Overdosed: The Pharmaceutical Takeover of Health Care

I recently started a subscription to the American Family Physician and, today, I received my March 1st issue in the mail. Spending some time reading it this weekend, I was once again struck by the overwhelming prevalence of drug advertisements. Out of the 143 pages of this issue, 81 pages are made up of ads (the majority of which are pharmaceutical company ads... there are a few pages of AAFP and classified employment ads). That is a whopping 56.6%.

Now, I didn't choose American Family Physician just because it's the only journal with a ton of drug ads. It just happens to be the one I read regularly. When I pick up copies of NEJM, JAMA or in my medical school library, it's the same. I may not even want to be looking at the ads - but, reading the article on "Systemic Vasculitis," I remember that Namenda can be used for Alzheimer's Disease because I flipped by that page. I also remember that Lexapro is "proven" to be effective for adolescent depression - that's on the back cover.

In 2008, Dr. John Abramson, a family physician at Harvard (this is amazing in itself!) published Overdo$ed America, a book that describes the growth and power of the pharmaceutical company industry in the United States. Up to the 1970s, the majority of pharmaceutical research occurred in universities and other academic settings, funded by NIH grants. As government funding decreased over the next few decades, private drug companies filled the gap. At first they funded trials in university settings and then they gradually privatized the operations as well. In 1991, 80% of commercially sponsored clinical drug trials were run by universities and academic medical centers. In 2000, this number has dropped to 33%.

What's wrong with this picture?

The problem is that, all too often, physicians end up prescribing drugs that may not necessarily be evidence-based but advertisement-based. Family physicians and primary care doctors particularly fall prey to this since they prescribe for the broadest spectrum of diseases and have to be knowledgeable about the plethora of drugs available now.

Remember Vioxx? Used widely by PCPs to treat osteoarthritis and dysmennorhea, Vioxx was found to be associated with increased adverse cardiovascular problems including MIs and strokes. In the 5 years it was available on the market, over 80 million people were prescribed it.

But we continue to prescribe drugs, especially in the United States, that lack sufficient evidence of benefits that outweigh risks. Take for example ezetimibe. Ezetimibe is the most common second line drug for cholesterol (after statins, which are first line). There are purported fewer side effects than that of other second line drugs - however, clinical trials to demonstrate improved CV outcomes and mortality outcomes are still underway.... with no results published to date. Let's compare prescription drug rates of ezetimibe in Canada and the USA.

• Canada: in 2002, 0.2% of those on a lipid-lowering drug were using ezetimibe; in 2006, 3.4%
  
• USA: in 2002, 0.1%; in 2006, 15.2% (NEJM 2008; 358:1819-1828)

We continue to medicate our patients when we don't know if there are any beneficial outcomes.

So what can we do about this?

1. Don't rely on a drug advertisement or word-of-mouth when prescribing drugs. Check out a evidence-based source.
2. Advocate for national changes in the way that drugs are approved and distributed.
3. Advocate for changes in drug advertising!

We need to do this for our patients - and for the future of primary care.