Tuesday, March 04, 2008

What the Public Wants: Pills

I have often been critical of the pharmaceutical industry here for a number of excesses pushed in the name of profits:
their egregious hyping via "scare" ad campaigns of minor syndromes into horrible diseases you just have to "cure" with their costly new drug; medications which don't work for most people, or which lose their effectiveness in relatively short order; medications which have not been tested in combination with other common drugs patients may be taking, and medications with major under-reported side-effects.

Frequent contributor Nurse Dorothy filed this report and made this cogent observation: we're just getting what we want: pills.

"When I read your article about over prescription, I wasn't even sure how to describe the chaos in our healthcare system when it comes to meds.

The fact is we are a pill popping country and contrary to popular belief it's not the medical community's fault. It's so easy to blame the pharmaceutical company, doctors, the government, etc. But blaming them is like blaming prostitutes for prostution. What about the johns. In the end you have to look at the root cause for America's appetite for pills.

In my opinion it boils down to one root cause: a total collapse of the American value system. The accumulation of stuff has become our number one goal in life. We have traded our mental and physical health for it. Obviously I don't need to remind anyone of the direct correlation of working long hours and bad health. Nutritional food gets substituted with restaurant fare and physical exercise in any form goes out the door.

When both mom and dad work long hours to give their kids the "stuff they never had" the whole family suffers. Family dinner becomes "what can I pick up on the way home". So parents get fat, the kids get fatter, everyone becomes unhappy and in come the mind numbing pills. Eventually the bad lifestyle choices lead to diabetes, COPD, and heart disease thus requiring more pills to keep your legs from swelling, your lungs from collapsing and your heart pumping. Now you can barely get up the stairs of your McMansion with out passing out and so you order even more psychiatric pills to handle more depression.

And all because you want you or your kid to have the latest fashion and a flat screen TV to play video games on. Ah, yes, the American dream.

Now here's the scariest part of it all. No one knows what the long term effects of taking all these pills together are because no other generation has taken so many pills until now. I have patients who take 20 pills a day and no one knows what the outcome will be. Most of the medications out there are not for cure. They were develped to help control the symptoms of a disease. Most of the common diseases out there are preventable but not cureable.

In the end, it doesn't matter what programs are developed to control the prescription of medication, it will not work. So long as there is a demand for meds, we will overprescribe them. So long as there is a demand for street drugs, they will be sold. So long as men want unconditonal sex, there will be prostitutes. Econ 101, demand and supply.

After reading this, I asked Dorothy to describe a bit more about her experience as a healthcare professional, i.e. nurse. Here are her additional comments:

I've been in the field for six years so that does make me a little bit of a newbee when compared to some of my 30-year nursing vets. I first worked in surgery where there was nothing to do in the middle of surgery but talk to the doctors about every topic under the sun. I then went on to the trenches of the floor in a second hospital where I saw first hand how inadequate our system is.

Currently, I work for a doctor making rounds at several area hospitals where I have access to medical journals and more importantly the ideas and opinions of doctors, administrators and other peers. It's my discussion with all these people where I get my information and ideas. I have a double bachelor's degree in nursing and business and will hopefully start my master's in nursing next year...God willing.

As for the topic of not testing drugs together, it comes down to money. It's too cost prohibitive to test every new drug with every other drug and combinations of each. Before going to market drugs are tested with other popular drugs and/or drugs which the new drug would most likely be used with. Example, a diuretic might me tested with an anti-hypertensive since they usually go together for treatment of CHF. This info I got in pharmacy 101 class.

As for long term outcomes, all you have to do is look at the news. Every month there is some drug out there that gets taken off the market because now, some 20 years later, it's been shown to cause blindness and what not. So if the long term effects of one drug isn't known, then how can they possibly know the effects of 10 drugs taken together? In addition, many drugs are prescribed to ease the symptoms other drugs cause. It's crazy when you really think about how enormously complicated the world of pharmacy is. Don't get me wrong, drugs have helped millions to live longer or more comfortably, but how many lives have drugs caused harm too in terms of over-use, bad combinations, etc.

One last tidbit to nibble on which has become a hot topic in the medical community. More and more people have been surpassing their life expectancy due to drugs and new technology. This has caused a moral dilemma to surface: How long is too long? At what point does quantity override quality? This is another topic I will write to you about at a later date, but I have to get going.

So I hope this helps you understand where I come from when I speak of medical matters. "

Thank you, Dorothy, for your experientially-informed observations. One of the great pleasures of hosting oftwominds.com is receiving informed opinions from those actually working in complex fields. Want to understand today's U.S. Armed Forces? We have correspondents both active duty and retired to share their real-world knowledge. Want to understand the stock market's actions? We are fortunate to have professional traders as correspondents. And so on, in many fields of endeavor--not just in the U.S., but also in the U.K. and other nations as well.

So what Dorothy is suggesting is the pharmaceutical industry is responding not just to the goal of profits, but to the cultural demand for a pill solution. And if that pill causes unfortunate side effects, we have another pill for those symptoms, and another pill for the side-effects of that med, and so on down the wormhole.

One possible issue I have been pondering is the mindset of "cure." In the 20th century, terrible infectious agents such as polio were in fact "cured" by vaccines and anti-bacteriological medicines--penicillin, et. al. After those stunning successes, it was natural to apply that mindset to other diseases such as cancer and heart disease.

But alas, those diseases are mind-bogglingly complex. Infectious agents may be partly responsible for some cancers and heart disease, but the effects are subtle and the result of interactions with extremely complicated systems: the immune system being but one example.

In our usual human drive for a reductionist "solution" to complex problems, we have sought a "magic pill" or single medication to "cure" lifestyle and genetically-influenced diseases like diabetes, heart disease and cancer. In some rare instances, a medication or treatment (radiation, etc.) does in fact cure the condition. But more often than not, such hopes are dashed. As Dorothy notes, much of what is prescribed today is not a "cure" in the sense we once hoped for, but some agent to relieve the symptoms of disease.

In many other cases, medications are simply helping patients "hold the line": keep the tumor from growing any larger, maintain bone mass, etc. It is these incremental improvements, along with the control of infectious diseases, which have prolonged so many lives.

But what of the diseases we influence with our own behavior? As the ancient Chinese saying has it, "All disease comes through the mouth," i.e. what we eat. While this too is a reductionism to be treated warily, there is truth in it in terms of many lifestyle diseases--diseases of wealth and excess, in many cases.

Clearly, we need a medical system which encourages people to take responsibility for their own health as opposed to a paternalistic system in which a pill is provided (for a handsome profit) as a "solution" because it is profitable for the industry, essentially demanded by a legal system which places all the burdens on the caregivers and virtually none on the patient, and it's easy for the patient.

What kind of system would we have if doctors and nurses were legally able to tell a patient: "There's no pill we can give you to cure your condition. As far as the best medical science can ascertain, the cure is changing your lifestyle. To get well, you need to do X, Y and Z for six months and then we'll monitor your progress. It's really up to you."

Not every condition or disease has a lifestyle component, of course; but how many do? What kind of cultural and legal changes will enable the nation to wean itself from the notion that a pill will do the impossible without us having to lift a finger on our own behalf?

NOTE: I have returned to my desk after being away to assist my in-laws during a medical recuperation. I am sorry I have been unable to check email the past few days, and hope to reply to all correspondence within the next few days. Your patience is much appreciated.

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