to a new law in Connecticut.
Called “expedited partner therapy” (EPT), the burgeoning practice allows patients to give antibiotics to their lovers.
This practice is already explicitly legal in at least 27 states, according to the latest tally from the Centers for Disease Control and Prevention.
Doctors are trying to crack down on the spread of sexually transmitted diseases as chlamydia reached a record high last year, with 1.2 million cases in the U.S.
Traditionally, when a patient is diagnosed with an STD in a private doctor’s office or a public clinic, he or she is urged to provide the names of sexual partners to the physician so those partners can be contacted to come in for treatment. Or the patient is told to inform the partners to see a doctor for treatment.
Under EPT, the partners can skip the doctor’s appointment. The physician can simply write a prescription for the patient’s unnamed partner under the assumption that the partner will be infected. Then it’s up to the patient to have the prescription filled and give it to the partner with information on how to take the antibiotics.
This is far from ideal medical care, but the CDC has endorsed the practice -- and for good reason say experts.
“We have clinical trials showing a decreased risk of being re-infected,” said Matthew Golden a physician and public health researcher at the University of Washington. He helped write a 2006 CDC report on EPT that has led to its widespread adoption.
That’s important, Golden explained, because millions of Americans are infected with chlamydia and many don’t know it. Undiagnosed infections can lead to infertility and ectopic pregnancies.
“Men in particular, with no symptoms, when their partner says ‘You might have it. Go to a doctor’ they will not do it,” Golden said. Those men can then re-infect the original patient, or go on to infect others. EPT eliminates the cost, time, and embarrassment barriers to treatment.
A trial with 977 men infected with either gonorrhea or chlamydia found that men referred to a doctor by the original patient showed 43 percent of them had persistent or recurrent infection at follow up compared to 14 percent who used EPT. In another trial, 1,787 women in six cities were diagnosed with chlamydia and randomized to either EPT or traditional referral to a doctor. At follow up, 15 percent of the women in the referral group were re-infected compared to 12 percent in the EPT group.
While those results are not dramatic, any improvement in cutting rates is good, argued Gregg Lichtenstein, the medical director for student health services at San Diego State University. With a population of approximately 30,000 undergraduates, Lichtenstein’s clinic sees a steady stream of chlamydia infections.
“At our facility we use it fairly commonly,” he said. Student-patient reaction to EPT is mixed.
“Some say, ‘Oh, sure, I’ll give it to my partner,’ and then others say, ‘Uh, no thanks. I will just tell them to go see the doctor,’” Lichtenstein said. “You do wonder about that latter group, if they really do tell the person or not.”
There are other possible drawbacks besides not telling a partner. Some experts are concerned that EPT could exacerbate the risk of developing and spreading drug-resistant strains of gonorrhea if partners fail to take all the oral antibiotic prescribed or it is not effective against the particular strain.
According to Golden, the risk that EPT could worsen the problem of resistant gonorrhea is small, but the fact of that growing resistance may soon eliminate EPT as a strategy since the only drug effective against resistant strains must be administered by injection.
Some also worry about drug reactions in patients a doctor never sees. When an EPT law was debated in Wisconsin, the Wisconsin Pharmacy Society, while supportive of the law in general, objected to EPT’s anonymity.
“We thought it important for a name to be given,” explained Tom Engels, the society’s vice-president of public affairs. “By dispensing something to a patient you do not know, you don’t know if that patient might have an allergic reaction, and you can’t give advice.”
University of Pennsylvania bioethicist and msnbc.com contributor Arthur Caplan isn’t so worried about the issue of allergies, which he says is minor with azithromycin, the drug most often prescribed for chlamydia, but he does worry about introducing a shortcut to the way doctors practice.
Even patients who hand over the prescribed drug to a partner may fudge on the reason why the partner should take the drug. Nobody likes saying “you might be infected with an STD,” so it’s important for doctors to educate patients so patients will educate partners. “If this program is a substitute or a reason for a doctor to avoid counseling the infected about the need to let the partners know, that is troubling,” Caplan said, “and there is reluctance to take on this issue on the part of nurses and doctors.”
Normally, Caplan said, he would oppose such a shortcut outright, but worry aside, if EPT does prove significantly more effective at stemming chlamydia infections, he thinks it is worth the risk.
Golden is hoping that a large trial now being conducted in the state of Washington will show that not only can EPT help reduce the risk of one person’s re-infection, but that it will lower the infection rate across a large population.