EpiPens and EpiSpreadsheets

Michael Kaplan traveled from his home in Iowa to Clearwater, Florida to see his father.  It was August 2009 and his father, Sheldon Kaplan, had been diagnosed with a liver cancer.  

Sheldon Kaplan would live one more month before dying in his modest home where he and his wife lived out his unassuming retirement.  During their conversation his son shared that a friend’s child and his own mother in law’s life had been spared using an Epipen.  It probably brought a smile to the elder Kaplan’s face.  

Sheldon Kaplan was trained as an engineer at Northeastern University and worked at NASA in the 1960’s.  He then took a job working on a treatment for nerve agent poisonings with a military contractor and invented the ComboPen to be used in combat.  

He then had an idea to modify the ComboPen so that it could deliver a medicine that had been around for decades.  Epinephrine, or adrenaline, is naturally produced by the adrenal glands and triggers the “fight or flight” response humans feel when threatened or fearful.  It also is the life saving medication for allergic reactions to insect stings and certain foods. 

Epinephrine was discovered in 1901.  Placed in Sheldon Kaplan’s device, the Epipen was born and patent issued on June 28, 1977.  

As an employee of his company, he never made any financial gain from royalties for the EpiPen.  

But financial gain has been made in a very large way by the corporate owners of the patent.  

Recently Mylan, a pharmaceuticals company, announced that the EpiPen cost was increasing from $400 to $600.  This was a peculiar move by the company that owns 85% of the market for epinephrine pens in the United States.  Even more so given the fact that the EpiPen was $57 in 2007 when Mylan took over marketing of the product.  

It is estimated that the drug epinephrine in the EpiPen cost less than one dollar.  One dollar. 

Mylan quickly achieved something that is rare in our country nowadays.  They united Republicans, Democrats, Hillary Clinton, Donald Trump, Socialist pretending-to-be-Democrat Bernie Sanders, consumer watchdog groups, the American Medical Association, parent/actress Sarah Jessica Parker (ended a publicity campaign with Mylan) and angry parents who have ready access to social media.  

Mylan CEO Heather Bresch, the daughter of Democratic Senator Joe Manchin of West Virginia,  has tried to spin this media nightmare by saying it isn’t her company’s fault but simply the “broken system” of healthcare in America. Her company, just as I began to write this column, announced a very, very curious “generic version” of the EpiPen available for only $300.  It, the generic, is not different from the name brand EpiPen according to Mylan. 

Really?  You change the label on the same device and drop the price by half and yet still deliver a $1.00 drug in a device that costs $300?  Sounds like one of those “I’m sorry if I offended anybody” apologies that never really says “I was wrong.” 

This comes in the fortuitous timing of competitor Sanofi’s competing product recall in 2015 and Teva’s generic product approval denied by the FDA in March 2016.  Mylan’s 85% market share delivers 1.5 billion dollars and forty percent of their profit.  And that was before the competitors were conveniently eliminated.  

To be fair, Mylan has been generous with providing EpiPens for schools and athletic programs where students are involved.  That’s nice.  It looks good in the yearly corporate earnings report. 

The names Adrenalina WZF, Altellus, Anapen, Emerade, EpiPen, Fastjekt, FastPen, and Jext may be unfamiliar but are the competing epinephrine pen products in Europe.  One report lists a price of $75 for an over the counter device in France.  

I believe Heather Bresch is right.  It is the fault of the “broken system” of healthcare in America.  The “broken system” of healthcare seems to have its roots in one central axis and several supporting spokes:  a large, readily influenced by money, controlling governmental bureaucracy and the willing insurance, pharmaceutical, and hospital corporations who are eager to contribute to it.  

Physicians clearly are in that mix after sampling the taste of government money in the 1960’s and then becoming addicted to it.  Take government money, accept government control.  

But somewhere in America some man who was forced to purchase a health care insurance with a high deductible and no pharmacy benefits will need an EpiPen after multiple bee stings while he is working to support his family.  Or some child will have a food reaction while camping or at a friend’s house.  Both desperately will need the life saving one dollar’s worth of epinephrine.  Both may die because they didn’t have the $300 to get it nor the insurance to cover it. 

Sheldon Kaplan died shortly after his son traveled to see him.  His idea and work likely has saved hundreds of thousands of lives.  He died without making a dollar from it.  He died with the satisfaction that he had made a difference in this world.  

Now, on the other side of billions of dollars in sales, someone may die because access to an invention of a device, not the medicine, is limited by big government, big donors and big influence.  

The out of touch world of politicians, bureaucrats, lawyers and their ilk who have generous federal health insurance benefits in the Washington DC Beltway need to wake up to the reality of real America and worry about competition beyond their Nationals’ and Redskins’ teams.  

This country was made great on competition.  Competition, driven by the medical consumer, can fix a lot of the “broken healthcare” system.  

Rest in Peace, Mr. Kaplan. 

Eric J. Littleton, M.D. (@DrEricLittleton) is a musician and Family Physician in Sevierville, TN.  Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com

Roger Williams - Mr. Piano

I typed his name into the internet to see when he had died.  I hadn’t read much about him recently or heard of any new music.  Surely he must have passed. 

Not only was he not dead, but he was still touring.  He had five concerts that year.  Two in New York, two in Las Vegas, and one in Bristol, Tennessee.  Bristol, Tennessee?  In two days.  

It was April 2006.  My wife and son couldn’t go, so I ordered one ticket from the Paramount Theater’s website.  Downtown Bristol, on the Tennessee Side of Main Street.  

Roger Williams had been in the public eye playing the piano since his arrangement of “Autumn Leaves” grabbed the nation’s ear in 1955.  Born in 1924 in Omaha, Nebraska he served in the Navy in WWII, graduated Drake University and then Juilliard School of Music in New York.  

He had the classical training of a fine concert pianist, but he had more.  He had a way of hearing a song, processing the music, and then making it his own.  He mixed this with a quick wit and self-deprecating humor that made his concerts more than just a musical experience.  It was like you were in his living room.  

I found my way into downtown Bristol and into the the theater.  It was a full house and the only seats left were in the back.  A quick scan revealed I was likely the youngest person there. They, however, were a laughing and noisy group excited to be together to listen to one of their favorites.

The event was to celebrate a renovation of the the Paramount Theater and a new Baldwin Piano.  Roger Williams was a Steinway Artist, noted for playing twelve hour marathons at the Steinway Piano Store in New York for his birthdays.  He, however, had graciously agreed to play the new Baldwin for the event.  

The piano, resembling a small aircraft carrier, occupied most of the right of the stage.  His five piece band was on the left.  His bench was a plastic chair that was positioned exactly where his manager measured with a piece of wood for reference.  The tuner was finishing up his work.  

The house lights dimmed and Mr. Williams walked, actually shuffled, to the stage.  He smiled, waved, and sat down without moving the seat an inch.  He placed his hands to the piano in a most unorthodox and odd curve with his palms below the keys - and started to play.  

It was as if the new Baldwin had 176 keys instead of the standard 88.  As quick as lightning, but as light as a butterfly, his hands, still in the unorthodox position, went up and down the keyboard. The entire energy of the theater became focused on one stretch of black and white that he commanded, coerced, caressed and corralled.  It was breathtaking, and that was only the first few moments.  

Williams reputation began in Drake University where he was kicked out of a practice room for playing “Smoke Gets In Your Eyes.”  He could play the classics, but he found his love in playing more modern music from popular artists and movies.  Later on he played the classics Juilliard required, but that music became merely his tools for rearranging modern songs.  

The song he is most noted for, “Autumn Leaves,” has a particular right hand part that resembles, well, leaves falling.  It is exceedingly difficult to play, yet he made it look like a wave of the hand.  

He shared how he had played for every president since President Truman noting each one’s favorite (Ronald Reagan “The Impossible Dream”). He gave background history on “Born Free” and main theme music from “Star Wars” from his good friend John Williams (no relation). 

After intermission, he walked to the front of the stage to talk to the crowd about the songs they love.  Twenty-three songs were mentioned, a few followed with the comment “Oh, I haven’t played that in years.”  His band members, obviously old pros at this, wrote down the names of the songs.  Mr. Williams then took the listing of songs and played a medley of the twenty three pieces sewn together in a quilt of music.  

It was staggering.  I heard he had over ten thousand songs memorized, but to see it on display was just an unimaginable feat of memory.  He would search occasionally then pick up the scent of the song and the band would follow right along.  The crowd roared with approval.  I was nearly in tears.  

That was ten years ago.  It is still one of the most inspiring musical performances I have ever witnessed.  An eighty-one year old man mesmerizing a crowd with simply the music they grew up with played in his own style.  Some of it the notes, some of it the spaces between the notes, some of it a different velocity of the notes.  All of it - his.  

I have been graciously asked to play the piano for The Robert F. Thomas Foundation’s Evening of Elegance on August 13th at the Sevierville Event Center.  The Foundation supports many non-profit medical organizations and promotes better health for all of Sevier County residents.  I am honored, and humbled, to be asked to play and look forward to it with anticipation.  

I am not Roger Williams and wouldn’t even begin to pretend I can play one note like him.  But, I learned from him to take songs people know, internalize it, then try to make it my own.  That is the beauty of music.  It is the same notes on a page, but different music from the person.  

It will be two hours of complete musical relaxation for me, and I hope in some small way for the attendees of the event.  Nevertheless, if I can motivate, encourage, or interest a child to begin their own musical journey at the piano for a lifetime - that will be true success.  

Eric J. Littleton, M.D. (@DrEricLittleton) is a musician and Family Physician in Sevierville, TN.  Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com