Is Big Pharma evil? Doctors should share the blame

Despite representing only 4% of the world’s population, the United States accounted for almost 35% ($326 billion) of the global market for pharmaceutical drugs in 2012. Not surprisingly, the pharmaceutical industry’s business practices, considerable marketing budgets, and substantial profits are hotly debated as part of virtually every health policy discussion. But before addressing the possibility of transcendent evil in that industry, we should pose a more mundane yet critical question: Is our enormous investment in pharmaceutical drugs paying off?

Given the variability of drug prices and the lack of reliable, publicly available prescription data, the collective impact individual therapeutic classes have on their respective target diseases is difficult to determine with certainty. But by comparing prescription data from IMS Health with mortality data from the CDC for two separate years (2008 and 2011), one can gain at least some insight on the issue. And the tale that emerges from this rudimentary exercise is a cautionary one for both patients and physicians.

First, consider the impact of pharmaceuticals on diabetes, our 7th leading cause of mortality. In 2008, it was responsible for 2.9% (70,553) of all deaths. We spent $13.6 billion on the disease that year, writing 166 million prescriptions for things like injectable and oral hypoglycemics. By 2011, our spending on those drugs had increased by over 50% to $20.5 billion (173 million prescriptions), yet diabetes remained the 7th leading cause of death, again accounting for 2.9% (73,282) of all deaths.

Next, let’s look at cancer, the 2nd leading cause of death in this country. In 2008, it accounted for 23% (565,469) of all deaths, and we spent $19.7 billion on pharmacological interventions to combat malignancies. In 2011, however, cancer again caused 23% (575,313) of all deaths, despite spending $24 billion (an additional $4.3 billion) on pharmaceutical drugs.

Finally, let’s consider suicide (no pun intended), the 10th leading cause of death. In 2008, intentional self-harm was responsible for 1.5% (36,035) of all deaths. We spent $26 billion that year on mental health drugs including SSRIs, antipsychotics, and anxiolytics. Three years later, suicide again accounted for 1.5% (38,285) of all deaths, despite an additional $3.7 billion investment in those pharmaceuticals.

Admittedly, this type of aggregate analysis fails to establish causation, or even correlation, and ignores the performance and prices of individual drugs, the impact drugs have on outcomes other than death (e.g. quality of life), and the role these drugs play in a particular patient’s health. It also fails to control for many other variables that significantly affect outcomes, and the three-year span may be too short a time frame for any investment to “pay off.”

Despite their limited statistical significance, however, the data are quite intellectually significant. They help us understand that pharmaceuticals don’t cure all, that over-reliance on prescription drugs is quite possibly not only costly but also stunningly ineffective. They help us see that many of the clinical trials touted as “evidence” of a drug’s efficacy are poor indicators of the drug’s impact in real-world situations. Even with cardiovascular disease, where pharmaceutical drugs may have slightly improved aggregate mortality, the costs associated with exceedingly modest gains should give us pause.

Intuitively, spending billions of dollars on drugs that produce little or no improvement in mortality should generate considerable cognitive dissonance. Yet our country, more than any other, continues to exhibit an unquenchable thirst for drugs that produce lackluster results. The aspect of the pharmaceutical industry’s business model worthy of scrutiny, then, is not how often sales reps buy lunch for physicians (the Internet, social media, and DTC advertising have rendered patients a much more powerful influence on prescribing habits than industry lunches). Instead, value delivery should be our focus — how well the industry’s drugs perform in the real world relative to their cost, their ability to improve outcomes or quality of life.

Now, back to the original question: Is Big Pharma evil? Pharmaceutical companies are businesses, entities with a fiduciary responsibility to deliver the highest possible return for shareholders. That certainly doesn’t mean one should tolerate illegal or unethical business practices, but that industry does not exist in a vacuum. Given the medical profession’s inextricably interdependent relationship with the industry and the relative infrequency of blatant crime therein, it is disingenuous and counterproductive to label the entire industry “evil.” Pharmaceutical companies employ millions of Americans and deliver many drugs that work, drugs that actually do improve the lives of patients.

Expecting legislation alone to curb our country’s appetite for pharmaceutical drugs is unrealistic. Spending on pharmaceuticals has increased despite FDA marketing restrictions, and the costly trend began well before the industry was allowed to market directly to consumers. While instituting price controls or allowing the importation of drugs from other markets may control costs initially, it will do nothing to slow the increasing rate at which ineffective drugs are being consumed. The only way to drive real change is to align the interests of all stakeholders. And, as much as it pains me to add to an already full plate, physicians are the only ones capable of achieving this. But they need help.

Physicians have a fiduciary responsibility to patients, an obligation to advocate for them. And each prescription a physician writes delivers a powerful message to the market: “We want more of this; this is what our patients need.” Collectively, then, the threshold for prescribing a drug needs to be significantly higher than it currently is. Specifically, if a new drug does not offer a substantial health benefit over behavior modification or existing therapy, that drug should not be prescribed. If physicians simply stop prescribing medications with marginal or no benefit, the pharmaceutical industry will be forced to develop more efficacious drugs or face decreasing profits. We can blame Big Pharma all we want, but the truth is without physicians there is no market.

It’s also critical, however, that patients become increasingly aware of the limited benefits of, and significant risks associated with, most pharmaceutical drugs. As difficult as it is to do, they must accept that diet, exercise, and many other health behaviors, along with socioeconomic phenomena, are what truly determine health status and susceptibility to disease. Advances in molecular biology have elucidated the genetic basis of some diseases, but, for many of the most common illnesses, the aforementioned facts are indisputably true. So viewing office visits that don’t yield a prescription as failures is counterproductive, particularly if sustained, improved health is the goal.

Patients must understand that the number of diseases pharmaceutical drugs can actually “cure” is still exceedingly small. No pill can reverse all of the effects of unhealthy lifestyles or harsh socioeconomic realities. Despite what television ads often seem to imply, oral hypoglycemics don’t effectively emulate the effects of exercise, SSRI’s alone are no match for unemployment or child abuse, and chemotherapy can’t reverse the effects of smoking. And sadly, spending billions at the end of life often does nothing more than alleviate guilt, guilt that stems from the mistaken belief that drugs can effectively reverse death, that all death is unnatural. Regulation alone won’t change these misconceptions.

Marginally outperforming a placebo should by no means be sufficient motivation for physicians to prescribe a new drug, regardless of its price. And patients need help performing truly informed, realistic risk-benefit analyses for any proposed therapy. Moreover, when professional organizations release “evidence-based guidelines” that, in effect, lead millions of Americans to take prescription drugs offering little or no true health benefit, they only make matters worse. Until the prescription pad becomes more of a last resort and less of a foregone conclusion at every office visit, we’ll all continue to die expensive, “chemically modified,” but still unavoidable, deaths.

Luis Collar is a physician who blogs at Sapphire Equinox. He is the author of A Quiet Death.

Comments are moderated before they are published. Please read the comment policy.

  • NormRx

    “First, consider the impact of pharmaceuticals on diabetes, our 7th
    leading cause of mortality. In 2008, it was responsible for 2.9%
    (70,553) of all deaths. We spent $13.6 billion on the disease that year,
    writing 166 million prescriptions for things like injectable and oral
    hypoglycemics. By 2011, our spending on those drugs had increased by
    over 50% to $20.5 billion (173 million prescriptions), yet diabetes
    remained the 7th leading cause of death, again accounting for 2.9%
    (73,282) of all deaths.”

    Maybe, just maybe, the reason we are spending more money and not achieving any better results in diseases like diabetes is because we are treating people that do not need to be treated. Most of you remember when a BC under 140 was considered normal, then it dropped to 130 than 120 and now if one is between 100 and 120 they are pre-diabetic.
    We are lowering the threshold in treating other diseases as well, change the criteria and include more people, consequently we have seen an explosion in the number of people suffering from diabetes, hypertension, elevated cholesterol, autism, depression and ADHD.

    • NewMexicoRam

      Wrong.
      50% of the diseases attributable to diet would be improved if we just quit eating so much sugar.
      Seriously.

      • Luis Collar, M.D.

        Agree that diet / exercise are much more effective than drugs for many of our most common illnesses. Drugs do have a role (I’m not anti-drug therapy at all), but the numbers seem to imply that we are overly focused on treating surrogate markers of disease with pharmaceuticals rather than addressing patients and the disease itself. We rely too heavily on drugs as primary prevention. Thanks for commenting.

        • NormRx

          I’ve often said “if everyone would control their weight, exercise and eat a well balanced diet half of the drug companies, physicians and hospital would be out of business.”

          Excuse me it is time for my metformin and losartin. Well, as long as I am getting up I might as well grab a beer and a plate of nachos.

          • Patient Kit

            Which reminds me to throw another big player into this picture we’re talking about today — Big Food and it’s engineered addictive processed foods. Of course we all must take individual responsibility for what we eat, but the fact remains that Big Food has a financial stake as big as Big Pharma in keeping people unhealthy. Big Food sells us junk food that makes us sick and Big Pharma sells us medication to fix what the unhealthy food did to our bodies. It is ultimately within our power, individually, to resist and reject this. But there are some powerful forces in play.

          • querywoman

            It’s important to take your diabetes meds and eat at the same time each day. That’s the way my own body is trained.
            Nachos are a good mix of carbs, fat, and protein. Enjoy your sedating beer, one of my most detested substances.

          • hawkeyemd1

            Beer and nachos…now you’re talkin. Seriously, getting patients to make lifestyle changes isn’t easy, and it takes considerable time. The way the system is right now, that time isn’t always there, and the effort isn’t rewarded, or even respected.

          • Luis Collar, M.D.

            Great point. Prescribing a drug is not only easier for patients but also often easier for physicians. Discussing health behaviors is time consuming and often requires follow-up. The system isn’t set up to support those types of visits consistently.

          • Deceased MD

            I think that’s a central problem. They have taken the “care” out of healthcare and made it into a hard science. Medicine has recreated the doctor’s role to just prescribing and procedures.

            Especially as you have pointed out the lack of time given to see pts, faulty payment structures for pt education, are all additive to create this monstrosity called healthcare.

          • GeneDog

            As a scientist, I must disagree with part of your statement. Healthcare has in no way become a “hard science” as you state. Hard science implies hypothesis-testing and in my humble opinion, pharma companies are out to maximize profit (and they are willing to twist scientific data to do this). I am not saying that is a bad thing (I am not sure how I feel about it). But I definitely do not think they represent “hard science”.

          • Luis Collar, M.D.

            —I’ve often said “if everyone would control their weight, exercise and eat a well balanced diet half of the drug companies, physicians and hospital would be out of business.”—

            Well said.

    • rtpinfla

      There are plenty of studies backing up the use of drugs for ever lower thresholds. Glucose, blood pressure, lipids: You name it.
      Of course most, if not all, of those studies were funded by- you guessed it- the drug companies.

      • Luis Collar, M.D.

        That is also part of the problem. And that is why “evidence-based medicine” needs to be only one part of the equation when deciding on whether or not to prescribe a new drug. Although we seem to increasingly frown on anecdotal evidence, a physician that treats hundreds of diabetics in the real world is often in a better position to decide if a drug will be of real benefit (outcomes / quality of life, not just HbA1C) to her patients than isolated studies conducted under unrealistic study conditions that are not widely applicable. Thanks for contributing.

      • Suzi Q 38

        Makes sense.
        The pharmaceutical companies aren’t all bad.

        Who else would pay for all the the R and D plus studies?
        It all costs a “pile” of money that few companies have to spend. Some drugs are “duds,” and written off as a loss.

        Your point about lower thresholds for “numbers” sound valid.
        The drug companies will do whatever it takes to sell more and more of any drug.

        My favorite is that any given drug pro-ported to be excellent and “the best” before the patent runs out.
        When the very same drug turns generic and is cheap,
        this drug is no longer promoted at all.

        For this reason, I will admit that I like it when my physicians prescribe generics whenever possible.

        • Luis Collar, M.D.

          “My favorite is that any given drug pro-ported to be excellent and “the best” before the patent runs out. When the very same drug turns generic and is cheap, this drug is no longer promoted at all.”

          Very true. Most marketing is aimed at branded drugs to maximize profit while they still enjoy patent protection. That is also why drugs are often “reformulated,” or new indications for use are sought, in an effort to extend patents and further maximize profit. Once the patent runs out, margins tighten and marketing efforts decline significantly.

    • southerndoc1

      And there’s the role of pay for performance, which gives the doc a financial incentive to get the A1C down, no matter how many drugs it may take (or what side-effects they cause).

      • Luis Collar, M.D.

        Very true. Assessing quality of care based on disease markers such as HbA1C, LDL and others is a mistake (I’ve written about this in the past). Those numbers are used, in my opinion, simply because they are easily measurable, despite being a poor reflection of true quality of care and overall health status.

        • querywoman

          My endo was pleased with my 6.9 A1C the last time, although I thought I’d been running high.
          I’m not comfortable with a faster sugar less than 110.

          • Luis Collar, M.D.

            Hi QW… Thanks for commenting. Glad to hear your doc is pleased with where you are on controlling your blood sugar. Hope all is well.

          • Suzi Q 38

            Is 6.9 a good score for the A1c?
            My A1c was 5.4 and my AM fasting is about 88 to 100.
            Is that O.K.?
            I test my blood sugar about once a month.
            My doctor told me to quit doing that, as he was no longer concerned about it, but since I have a monitor, I do it anyway. This way, I know what foods I do not process well.
            Once I ate a whole tamale for dinner and my blood sugar was fairly high the next morning.

          • querywoman

            It’s a good idea to check on your own once a month, regardless of what your doc says. Many diabetics now get dx’d on a friend’s meter.
            You have very good blood sugar. A lot of diabetes can’t function with that low of a fasting sugar.
            On insulin, the docs were happy when my A1C was between 7.0 and 7.5.
            Victoza has brought a lot of us down under 7.0. I thought mine had climbed back up to over 7.0, but it hadn’t. He was pleased with 6.9.
            I told him I had missed too many nights. Sometimes I crash out without it. I can skip Victoza one night, but not two. I knew that I had done without it two nights.
            I also was shooting a little less than 12 due to an insurance payment problem.
            It’s hard for me to function, get moving, with a fasting sugar under 110.
            My sugars don’t fluctuate as much on Victoza as on insulin. On insulin it’s easy to go between 50 and 400 in a day. That’s hard on the body.

      • guest

        Let’s not discount that lifestyle changes are free! But, they’re not an easy fix and that’s what most Americans want unfortunately.

        • Luis Collar, M.D.

          Very true. Part of it is certainly cultural (quick fix mentality), but part of it may also be socioeconomic. For example, with families working harder than ever in the context of declining real wages and other market pressures, finding time to exercise, educate oneself on healthy eating habits, etc.. may be getting harder, despite the widespread dissemination of health information via the internet / social media. Just a thought. Much easier to take a pill and head to work than it is to get to the gym.

    • Luis Collar, M.D.

      Great points. The two phenomena are linked, in my opinion. Importantly, whether we look at oral hypoglycemics or statins, BC or LDL, to name just a couple, the focus on surrogate markers of disease is, in many cases, not producing the desired results: reduced mortality and / or improved quality of life.

    • querywoman

      Diabetes has only been a treatable illness about 100 years ago. Has the average age at which diabetics are dying increased? If the age has increased, the 7% figure is not so important.

      I am considered a very compliant diabetic. I got off large doses off insulin by using Victoza. My doctor is amazed. My father’s last surviving sibling, his sister, just celebrated her 97th birthday and has been diabetic and frail for years. I assume she has complied well with some of the older diabetes drugs.
      I lost my own brother to diabetes at age 55. He was a noncompliant diabetic who had three amputations over 10 years, still wouldn’t take his meds, then had strokes and heart attacks and lived almost 2 1/2 years in a nursing home after that. Most people would have died much sooner.
      Most diabetics are probably somewhere in between my compliant aunt and me and my noncompliant brother. Do they comply with their meds well? Many people don’t. Do they check their blood sugar regularly and make adjustments?
      One night I had a friend with HIV, in his mid-30s, with me in my apartment. He was already pretty drunk or high. He kept asking me to do this or that when I was trying to check my blood sugar, do meds, and eat appropriately. I’m used to being alone for my rituals.

      The most important thing for all diabetics is to follow a schedule, use the glucometer, eat appropriately and regularly. The new machine, the glucometer, gives us the ability to treat ourselves that people with other illnesses don’t have.

      I tried to explain this to him when he was more sober. He said he should be on a schedule also. Ha! That’s what I thought.

      • Luis Collar, M.D.

        Very sorry to hear about your brother, QW. Glad to hear you seem to be knowledgeable regarding your condition and what works best for you. Those two things are critically important for patients with any chronic illness.

        • querywoman

          Dear Luis Collar: you are kind and one of my fave doctors here. My brother’s struggle ended a few years ago. I could go on about here, but I’ll toss in one thing appropriate here for this thread.
          I told him once that, “insulin wouldn’t have been invented (isolated) if the natural stuff cured diabetes.”
          He screamed at me, “Not necessarily.”
          Wasted breath and words on my part, and I knew it before I opened my mouth and shot it out.

          • Luis Collar, M.D.

            Thank you for the kind words, QW. Health behaviors are tough to change. I’m a physician, and I would be lying if I said my diet, exercise habits and other health behaviors were beyond reproach. I do my best, but I’m certainly far from perfect, even though I should know better.

          • querywoman

            When I threw in my bit about telling him the importance of insulin’s discovery was that medicines do help certain conditions.
            He thought he could manage it with diet and herbs. His diet was terrible.
            He used echinachea for his diabetes, and that’s not an appropriate herb. I do some natural stuff, but I’m not doing echinachea. I don’t want to lose my feet.
            A friend just recently suggested some dollar store treatment with echinachea for an upper respiratory infection, and I told him I would not use that because of my brother.
            Then I researched echinachea, and diabetes are advised not use this that.
            Surely you will understand this. I think I would have been pleased if my brother had gone to an American version of a witch doctor, at least, cause then maybe he would have listened to someone else and stopped trying to do it all himself!

    • hawkeyemd1

      You can’t treat a fever if you don’t take someone’s temperature. And you can’t prescribe (or sell) a drug, unless you have “proof” there’s an illness. lol

  • John C. Key MD

    Yes, Big Pharma is evil–any industry that produces a product whose per-pill cost is prohibitive to the working poor cannot be considered altruistic; further, despite garish direct-to-consumer ads to the contrary, most recent offerings from Big Pharma offer only small incremental improvements over well-established “old” generics.

    You are correct in saying that this doesn’t let doctors off the hook. We, after all, are the prescribers, and it remains (usually) our choice as to what drug to use and how to use it. Talking patients out of a drug can be quite difficult: it’s recently been cited as a reason for failure in functional medicine practices that many patients don’t WANT to be treated with foods–they want their handful of pills, dammit!

    So great. Thus we have another multifactorial impasse. But Big Pharma remains the 800 pound gorilla of the problem.

    • Patient Kit

      I agree that Big Pharma is evil. I don’t need to look any further than the growing number of Americans who cannot afford the cancer drug treatments they need because the price of those chemo drugs is so high. The health insurance companies are no angels either as they move more and more of the cost of those expensive drugs onto the backs of cancer patients. It is obscene that Americans suffering from cancer are not getting treatment because they can’t afford it.

      • Deceased MD

        Actually what is interesting, depending on what kind of cancer is being treated, many respond to generics that have been around for years and can be very effective and are fairly cheap. Not sure if you are aware that there is a shortage of these generic drugs. That is a huge problem that most cancer centers complain about quite a bit these days. that is a crime.

        • Luis Collar, M.D.

          Agreed. See above response to PatientKit. Thanks for the insight.

      • Luis Collar, M.D.

        Great point on insurance industry complicity in all this. Additionally, the other side of the issue involves patient education as to the real benefits of those cancer treatments to begin with. There have been great successes in cancer treatment, but there have been complete failures as well. The system is still not very good at truly distinguishing the former from the latter. This often leads to false hope, unrealistic expectations, and misallocation of resources.

      • hawkeyemd1

        In many cases, we are forced to prescribe additional drugs (some more expensive than the alternative) because insurance companies won’t pay for the single-drug therapy we initially prescribed. Seems silly on their part (actually forcing less effective, more expensive multi-drug therapy) but it really happens.

        • Luis Collar, M.D.

          Many insurance company policies seem “silly,” but, unfortunately, I think a more accurate word might be sad, or intrusive. Pharmacology is difficult enough for physicians and patients to grasp as it is; insurance companies should really not be involved in that process at all. Sadly, as you stated, they are often involved. Ideally, though, patients and physicians should be making these decisions, not third party payors. Thanks for the comments.

          • GeneDog

            The insurance industry is just that: an industry that is driven by profit. So although I don’t agree with many of their policies, it makes sense they will set policy that will maximize their profits.

          • Luis Collar, M.D.

            That is precisely why physicians and patients (the market) both need to demand more from the industry by making informed decisions. Not prescribing or consuming new drugs that are ineffective or no more effective than health behavior modification / existing therapy would send a powerful financial message. Regulatory oversight alone is not enough. Thanks for the comments.

    • Luis Collar, M.D.

      I agree with the majority of your comments. Big Pharma is no more evil or altruistic than any other industry, though. They operate somewhere in the middle, as most industries do, between “evil” and “altruism.” They are driven by profit, not good, evil, or any other transcendent ideal. The goal of the article was not to alleviate the industry of any responsibility (indeed, they should be regulated and their business practices should be scrutinized). It simply sought to point out that pharmaceutical companies do not operate in isolation. Unless physicians raise the bar on what drugs they are willing to prescribe and patients become increasingly educated as to the real benefits / limitations / dangers of pharmacological intervention, there will be no financial repercussions associated with continuing to produce ineffective / costly drugs. Regulation aside, the only way to align interests is for ineffective drugs to fail. Physicians, patients, and professional organizations all need to deliver a message: unless a drug truly improves outcomes or quality of life, that drug will not be prescribed, become part of a guideline, or be consumed. You are quite correct, though, regarding the pressure physicians face to prescribe these drugs, pressure created by patients, guidelines, fear of malpractice, and the pharma industry itself. The problem is indeed multifactorial but, short of legislation, only demanding better products through judicious use of the prescription pad can help solve the issue. Thanks for commenting.

      • querywoman

        You are right about Big Pharma being no more good or evil than any other industry. Just like there are good and bad doctors and in-betweens, always and forever.

        • Luis Collar, M.D.

          Precisely. Human nature is what governs these things. No company, no system, no industry, no political party can be better than the people that create and manage it. There is good and bad in all of those entities because that is where we are collectively as people at this point in our evolution. In any business or profession there is good and bad; trying to realistically address the bad while supporting the good seems to be the key to progress.

          • hawkeyemd1

            Now that is the truest thing I’ve read in a long time.

          • Luis Collar, M.D.

            Thanks. I appreciate the feedback.

      • Deceased MD

        Very well said and lovely article Dr. Collar. I remember the first time I became aware of this issue. I met a pharm rep years ago promoting a new product. To my surprise and disgust, all they were doing was repackaging buproprion. They changed the dosing to a once a day pill and changed the inert compound it binds to and walla there was their “new” “innovative” costly product that made no improvement for anyone but their own wallets.

        • Luis Collar, M.D.

          Thanks, DeceasedMD. That’s definitely part of the problem. True pharmacological innovation that improves mortality / quality of life should be rewarded. However, the market should see to it, whenever possible, that ineffective drugs, or drugs that are little more than expensive variations of cheaper, existing drugs, fail (many of these, as you correctly assert, are almost identical molecules with virtually no improvement in outcomes in trials).

  • Deceased MD

    I think you have a point, that people have a sort of oral dependence on drugs if you will to solve their problems, many things that cannot really be solved with drugs. ADHD drugs are a great example. Numerous articles tell us they are overprescribed and overdiagnosed. Big Pharma has done a bang up job of manipulating the public and doctors to prescribe and now here we are. Many students buy them to help study. the list goes on. but to address say the behavioral problems that are misinterpreted often as ADHD would require more psychosocial treatment and that ain’t gonna happen.
    Also Big Pharma has rewritten antitrust laws to the point where needed previously cheap generic drugs such as for gout and asthma are cost prohibitive for many.
    But the public plays a role by demanding these drugs to solve all illness, despite their often limitations.( and so do MD’s as you rightfully point out.)
    Compound pharmacies are a great gimmick as well. They are not FDA regulated: thus the whole fungal in the injectable steroid debacle caused much morbidity and mortality. I heard one pt tell me about a compound pharmacist that wanted to charge $300 for a 30g tube of cream that was definitely cheap to make. The gimmick was the pharmacist was not willing to make a larger tube of 120 grams. So his solution was billing the insurance every 5 days and making 30 grams at a time costing the insurance thousands for a rather cheap compound cream which minimally helped the pt. The value is just not there.

    • NormRx

      Hi Deceased MD. You state “Also Big Pharma has rewritten antitrust laws to the point where needed
      previously cheap generic drugs such as for gout and asthma are cost
      prohibitive for many.”

      I may be wrong, but I though that it was the FDA that wanted studies done on colchicine to demonstrate safety and efficacy, this for a drug that has been around since Moby Dick was a minnow. Takeda pharmaceuticals took it upon themselves to do the necessary studies and as a reward the FDA gave them exclusivity to market this drug, which they did after jacking up the price. In my opinion the problem lies with the FDA not Takeda, what next, doing safety and efficacy studies on aspirin? If I am wrong on this please correct me.

      • Deceased MD

        haha you are so funny. You are right and know more details than I on the colchicine.

        But I was referring for example, to lipitor. After the patent expired, Pfizer was PAYING off the generic competitor NOT to produce lipitor. So for at least a year or 2 after the patent expired, the only thing available was the expensive brand! All made LEGAL by the drug company tweaking the antitrust laws. In essence they created a monopoly during that time by paying off the competitor.

        • Suzi Q 38

          You are so right. Pfizer does what is needed to make money. Ethics is not one of their strongpoints.

          Before Tijuana became a dangerous place to visit, we used to get the cheaper versions of any drug at one of their pharmacies. No prescription required.

          Maybe it can be bought online from a company in Mexico or Canada.

    • Patient Kit

      I don’t think it’s so much an oral dependence on drugs but more like a mindset of doing the easiest thing and looking for something that will give them results without having to do anything (but swallow a pill). People seem to want a magic pill to solve every problem. It’s the “diet pill” mentality of wanting to lose weight by taking a pill instead of having to actually exercise and eat healthy and less. Patients want the easy fix that they think pills are. And, I guess, doctors cave in to prescribing unnecessary medication because it’s less time consuming than explaining why it isn’t necessary. So, patients and doctors are both often doing the easiest thing when it comes to medication. And it’s win/win/ka-ching for Big Pharma.

      • Luis Collar, M.D.

        That is certainly part of it. The issue certainly involves pharmaceutical industry marketing, but it also involves much more than that. Patient expectations / education; physician pressure to achieve quality metrics, fear of malpractice for not following “guidelines,” fear of not meeting patient expectations for a prescription, limited time to see patients and address true health behaviors / provide in depth information; academic pressure to publish or perish which leads to “guidelines” of questionable real-world utility; lack of transparency on drug prices which make cost vs. quality difficult to assess on the fly; a mistaken focus on controlling surrogate markers of disease rather than outcomes and quality of life; socioeconomic phenomena (e.g. unemployment, fast food, cost of living, low wages); a belief that science is ahead of where it actually is and is capable of healing all, even reversing health behaviors, all contribute to the problem. Thanks for the thoughtful comments.

      • Deceased MD

        Like the win win ka- ching part. LOL

    • Luis Collar, M.D.

      All great points. That’s why the goal of the article was simply to point out that drugs are not always as effective as one is led to believe and the increasing rate at which ineffective drugs are being consumed is a difficult problem to address in isolation. The pharmaceutical industry bears some of the responsibility, sure. But physicians and patients also need to adjust their expectations and modify certain habits if the problem is to be truly addressed. As long as patients are not informed of their limitations / dangers and physicians continue to prescribe them, pharmaceutical companies will respond to market demand and produce more of the same. Patient education and true physician autonomy are key to solving the problem.

  • Patient Kit

    Roughly half of antibiotics prescriptions in the US are said to be unnecessary because they are written for and sold to patients with viral-caused colds and flus. That’s a big unnecessary chunk of money spent in the US healthcare system, not to mention a factor in the rise of antibiotic-resistant bacteria. Why is this so rampant?

    I realize that Big Pharma wants to sell those antibiotics and that patients ask for them. But every one of those scripts has to be written by a doctor who knows they are unnecessary. Why?

    • NewMexicoRam

      Malpractice lawsuits.

      • Patient Kit

        Doctors fear being sued if they don’t prescribe antibiotics for colds and flus? Really? I totally understand the threat of malpractice suits in general that doctors live under and I empathize with that. I can see how it leads to the ordering of unnecessary tests. But I don’t see how it leads to all the unnecessary antibiotics being prescribed. Are you saying docs write them just in case it’s not a virus?

        • GeneDog

          I think it makes people “feel” like something is being done to treat the illness. Can doctors prescribe a placebo and tell the patient it is a real drug? I assume it is not legal. Does anyone here know?

          • Patient Kit

            So doctors give their patients unnecessary Rxs to give those patients the illusion that something is being done? We’re not talking about this happening occasionally. We’re talking about half the Rxs being written for antibiotics in the US being unnecessary. That is not harmless doctor behavior. For starters, by doing that, doctors have miseducated a huge chunk of the US population to believe that viruses can be treated with antibiotics. Kind of hypocritical to see all the handwringing about those misinformed about vaccines, when it’s largely doctors who have taught people to misuse antibiotics. To make them feel treated? I’m sorry but I’m just having a hard time grasping why doctors do this. We go to doctors for treatment and advice because doctors know a lot more than we do about medicine. And then we get massively prescribed unnecessary medicine because we want it? More trust in doctors down the drain. Like I said, it’s not harmless prescribing.. And good luck trying to undo this widespread misinformation.

          • Luis Collar, M.D.

            Again, great point, PK. That’s one of the reasons I wrote this piece. The pharmaceutical industry clearly bears some of the responsibility. But unless physicians and patients both (in their own way) do their part, our national “addiction” to prescription drugs will continue to worsen.

      • querywoman

        Nah! Malpractice isn’t that common. Doctors write them because people want them.

        • Luis Collar, M.D.

          Valid point, QW. Prescribing habits are dependent on a multitude of things. Addressing any one of those in isolation won’t lead to significant change (in areas where change is needed, that is).

        • NewMexicoRam

          It’s all part of the fear culture.

          • querywoman

            Overprescribing antibiotics is easy. Doctors are practicing slightly “older” medicine. In the late 1950s and throughout the 1960s, our family doctor gave us a penicillin shot for everything. I hated shots, but as a kid, I wondered if it was always necessary.
            Now doctors are dealing with antibiotic resistance. These doctors may have been raised, as I was, getting antibiotics for everything and patients who want them.
            Since I am on disability. I can sleep some illnesses off now. When I worked, I needed mor antibiotics to get me on my feet.
            I am a Christian, but have done a lot of yoga and studied Hinduism some. Yoga is about balance. We don’t know the right balance of antibiotics to infections.

          • GeneDog

            I agree NewMexicoRam. Humans have this weird inherent need to always be afraid of something. It is a shame that there are some that capitalize on that fear.

  • southerndoc1

    Like the case of colchicine (on the market since 1833)?

    “URL Pharma then (2009) raised the price per tablet from $0.09 to $4.85 and sued to remove other versions from the market, increasing annual costs for the drug to U.S. state Medicaid programs from $1 million to $50 million.”

    Yeah, I’ll take the blame for that.

    • NormRx

      Southerndoc1–I believe the blame for the increase in prices on colchicine goes to the FDA, they were the ones that removed colchicine from the market and required safety and efficacy studies for the drug to be approved. Check out this link.

      http://www.hcplive.com/articles/Why-Is-Colchicine-So-Expensive-Now

      • southerndoc1

        Agree that the FDA was definitely proposing a solution in search of a problem. Maybe they should pull aspirin from the market.

        • JPedersenB

          Actually my late father (a physician) told me that if aspirin was a “new” drug that it would never be approved….

          • querywoman

            I’ve heard that umpteen times. I’ve got some hydrocodone, which I use sparingly. So I guess I’m not interesting in raising a poppy plant and getting my own.
            I make wine, but don’t drink it much. I use it in cooking more.
            I could get some plants and make herbal teas, but I’m not really interested. I do use essential oils for healing some, but someone else did all the hard work already.
            I suppose licensing and regulating medicines is culturally new.

      • rtpinfla

        I’d bet my next paycheck that there was a back room meeting where URL convinced the FDA that it was a good idea to require studies on Colchicine knowing they’d benefit. It doesn’t excuse the FDA but I sincerely doubt that they went looking for a problem without some lobbying. If Bayer aspirin could do the same thing I they would do it without blinking an eye.

  • Luis Collar, M.D.

    Great point. I think the exact opposite is true. Lack of awareness is the status quo right now. Again, many drugs are great and worthy of prescribing. But spending billions of dollars on drugs that produce lackluster results, while simultaneously carrying significant health risks (many of which, in all honesty, are NOT KNOWN), is a real problem. And the issue is much more than a financial one: How often are patients being given false hope? What will be the long-term effects of placing millions of Americans on drugs as primary prevention, drugs that often cause more problems than they solve? Where will the true motivation for improved R & D by the pharmaceutical industry come from when relatively ineffective / costly drugs are prescribed with such frequency? Thanks for the comments.

    • Patient Kit

      Re “drugs that produce lackluster results while simultaneously carrying significant health risks”, shouldn’t that risk/benefit analysis that should be part of both doctors’ and patients’ decision-making process (ideally together) rule out prescribing/taking some of these drugs?

      Most recent example of that for me, personally, was the decision not to do chemo after successful surgery for early stage ovarian cancer, which turned out to be stage 1A. I initially was terrified and wrongly assumed that all cancer patients need chemo “just to be sure”. My awesome GYN ONC took the time to calmly and clearly answer all my questions and explain his (and the hospital’s Tumor Board’s) reasoning for believing that chemo was unnecessary. We talked about the stage, grade and type of tumor and how good my chances already were and about how harmful and serious chemo side effects can be and how, in my case, chemo would not improve my already good chances against the cancer but could make me very sick. He made me really understand and the decision was made not to do chemo. At the same time, I understand that there are no guarantees and that the cancer could recur. That’s why I see him for follow up monitoring every 3 months. But if it does recur, I’m not going to sue him. He won my trust with his skill, compassion and communication. And I didn’t put my body through serious harmful drugs for no benefit.

      • Luis Collar, M.D.

        PK, sorry you’ve had to deal with such a difficult illness, but I’m very glad you seem to be doing well. It is really great to hear how well informed you were regarding treatment options. To answer your question, yes, patients and physicians need to consistently discuss benefits vs. risk together, but, unfortunately, that doesn’t always happen for several reasons. If it did, more often than not, those drugs would, in fact, not be prescribed or consumed. Thanks for the comments, and I sincerely wish you the best.

        • Patient Kit

          Thank you. All things considered, I do realize what a lucky woman I am, given how often OC is found too late. I’m coming up on my one-year anniversary from dx/surgery soon and feeling good and energetic. I swim a mile 5x a week and am on my way to the Y now. I admit that I am addicted to swimming. Initially, the dx was terrifying. But I lived through 9/11 in NYC, which was also terrifying but I.quickly moved on to live my life here without constant fear. I think I’ve quarantined my cancer fear into the same place I put my fear of terrorism/violence. Life is too precious to live in constant fear and perspective is a wonderful thing. Good doctors are wonderful things too and I’m lucky to have some. I’m also very happy that I discovered this wonderful blog site recently where doctors and patients have the opportunity to talk about things that concern us both and to get better handles on each others’ perspectives. We really need to stay on the same side.

          • Luis Collar, M.D.

            Outstanding comments… So happy you are doing that well… (Incidentally, I was in my office building just across the river from Manhattan in NJ on 9/11, and I watched the second tower come down from my window as it happened. Very traumatic even for me, and I didn’t lose anyone.) And couldn’t agree more on the importance of what Kevin has created here. Thank you so much for sharing your story.

  • Curtiss Mull M.D.

    As a surgeon who tells his patients that all drugs are poisons or potential poisons, I am amazed at the numbers of medicines my older fracture patients take. Some of these must contribute to their falls, while many of them cause serious side effects. Our responsibility should be too cause no harm. Recall in the 80s when we were told we were under treating pain? As a result we have created the worst legal drug epidemic ever seen. We need to better counsel patients, not just send them home with a new script or surgical scar

    • Luis Collar, M.D.

      Thank you very much for sharing your thoughts. Could not agree with you more.

      • GeneDog

        My Mom was on 8 different prescriptions when she died. It was initially 11 but we discovered she was prescribed the generic and the name brand by the same doctor as separate prescriptions and she was taking them both thinking they were unique meds. I am not blaming the doctor entirely, but docs need to be more aware of their older (more senile) patients drug routines.

        • Luis Collar, M.D.

          Very sorry to hear about your mom, GD. Polypharmacy is dangerous for a number of reasons, and I agree physicians need to exercise great caution when prescribing new medications for, or reconciling medication lists with, their elderly patients. Sometimes it can be beneficial, and even necessary, to discuss medications with a patient’s family members or other caretakers to ensure they are taken correctly as well. It is a tough issue. Thank you for sharing your story.

    • querywoman

      An honest doc! They are poisons. Too much water or salt can also kill.
      Insulin is safe and wonderful in the correct dose, but an easily kill.

  • Deceased MD

    I think they’re all gaming the system and getting away with it.

  • hawkeyemd1

    Another great article. Patient education is critical. As you state in the piece, many patients feel like an encounter with their physician was a failure if nothing is prescribed. I think that part of it is just a societal issue that at this point will be very difficult to reverse.

    • Luis Collar, M.D.

      Thank you for the feedback. I really appreciate it.

      • hawkeyemd1

        You are quite welcome. Great job on this piece.

  • hawkeyemd1

    Put another way, they are conditioned by the system to not see it.

  • hawkeyemd1

    One way or another, they all do it. Another common practice is to extend patents by setting up trials to add new indications for use.

  • GeneDog

    One of my friends is a chemist for a pharma company and he said his company has hundreds of developed antibiotics that they have literally shelved with no plans for distribution, marketing, etc. Why? Because an antibiotic is something to be taken only during a bacterial infection and not over the course of a person’s life…in other words, there is no money to be made.

    • NormRx

      There is no doubt more money can be made with maintenance drugs than drugs that are only taken occasionally. The very best drugs that a company can come out with are lifestyle drugs. Drugs that grow hair, drugs for impotence and weight loss drugs there is a tremendous backlash on expensive lifesaving drugs. But, if it cost thirty dollars to get a woody nobody care.

  • querywoman

    A doctor told me once that pharmacies make more money off generic drugs.

    • Luis Collar, M.D.

      Because of how the industry is organized, drug prices and profit distribution (between manufacturers, PBMs, pharmacies, etc.) are hard to nail down. Here is an overview of how these are all connected. I found it informative, so I thought I’d pass it along.

      http://kff.org/other/report/follow-the-pill-understanding-the-u-s/

      • querywoman

        Wow! G00d d0ktor, that’s some heavy duty reading. Perhaps in a few days!
        Even if the $4 to $10 meds are almost pure profit, they are still not much money. But they do bring in business to the pharmacies.
        Wonder how much each pharmacy makes off my $600 Victoza, for which the drug companies and the patients pay plenty.
        I have come to believe mail order pharmacies are a racket. I had to convince both my deceased bio mama and my surrogate mama that they could refuse to use their insurance at a local pharmacy and get 90 day meds for $10 instead of the $25 their mail order pharmacies wanted for certain cheap meds.

        • Luis Collar, M.D.

          Great points. Unfortunate but true that, given the variability of drug prices and PBM / large retail chain deals, patients have to “shop around” for deals on prescription drugs (generic or branded). Many often overpay because the process is overly complicated and they aren’t aware of available programs or discounts.