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Arterial Disease

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A Bias Toward Drug Prescription

There are deep and fundamental problems with drug prescriptions. The problems are located in five groups; the producers, the prescribers, the dispensers, the users and the payers. Drug users are essentially naive and gullible and assume that the other groups have their interests first and foremost in mind. The producers have profit as the main motive. The prescribers are dependent on the drug producers and are remarkably obedient to the producers marketing commands. Some have argued the drug producers now own medicine and simply compete with each other for their market share.

A bias toward drug prescription is endemic in medicine. In Canada, there are 5,000 prescription drugs for sale. In the year 2000 in the United States, 173 million people filled 2.2 billion outpatient prescriptions, accounting for $103 billion in expenditures. Each year in Canada and the USA the money spent on prescription drugs increases. Total drug costs in Canada in 1985 were 3.8 billion, 9.5% of medical care cost. In 2005, drug costs rose to 24.8 billion, 17.5% of total medical care costs. Drug costs continue to rise.

The World Health Organization's Model List of Essential Drugs has 350 entries. The WHO defines essential medicines as those drugs that "satisfy the priority health care needs of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness."Even if you agree with the WHO drug list, most of the drugs are special purpose agents that have limited applicability. I have long thought that a physician could serve his or her patients best with a list of about 20 well-chosen, and well-understood drugs. As it now stands, primary care physicians prescribe 80% of the 5000 drugs available and understand less than 20 in any detail. Many patients take 6 to 10 prescription drugs daily; the number of drugs increases with age.

The medical management of arterial disease, for example, provides major markets for a variety of expensive prescription drugs. The scientific evidence that links high blood pressure, heart attacks, strokes, Alzheimer’s disease, diabetes 2 and obesity grows stronger everyday. These are inter-connected diseases caused by eating too much of the wrong food and exercising too little. In Canada, a public financed health care system is too costly and is deteriorating rapidly as budget cuts reduce resources available. The tidal wave of food-related disease threatens to bankrupt health care systems if existing methods of diagnosis and treatment continue to be used.

A bewildering number of drugs and drug combinations have appeared for the treatment arterial disease. The battle for market share is fought among the drug producers with double blind controlled studies that compare drugs to placebo and drugs to one another. The studies are designed to impress the prescribers and to provide good pubic relations thru press releases to the users. Despite years of research, thousands of publications, hundreds of conferences and billions of dollars spent; there is still doubt about the best way to manage arterial diseases. The drug industry prefers that medical doctors only think in terms of drug therapy and the producers aggressively market their newest and most expensive drugs. Payers should prefer that medical doctors prescribe older, less expensive generic drugs. Smart patients prefer to change their diet, lose weight and exercise, rather than become drug users. 

You could argue that the exclusive interest in drug treatments in medical studies is a gigantic error. As long as physicians see themselves as drug prescribers and not problem solvers, most people will have to look elsewhere for a solution to heart attacks, heart failure and strokes. The real solution is to remove the causes of arterial disease. The Heart and Stroke Foundation of Canada stated that three quarters of Canadians with high blood pressure could throw their medications away if they took up good eating and exercise habits. A 10-pound drop in weight can reduce blood pressure as effectively as a blood pressure pill as can exercising for 45 minutes three or four times a week. A healthy diet high in fruits and vegetables, reduced salt intake, and exercise are all keys steps to avoiding cardiovascular disease.

Writing in the New York Times, Harris reported that drug company payments to physicians to prescribe drugs is under investigation by federal prosecutors in Boston ( USA)as part of a broad government crackdown on the drug industry's marketing tactics. The pharmaceutical business has grown in from a small group of companies peddling a few antibiotics and anti-anxiety remedies to a $400 billion bemoth that is among the most profitable industries on earth. Harris stated: “ At the heart of the various investigations into drug industry marketing is the question of whether drug companies are persuading doctors — often through payoffs — to prescribe drugs that patients do not need or should not use or for which there may be cheaper alternatives. Investigators are also seeking to determine whether the companies are manipulating prices to cheat the federal Medicaid and Medicare health programs. Most of the big drug companies, meanwhile, are also grappling with a welter of suits filed by state attorneys general, industry whistle-blowers and patient-rights groups over similar accusations..., most drug makers now spend twice as much marketing medicines as they do researching them. Their sales teams have changed from a scattering of semi retired pharmacists to armies of young women and men who shower physicians with attention, food and - until the drug industry recently agreed to end the practice - expensive gifts, just to get two to three minutes to pitch their wares. A code of conduct adopted in 1990 by the American Medical Association suggests that doctors should not accept any gift worth more than $100, but the guidelines are widely ignored… legal scrutiny will intensify once the new Medicare drug benefit takes full effect in 2006, the government will pay for almost half of all medicines sold in the nation....As states begin to require that drug companies disclose their payments to doctors for lectures and other services, a pattern has emerged: psychiatrists earn more money from drug makers than doctors in any other specialty. How this money may be influencing psychiatrists and other doctors has become one of the most contentious issues in health care. For instance, the more psychiatrists have earned from drug makers, the more they have prescribed a new class of powerful medicines known as atypical antipsychotics to children, for whom the drugs are especially risky and mostly unapproved. Drug makers generally spend twice as much to market drugs as they do to research them. ” (New York Times June 2007)

George Lundberg, Editor of MedGenMed states that the results of studies, even the existence, of huge numbers of clinical trials are unavailable, not only to the public but to doctors who care for patients, especially if the results of the trials are adverse or negative to the sponsors' products. A US survey found that 40% of persons aged 65 years or older take five or more different drugs/week, with 12% taking 10 or more. Overuse and misuse of drugs have all been linked to serious health problems, disabilities, hospitalizations, and death. Preventable drug-related morbidity is the fifth most costly health condition. In 2000, the United States spent $133 billion on drugs and an estimated $177 billion managing drug-related problems.

The Statins, cholesterol lowering drugs, are among the most widely prescribed and most profitable drugs on the market. Numerous studies champion their benefits. As time passes, more studies and more clinical experience with Statin drugs has tempered enthusiasm, Mandrola wrote a short and insightful review of statin use in 2014:" My mind is changing about statins. I'm growing increasingly worried about the irrational exuberance over these drugs, especially when used for prevention of heart disease that is yet to happen... When statins are used in low-risk patients without heart disease (primary prevention) there is no mortality benefit. That's right. Your chances of dying are the same on or off the drug, regardless of how much the statin lowers the cholesterol level. When statins are used for primary prevention, there is a small lowering of future vascular events (stroke/heart attack) over five to 10 years. The absolute risk reduction is in the range of seven per 1000. That means you have to treat 140 patients with a statin (for five years) to prevent one event. Or this: for 99.3% of statin-treated patients, there is no benefit. I like to call this the PSR, or percent same result... There is also general agreement that statins increase the risk of developing diabetes, especially in women, and that risk is about the same as preventing a stroke or heart attack, approximately 1%...There is great debate about the incidence of statin side effects, such as muscle pain, cognitive issues, decreased energy, sexual problems, and kidney and liver injury, among others... When you step back and look at medications as chemical modifiers of cellular processes in complex biologic systems like our body, it's easy to understand that health comes not from pills. Not even statins. "

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Listen to Drugs versus removing the cause of disease.



Posted Online Medscape General Medicine 3/4/2005 http://www.medscape.com

Heart and Stroke Foundation of Canada Press Releases - New Canadian Blood Pressure Guidelines support Lifestyle Change as The New ‘Drug’ 3/9/2004 Online http://ww2.heartandstroke.ca

Harris G. As Doctors Write Prescriptions, Drug Company Writes a Check. N. Y. Times. June 27, 2004.

Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, Mitchell AA. Recent patterns of medication use in the ambulatory adult population of the United States. The Slone survey. JAMA 2002;287:337-44.

Ernst FR, Grizzle AJ. Drug-related morbidity and mortality: updating the cost-of-illness model. J Am Pharm Assoc 2001;41:192-9.

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