Healers or Dealers?

Modern medicine has transformed the human experience, benefitting society in countless ways. The magnitude of the impact is hard to imagine for someone living in the 21st century United States.

But the healthcare system is not perfect. The pharmaceutical industry is a key player in modern medicine and, as a for-profit industry, it does not always act in the direct interests of consumers. Total spending on pharmaceutical promotion grew from $11.4 billion in 1996 to $29.9 billion in 2005. Predicted worldwide sales of these companies in 2018 reach $1.3 trillion.

But that might not be so impressive. After all, it is the world. But when you realize that 44.5% of those sales are made in North America... maybe it’s a little impressive.

High blood pressure, acid reflux, type II diabetes -- these are symptoms of a sick society, and we cannot necessarily blame companies for the rise in consumption of their respective drugs. In addition, pharmaceutical companies invest billions in the development and testing of new drugs. Working smoothly usually generates profit while the failure to do so tends to generate lawsuits.

But sometimes profit and efficacy do not fully align. There are some areas of business that are not suited to health care, and, upon closer examination, unsettling questions arise. Why do treatments need to be advertised? What happens when the best treatment for the patient only makes half the profit of a treatment that works only half as well? What if a treatment generates profit but can indirectly harm the patient?

Only in the United States and New Zealand can we enjoy being bombarded by heavily filtered actor portrayals promising that a pill can “fix it.” This is because we are the only two developed countries to have legalized direct-to-consumer-advertising, (DTCA) which is the ability of a pharmaceutical corporation to advertise their drugs to the general public.

Defenders of DTCA insist it can inform patients.  I would question that a 21st century citizen with serious symptoms and zero insight would be brought to epiphany via commercial. Google is available for anyone with concerns, and the power of suggestion is considerable. And while yes, WebMD might just tell everyone they have stage 4 cancer, the television is telling them Awesoma ® will make the world pretty and they will get to ride horses into the sunset while eating organic free-range berries (common side effects include thoughts of suicide and vomiting blood).

This is not an ideal system. DTCA affects many categories of pharmaceutical drug. Among the most clearly impacted is psychiatry, where diagnoses for less severe symptoms are quite nuanced and often left to general practitioners with little training in psychiatry. The rate at which general practitioners prescribe psychiatric medications has increased by 150% in the last 10 years, possibly in part due to DTCA. A 2005 study focused on the effects of DTCA found that those who ask for medication – for instance, a pill advertised in a specific commercial -- were more likely to be prescribed a drug, regardless of whether or not they met a clinical diagnosis.  According to Forbes, word of mouth has increased the off-label use of atypical antipsychotics such as Seroquil and Zyprexa as a sleeping aid and mood stabilizer. Both these drugs can cause tardive dyskinesia (uncontrollable and irreversible muscle movements), while Zyprexa can cause massive weight gain even in small doses. While drug companies cannot legally advertise off-label use, they have done so before and have also been accused of misrepresenting their drugs in sales. In addition psychiatric drugs are preferred to therapy by insurance companies for financial reasons. This can lead cases where doctors prescribe SSRIs or benzodiazepines to manage the symptoms of panic disorder, which responds equally well with longer lasting effects to cognitive behavioral therapy. While there are factors at play besides pharmaceutical companies, they play an important role via the means they use to push their treatments and their ability to influence research which insurance uses to consider which treatments to cover.  Independent studies have found pharmaceutical research to, at times, be biased towards positive results for their product.

And when it comes to indirectly harming patients coinciding with profit, 80% of heroin addicts in the US report starting with pills. Pharmaceutical companies are not only morally guilty on this account -- they have been found guilty in courts of law. Purdue Pharma marketed OxyContin as “non-addictive,” giving opioids a path into common usage. They also advertise heavily to doctors and lobby for the use of opioids. The “war on drugs” in this country never touched on the legal prescriptions, which are alarmingly easy to come by. When my little sister got her wisdom teeth out, she was handed a full bottle of hydrocodone (Vicodin, an opioid painkiller) with zero warnings. She “thought it was something like Motrin.” It came in the same bag as the Motrin. How many of us would figure that it is safe because the doctor prescribed it? We trust the white coat and orange bottle. And while many doctors have the best intentions, they are not omniscient or infallible. As the Russians say, trust but verify.

I doubt my sister’s dentist was plotting her downfall into the mire of heroin addiction. But what if it was an ongoing prescription for migraines and the delivery was just as careless? It suddenly becomes possible.

Prescription medication can be very confusing. The fact that it’s “medicine” makes it easy to trust the comforting glow of pharmaceutical advertisements. The average person doesn’t know the difference between amoxicillin and amoxapine, or levothyroxine and thiothixene, or hydroxyzine and doxycycline.  This letter scramble makes it easy to accept whatever the television or doctor might say. We are dependent on experts.

Fixing this problem would require massive infrastructure change, either in the industry itself or in the way it is regulated. Considering the divided political climate this is not likely to happen any time soon.  All we can do as patients is to make sure we are aware of the full risks of what we are prescribed. Because even if negative results are not our fault, they will be our problem.