Two researchers (Howard Brody, MD, PHD, University of Texas Medical Galveston and Donald Wright, PhD, University of Medicine and Dentistry of New Jersey) have outlined 6 things that have a large effect on physicians and lead us into prescribing drugs that may not be needed. It's not just the pharmaceutical marketing that has led us to this place...it is also how journals publish literature that physicians rely on for changing medical practice. Here are the 6 strategies that influence us:
- Reducing thresholds for diagnosing disease. For example, a diabetes diagnosis used to be fasting blood sugar above 130. Now it is glucose above 100. There is no evidence that tight control leads to improved outcomes in preventing stroke, total mortality, blindness or renal failure. Early detection is a good thing if it helps with diet and exercise but recent data shows that the intensive therapy (HbA 1c-<6%) group did worse.
- Relying on surrogate endpoints rather than outcomes as goals. We know that Statins lower cholesterol. From 1994-2006 the use of Statin drugs by adults 45 and older increased 10 fold. In a meta-analysis of 11 clinical trials involving 65,229 participants of high-risk patients without prior cardiovascular disease, the Statin use did not lower all- cause mortality. Surrogate endpoints make it easier for marketers to make claims that the drug will benefit the patient.
- Exaggerating safety claims. When drugs are initially tested, the test population is usually homogeneous and small. As a larger number of patients take the drugs, the potential for adverse effects increases. We need to always be aware of this.
- Exaggerating efficacy claims. Marketers often emphasis that a new drug is better than an established (lower cost) drug when actually the drug performs no better than the old one. New drugs might have an advantage for a smaller subset of patients but marketers emphasize the benefit for everyone.
- Creating "new" diseases. Social anxiety disorder (aka: shyness), Erectile Dysfunction (aka: aging men), Pre-diabetes etc. creates millions of new customers who might benefit, but will also be exposed to high cost and potential side effects.
- Encouraging unapproved uses. It is illegal for a pharmaceutical company to market a drug for a non-indicated condition, but that doesn't stop physicians who are on the honorarium payroll from shilling for dollars. This has been a common practice that has just lately had a light shown on it.
Modern pharmaceuticals are lifesavers and have increased longevity and good health for millions. But we should always stop and think before we start a patient on a "lifetime" drug if they have no complaints and make sure we are really preventing an outcome, not just a lab test.
(Jama, Vol 305, No.11)