By Donald R. Davis, Ph.D.
In John Abramson’s 2004 book, Overdosed America, he tells why he gave up his medical practice to write about “the broken promise of American medicine.” From 1982 to 2002 he practiced family medicine near Boston, Massachusetts. He also pursued research and teaching at Harvard and other universities. Experiences in his practice convinced him that pharmaceutical companies are increasingly corrupting medical research, misleading doctors and the public, and threatening our health. He decided that the best way he could help people find better health was to carefully research the influences of pharmaceutical companies and explain the evidence to the public and other doctors.
As Abramson illustrates, non-drug alternatives are often more effective, safe, and economical.
Big changes have occurred in medical research. Before 1980 most medical studies were publicly funded. Now three-fourths of clinical studies in top journals are industry funded. These studies are designed mostly to promote the drugs, not to find the best way to help patients. Thus medical knowledge now grows in the direction of drug company profits, not necessarily patient benefit.
For example, Abramson cites a major journal report that the statin drug Pravachol reduced the risk of stroke by 19%. Close inspection shows, however, that this “headline” number is an example of industry spinning. The seemingly impressive 19% reduction in relative risk corresponded to only a small reduction in absolute risk in the subjects studied. The 6-year incidence of stroke was reduced from 4.5% to 3.7% (3.7 is 19% less than 4.5). This reduction in absolute risk is so small that the drug cost alone would be $1.2 million just to prevent one stroke. To prevent one stroke per year, 1000 persons would require lifetime exposure to (and testing for) the drug’s potential side effects.
Further, the study· subjects were 83% male and averaged 10 to 15 years younger than most stroke victims, who are 60% female. In the study, older and female subjects who received the drug
actually had more strokes. Thus, the company studied the wrong subjects. A study of more representative subjects might well show that Pravachol increases the risk of stroke.
Industry spinning is the norm, in both research reports and advertisements. Worse than spinning, however, are overtly deceptive journal reports. Celebrex and Vioxx are pain relievers introduced with a great marketing blitz in late 1999. Both were touted as breakthrough anti-inflammatory drugs with reduced risk of serious intestinal problems. A 2000 journal report concluded that Celebrex indeed was safer than older drugs when used for 6 months. However, this result was contrived and later rejected by the FDA. The false impression was achieved by
artificially combining the incidences of minor and major intestinal complications and by omitting data from the last 6 months of a 12-month study. Six of 7 serious intestinal complications
had occurred in the last 6 months, a higher risk than the older drugs. Both the FDA and the journal protested the deception. Nevertheless, Celebrex had over $3 billion in sales during its first
2 years on the market. It is still widely perceived as a superior drug worth its high price.
Similarly, a 2000 journal report about Vioxx artfully omitted data showing that Vioxx had 2.4 times higher risk of serious heart complications than an over-the-counter, generic drug, naproxen (Aleve). The benefit of fewer serious intestinal problems was more than offset by an even larger number of serious heart problems, but the downside was not reported. Vioxx had over $7 billion in sales before the FDA took it off the market in 2004 for causing an estimated 100,000 to 150,000 serious cardiovascular problems, including tens of thousands of deaths.
We are bombarded by heavy advertising for new, expensive drugs, because the ads cause patients to ask their doctors for them. Abramson tried to tell his patients that Celebrex and Vioxx were no better than older, much cheaper drugs. But sometimes he relented, to preserve the trust of his patients who wanted “the best.” For many patients, the drug’s high cost was no deterrent, because their insurance transferred the cost mostly to others.
Drug industry influence on medicine goes well beyond spinning research and advertising. The industry now provides 70% of the continuing medical education that physicians must take to maintain their licenses. Practice guidelines such as those for treating high blood cholesterol were written by physicians who nearly all have multiple conflicts of interest with companies that produce cholesterol lowering drugs.
The cumulative effect on American medicine is a heavy overemphasis on drugs for every problem, from osteoporosis to shyness. As Abramson illustrates, non-drug alternatives are often more effective, safe and economical. But there are no large companies with huge marketing budgets to promote these alternatives, so they are neglected. The U.S. spends more than twice as much per person on health care as 21 other industrialized countries. But our health ranks dead last, as measured by the World Health Organization’s “healthy life expectancy.”
To protect our health and pocketbooks, Abramson shows that we must become aware of the pervasive influence of the drug industry on medicine, and remember that its first goal is profit, not helping the public. We must actively seek out those better, safer, and cheaper alternatives.
For those wishing to find unbiased information about drugs, Abramson recommends three Internet sources:
• Therapeutics Initiative: “The best site for complete, unbiased scientific evidence about commonly used drugs.” Pharmacists and family physicians at the University of British Columbia have produced 60 Therapeutics Letters since 1994, available at www. ti.ubc.ca. The Letters are brief, practical, referenced, and reviewed, “at arms length from government, pharmaceutical industry and other vested interest groups.” The 59th Letter notes the surprising fact that Canada now spends 25% more on drugs than on doctors. Rapidly increasing drug costs go mostly for new, “me-too” drugs that have no advantage over older, cheaper drugs.
• Center for Medical Consumers: “A truly non-profit, public interest group posting important information to help medical consumers make good decisions.” It covers both drugs and medical tests and treatments, at www.medicalconsumers.org. The Center also publishes a newsletter (where I first learned about Abramson’s book).
• Public Citizen’s Worst Pills: “Contains up-to-date information about drugs in the style of their book, Worst Pills, Best Pills.” It lists over 200 prescription drugs to avoid, with alternatives. It allows searching by drug, disease or condition, drug family, or drug-induced disease, at www.worstpills.org