Can I find someone in SF who will help me actually lose weight?

April 1, 2008 7:19 PM

Why can't I find a doctor or weight loss program in San Francisco that will prescribe phentermine?

Many years ago, I was morbidly obese. I tried and failed at many attempts at weight loss, and finally, with the help of a doctor (who is now half-way across the country), found a strategy that worked for me: strict calorie control and phentermine as an appetite suppressant. I lost hundreds of pounds, went off the phentermine, and still managed to keep it all off for many years. It was a big success, and it changed my life in many ways.

However, many years and "life events" later, I'm over the morbidly obese line again -- not back to my old, pre-diet weight, but over the line nonetheless. I've tried cutting back and increasing activity in a disciplined way without the phentermine several times, and (like all those times before my successful weight loss) I find I just don't have the will-power to get around the hunger. Naturally, I suspect that with a prescription for phentermine, I'd be able to stick with things a bit easier.

Here's the problem: nobody will prescribe it. My PCP, a wonderful man who guided me through a major (unrelated to my weight) medical emergency last year, won't do it. He attempted to refer me to someone who would, but couldn't find someone on my (decent) insurance. I myself sought out a weight loss doctor, and thought I had found one after many phone calls, but it turned out she'd only prescribe a fractional dose -- far less than the standard dosage -- which I tried and found was simply not effective.

Now, as far as I can tell, phentermine is still considered safe by the FDA. There's some evidence that it may have minor addictive properties, but it doesn't seem from anything I've read to be any more addictive than any number of mainstream medications that are very commonly prescribed for pain or ADHD or anxiety or depression. Also, I'm not talking about fenfluramine or Redux here, both of which were shown to be unsafe, and were taken off the market back in the 90's.

This is pretty frustrating to me. Most doctors and weight loss specialists I've spoken with are quick to tell you to lose weight, to recommend a system to control calories or increase activity, but they seem to want to resist giving you a basic tool to help with the basic problem -- the hunger that comes from the dietary changes. Getting a prescription for phentermine must be difficult for many others as well, given the amount of horrible spam that's sent out advertising the stuff. It seems completely idiotic to me that insurance companies will pay for stomach stapling and yet I can't get a prescription for a few months of a cheap, FDA approved medication to help me do it myself.

I've checked the local American Society of Bariatric Physicians doctors, BTW, and still had this problem... unless I missed someone.

So, I have two questions. First, what's going on with this? Seriously. Second, do you know a reputable doctor in San Francisco who is willing to prescribe a standard dose of phentermine and monitor a weight loss program?

Sockpuppet e-mail at wtphen @ hotmail.co m (no spaces). Thanks much.

posted by anonymous to health (12 comments total)

This is purely anecdotal but my wife has had no issues being prescribed this by two DO (Doctor of Osteopathy) doctors instead of MDs. I've rarely heard of MDs prescribing this but again this is purely anecdotal.
posted by Octoparrot at 7:39 PM on April 1

What's going on is that phentermine probably isn't 'safe' in the sense that you're using the word. Drugs have good effects and bad effects. Phentermine might help a person lose weight. But it raises blood pressure, can cause fatal or nonfatal heart arrhythmias, and probably causes heart attacks and strokes when used over long periods. It may also produce mood changes like irritabiity, and psychosis or hallucinations, and it disrupts sleep. In combination with fenfluramine (fen-phen) it produced serious, permanent heart and aorta problems in a lot of users - how many we'll probably never know for sure. It interacts with other medicines too - and these days, who ever really knows what a patient is taking? (I spend more time reviewing medicines in my clinic than the average PCP does on doing his entire encounter. Often this is all I need to do to cure a patient's 'neurologic' ailment.)

Now there are a few reasons to help a person lose weight. If you ignore the cosmetic benefits, we know that people who aren't obese live longer, have less strokes and heart attacks and diabetes, are able to exercise more and better, and all those good things.

But do those benefits accrue to people who lose weight - stop being obese - by taking phentermine? We don't know that they do. There's good reason to think that they may not. That means that the doc is looking at all this downside and a very uncertain upside. A lot of docs don't want to try to deal with instructing and guiding a patient through this kind of measured risk-benefit analysis, especially when they're shoehorned into these 15 minute visits. Some other docs, like me, think back to their Hippocratic Oath - "First: do no harm" - and decide that phentermine just isn't going to be part of their pharmacopoeia.
posted by ikkyu2 at 8:21 PM on April 1 [3 favorites]

I was prescribed this when I was trying to get approved for gastric bypass 2 years ago. I was required to see an endocrinologist as part of the approval process to rule out things like hypothyroidism and type 2 diabetes. This particular endocrinologist ran a "nonsurgical weight loss" type clinic. It felt like they were actively trying to keep me from having the surgery by making me come back several times, pushing phentermine on me, running tests repeatedly even with no indication of endocrine issues, etc. It took some angry calling on my part, and the intervention of my surgeon's office, to get them to release the results they were supposed to be gathering for me. (TMI, I am sure, but it still angers me.)

Therefore, I'm surprised that you're having such trouble. It could be that so many doctors are pushing the surgery route that no one's even considering nonsurgical options any more. You could try an endocrinologist, especially one that specifically addresses obesity. I don't have a specific referral for SF, though.
posted by cabingirl at 8:27 PM on April 1

Why not ask your PCP why he wouldn't prescribe it?
posted by rhapsodie at 9:34 PM on April 1

I can't overstate how much I agree with ikkyu2 in regards to this matter. It absolutely disturbs me that drug corps in US advertise direct to the public for this very reason: people do a little bit of research on their own and think they've found the perfect solution to their problem and think they know better than their doctor.

What did your PCP suggest? If he's been this good so far, maybe he knows what he's doing, no?
posted by PuGZ at 12:24 AM on April 2

Ikkyu2, could you elaborate on the "good reason to think that they do not" part of your reply re: the benefits of weight loss that's pharmaceutical in flavour? Is it from the fact that the loss may not be accompanied by an exercise routine, thus no increase in cardiovascular fitness, or am I on the wrong track?
posted by subbes at 8:27 AM on April 2

Perhaps your general state of health now precluded the use of amphetamines? When it didn't before?
posted by gjc at 8:28 AM on April 2

subbes, I believe ikkyu2 is suggesting rightfully, that using a stimulant with the possible side effects of causing systemic and pulmonary hypertension, increased heart rate, and valvular heart problems in order to treat a condition associated with cardiovascular mortality and morbidity probably rubs doctors the wrong way. While weight loss has been demonstrated to reduce the risk of various maladies, there's no reason to assume that it's irrelevant how you lose weight. Moreover, phentermine is really only approved for short term use, and the consensus is that weight loss is a long-term lifestyle problem. In someone who admits to wanting to use it as a crutch because they are unable to calorie reduce or exercise more, that doesn't really bode well for sustained weight loss. Bear in mind, the literature on phentermine is largely limited to a single prospective study over 36 weeks done in 1968. This study demonstrated improved weight loss (most would agree that it probably will help you lose weight), but the data on stimulant-assisted weight loss and morbidity/mortality is lacking I believe. Consequently especially in light of the withdrawal of FenPhen from the market after people started dying, most doctors are justifiably concerned. I'm sure there's some weight loss specialist out there that loves the stuff, but my estimation is that even among doctors who pharmacologically manage weight loss, other drugs are favored. Personally, as someone who takes care of many patient's with pulmonary hypertension, I'm also among the group that wouldn't touch it with a ten foot pole.

I would caution the OP about self-precribing or getting one's heart (pardon the use) set on a drug when clearly the world is telling him it probably ain't such a great idea. When you have a hard time getting a medication from people who make a living prescribing medications that should make your alarm bells ring. Doctor shop enough and I'm sure someone will eventually indulge you, but I'd like to humbly suggest that that ultimately might not be in your best interests.
posted by drpynchon at 7:01 PM on April 2 [1 favorite]

Oh yeah, what drpynchon said, to the letter. I find myself in complete and exact agreement with every word of that comment.
posted by ikkyu2 at 10:54 PM on April 2

[Followup comment from anony asker follows.]

rhapsodie, PugZ and gjc: my physician indicated that he had no problem with me taking the medication -- and as above, attempted to find another physician or program on my insurance that would provide it. . That's not the issue -- the issue is that he said he personally felt uncomfortable prescribing the medication. He's not usually evasive -- when I've brought up "what about... ?" in the past, he hasn't pulled punches in saying "I don't recommend that for ." That's not the message in this case. He doesn't appear worried that it would cause adverse effect on my health.

Clearly, other physicians feel uncomfortable prescribing the medication as well, as Ikkyu2's post expresses. Here's what frustrates me: Ikkyu2's scary list of side effects is nearly identical to the side effects of too much caffeine. Ikkyu2 is concerned about drug interaction, as he rightly should be, but that shouldn't be a concern for my doctor, as he has a complete understanding of what medication I'm on (I don't take any complex series of medications). From my point of view, it's very, very difficult to take arguments about the efficacy and side effects of the medication when I've taken it successfully in the past under a physician's care, without any significant presence of those side effects. PugZ, I'm not familiar with the drug through advertising, I'm familiar with it through the care of my former physician and my experience with it. This isn't a capricious request.

I do understand that phentermine has a bad reputation from being associated with the recalled drug fenfluramine, although neither of my doctors or Ikkyu2 have provided any information on how it is harmful when used on its own other than those side effects which match those of caffeine use. My concern is that this seems to be more about concerns about liability impeding my ability to find help; the pushback I'm getting seems disproportionate to the amount of harm this drug is capable of. I agree that doctors should follow the hippocratic oath and do no harm, but the message I'm getting is "We can't help either, sorry."
posted by cortex at 10:11 AM on April 3

I don't think people should overdose on caffeine, either. I certainly don't advise them to. If I were advising them to, maybe your analogy would make some kind of sense. Also, caffeine doesn't cause heart attacks or strokes, and its blood pressure effects are very modest in comparison to the sympathomimetics. In very high doses it can precipitate arrhythmias.

I don't care about liability or getting sued nearly so much as I do about harming my patients.

Because of that, I'm always delighted when a patient who doesn't appreciate that goes shopping and finds a different doctor, one who doesn't care, to rubber-stamp his prescription requests. In that case the patient has found a better fit for his desires, and I get to quit worrying about it. Everyone wins.

From my point of view, it's very, very difficult to take arguments about the efficacy and side effects of the medication when I've taken it successfully in the past under a physician's care, without any significant presence of those side effects.

This is the answer to the question you asked. If you don't like it, that's one thing. But berating me or other doctors for being cowards who won't do the right thing out of fear of a lawsuit, and accusing me or other doctors of lying to justify that fear, is something else again. If you don't want the answer to your question, maybe you shouldn't ask it here.

On the other hand, given what you described, you're probably a good candidate to be on phentermine, for the cosmetic purpose of weight loss. If you can't find someone to do it in S.F., take a trip to L.A. and look in the back of some local magazines like the L.A. Weekly. You'll find someone who'll write it.
posted by ikkyu2 at 7:36 PM on April 3

The other thing that occurs to me is that a lot of the patients who used to get phentermine are now getting sibutramine, because it's putatively safer (although a lot of docs don't think it's safe, either, for exactly the same reasons.)

You might consider looking into sibutramine.
posted by ikkyu2 at 7:39 PM on April 3