He sat on the edge of my exam table, seemingly deep in thought. Clearly he was nervous. Typical of a middle-aged guy, I quickly posited, who up to now thought himself indestructible. All his life he had steamed along, no worries about his health; and then there it was, his first major medical diagnosis. Norman had felt perfectly fine until he caught a cold that would not go away. It got worse and worse, until one night he felt so bad he thought he was going to die. He had no doctor, so he went to the emergency room. In the ER, he got the good news: the headaches and hacking cough really were just a typical upper respiratory infection. Then came the bad: His blood sugar was 423.
The emergency department referred him to me for follow up. "New onset diabetes," the ER discharge note said. The note was dated was six weeks ago.
I naturally assumed Norman had delayed following up because he was nervous about seeing a doctor. He was afraid of facing the diabetes diagnosis, the pills, the diets, and possibly, the dreaded insulin injections. Or perhaps it was the great fear of all, the fear that this new disease could kill him. I could understand that. I was ready to empathize.
"Doc, I won't have to be on shots, will I?" he asked.
A carousel spun noisily in my mind, and a CD with the words "Standard Diabetes Speech" printed on it dropped down.
"Some people with diabetes can control their sugars with diet and exercise, some with oral medications alone, and some with insulin shots. Some need all three approaches. The most important thing is not how you control your sugar, just as long as you get it controlled. I . . . ."
"I drive a truck for a living."
I hit the pause button. He wasn't nervous about seeing me or about taking medicine. He wasn't even nervous about getting bloodwork or facing his diagnosis, let alone being concerned about something as existential as his own mortality. No, his concern was altogether earthy.
The state of Mississippi, like most other states, will not issue a commercial driver's license to someone taking insulin injections. Norman was worried about losing his job.
This always struck me as a very dumb law. At one time, perhaps it made sense, but not any longer. On the surface, it sounds sensible: A diabetic who takes insulin must have significant disease. Diabetes causes many medical problems one would not want to see in someone guiding an eighteen wheeler, including stroke, heart disease, kidney failure, and blindness. Further, insulin shots are a tricky business. They have to be taken every day, on time, and the dose has to be exactly right. A lot of room for error, and any mistake could leave a 10 ton hunk of crumpled metal on the side of the road at one of the Jackson I-55 interchanges. Case closed, right?
Well, no. There once was a time when it may not have been advisable to allow insulin users to drive. Not very long ago, there was only one type of insulin, short acting. Short acting, or regular insulin, came from the pancreases of slaughtered cows and pigs. It only lasted 3-6 hours and had an unpredictable release. This meant diabetics had to check their blood sugars often, and had to take four or more shots a a day. A trucker on that kind of regimen would have to stop every few hours to give himself another shot, and might have to pull off the road for periods of time to contend with low blood sugars in the event of accidental overdoses.
Those were the dark ages. Today there are several types of insulin, ranging from ultra-short acting (with onset in less than five minutes) to very long acting (lasting over 24 hours). There is even an insulin that is inhaled, rather than injected. With so many insulin types to choose from, and with the flexibility to combine insulin with the numerous new oral medications available, many diabetics can control their sugars with only a single injection a day. And since the introduction of human insulin derived via recombinant DNA, today's insulin is more reliable than its animal-derived predecessor.
I prefer to manage a patient's diabetes with insulin. Though pills seem more convenient at first, I find that pills deliver uneven results. Most oral diabetes medications can only be given twice a day at the most, which means a patient cannot take a little extra if his sugar is running high, as he can with insulin. Pills also have significant toxicities. Sulfonoureas can drive blood sugar low enough to kill if the patient takes too much. Metformin can damage the liver. Thiazolidinediones can cause fluid retention and sometimes heart failure. Insulin, on the other hand, is a naturally occurring hormone and thus has few side effects. Unlike pills it can be given in an almost infinite variety of doses, which means an insulin regimen can be adjusted to achieve very tight sugar control, a control that, in many diabetics, cannot be attained in any other way. The only danger with insulin is the low blood sugars a patient can get if he takes too much, and the risk of skin infections from the daily injections. This problem, however, has been largely alleviated with the modern insulin pens, which are very easy to use and have an extremely low error rate.
Simply put, I do not think insulin use, as it stands today, carries a greater risk for trucking accidents than oral therapy does. If anything, the risk is probably less because the sugar control is likely to be greater.
This does not mean I frown on the use of pills to control diabetes. But for many patients, insulin injections are by far the better option, and result in tighter glucose control. Insulin therapy is not the last resort; it should be the first option for many. Herein lies the problem. For truck drivers, the prohibition of insulin injections means that many patients who would be good candidates for insulin therapy will resist taking it for fear of losing their livelihood. By clinging to oral medications when they are not adequate, such patients are trading their long-term health for the short-term benefit of a paycheck. I don't blame them for making this choice. I blame an old, outdated law for encouraging patients to do the wrong thing.
This problem also underscores a real weakness of the healthcare system in the United States -- the association of health insurance with employment. Even if Norman decided to quit his job and find another career just so he could take insulin, he would lose his health insurance because he is insured through his employer. Worse, if Norman were to get a new job, his diabetes would qualify as a pre-existing condition, meaning his diabetes medications and doctors visits would not be covered for a while, or possibly for ever. Not a good situation to be in.
In the U.S., health insurance is seen as a personal privilege rather than a social good. This makes no sense. As a matter of public policy, we should want as many people working as possible. We should think of health care as a way to keep our workforce strong and competitive. To achieve this end, our laws should be designed to help people continue to work as long as they can. It is hard to see how a law that bars truck drivers from taking advantage of the best combination of medications available to them does that. Instead, it encourages drivers to hide their diabetes as long as possible, and to avoid insulin until the disease is so bad that they cannot avoid it. Then at last they pay the price for delaying appropriate treatment for so many years, and end up disabled from this terrible disease.
At the moment, Norman is on pills only, and his glucose control is excellent. But I know something Norman has not acknowledged yet, that diabetes tends to progress over time and that many, if not most, patients that start on oral medications end up requiring insulin injections in the end. As I see it, his best chance it to hope he will win the lottery by then. After all, the government seems to be better at promoting lotteries than organizing a cohesive health care plan.