Many people think that laughter is really the only sensible reaction to the advertising excesses of the drug industry. Check out this site:
http://www.havidol.com/
An article in BMJ explains that this site is the brainchild of Australian artist Justine Cooper. What's scary, however, is that it has apparently been mistaken for a serious pharmaceutical website by many users and cross-listed on websites dealing with anxiety and depression. (The drug Havidol purports to treat the dread disease "DSACDAD" or "dysphoric social attention consumption deficit anxiety disorder", and of course the website features the obligatory quiz to tell you if you have this disease and so can qualify for taking Havidol for the rest of your life.)
Coombes R. Having the last laugh at big pharma. BMJ 334:396-97, 2007.
Wednesday, February 28, 2007
The Prescription Project: New Link
I've just added a link to The Prescription Project, funded by the Pew Charitable Trusts and affiliated with the Institute on Medicine as a Profession at Columbia. It's an outgrowth of a key paper published a little more than a year ago in JAMA, calling for major policy changes in academic medical centers to eliminate the conflicts of interest created by too-cozy relationships with the pharmaceutical industry (Brennan TA, Rothman DJ, Blank L, et al. Health industry practices that create conflicts of interest: a policy proposal for academic medical centers.
JAMA 2006;295:429-433). Time will tell whether this new organization will become a forceful player on the U.S. scene.
JAMA 2006;295:429-433). Time will tell whether this new organization will become a forceful player on the U.S. scene.
Sunday, February 25, 2007
Patents: A Helpful Analysis
The current issue of the Hastings Center Report contains a 36-page supplement, "Patents, Biomedical Research, and Treatments: Examining Concerns, Canvassing Solutions," by Josephine Johnston and Angela A. Wasunna. The report provides an extensive review of the current status of patents and licenses in pharmaceutical marketing, with special focus on problems in the developing world, with an especially complete catalogue of possible reform measures.
The report nicely supplements the discussion of patents in HOOKED, and confirms the position that patents are tools of public policy, not basic rights (as the oft-used phrase, "intellectual property rights," is intended to convey). If patents produce consequences that run contrary to good public policy, as often occurs in pharmaceuticals, then we need additional measures of some sort to mitigate those bad consequences. High on the list are questions of whether people in developing countries will be able to afford medications needed for life and health; and whether in the future, pharmaceutical firms will discover desperately needed new medicines for afflictions prevalent in poorer nations.
Johnston J, Wasunna AA. Patents, biomedical research, and treatments: examining concerns, canvassing solutions. Hastings Center Report 37(1):S1-S36, 2007; http://www.thehastingscenter.org/patents-biomedical-research-treatment.asp
The report nicely supplements the discussion of patents in HOOKED, and confirms the position that patents are tools of public policy, not basic rights (as the oft-used phrase, "intellectual property rights," is intended to convey). If patents produce consequences that run contrary to good public policy, as often occurs in pharmaceuticals, then we need additional measures of some sort to mitigate those bad consequences. High on the list are questions of whether people in developing countries will be able to afford medications needed for life and health; and whether in the future, pharmaceutical firms will discover desperately needed new medicines for afflictions prevalent in poorer nations.
Johnston J, Wasunna AA. Patents, biomedical research, and treatments: examining concerns, canvassing solutions. Hastings Center Report 37(1):S1-S36, 2007; http://www.thehastingscenter.org/patents-biomedical-research-treatment.asp
Thursday, February 22, 2007
Patient Advocacy Groups: In the Pockets of Industry?
Michael Day, writing in BMJ (the British Medical Journal in olden days), relates an account of a World Health organization official who apparently tried to launder a drug company contribution through the European Parkinson's Disease Association. The WHO rules don't allow accepting drug company money to fund reports and othjer activities of WHO; but WHO is chronically short of money. In an ironic twist, when the company (GlaxoSmithKline) found out about this plan, which would deny it any credit for supporting the WHO report, it refused to go along, indignantly protesting the hypocrisy of the arrangement.
One quote from the article is worth the price of admission: Tim Reid, identified as European director of Health Action International, dedicated to supporting the rational and ethical use of drugs, said, "Patients' groups are so close to the industry, that they might as well be taking money straight out of the drug company advertising budgets."
On the U.S. scene, there are a few indications that the wind may be shifting slightly, as Marc Santora wrote last fall in the New York Times. He described how the American Diabetes Association, stung by negative publicity, is trying to tighten up its rules about accepting industry donations. (In the case of the ADA the PR problem was less drug company money--with which ADA is replete by the way--and rather accepting money from manufacturers of junk foods.)
Day M. Who's funding WHO? BMJ 334: 338-40, Feb. 17, 2007.
Santora M. In diabetes fight, raising cash and keeping trust. New York Times, Nov. 26, 2006: A1.
One quote from the article is worth the price of admission: Tim Reid, identified as European director of Health Action International, dedicated to supporting the rational and ethical use of drugs, said, "Patients' groups are so close to the industry, that they might as well be taking money straight out of the drug company advertising budgets."
On the U.S. scene, there are a few indications that the wind may be shifting slightly, as Marc Santora wrote last fall in the New York Times. He described how the American Diabetes Association, stung by negative publicity, is trying to tighten up its rules about accepting industry donations. (In the case of the ADA the PR problem was less drug company money--with which ADA is replete by the way--and rather accepting money from manufacturers of junk foods.)
Day M. Who's funding WHO? BMJ 334: 338-40, Feb. 17, 2007.
Santora M. In diabetes fight, raising cash and keeping trust. New York Times, Nov. 26, 2006: A1.
Wednesday, February 21, 2007
A Doctor Takes his Camera to the Medical Conference
In HOOKED, Chapter 11 I offer the reader a sort of guided tour of the pharamceutical exhibits at a major medical conference--in that case, the Berlin Psychiatric Congress. Staying a bit closer to home, "Kevin, MD," a practicing primary care physician, has collected a photo collage of the exhibit hall of a U.S. primary care conference, "Pri-Med". Check it out on his blog-site:
http://www.kevinmd.com/blog/2006/10/how-to-get-doctors-attention-or-how.html
Be sure to read the comments-- they are very insightful. Especially one commenting that the surgeons, at their conferences, have MUCH more professional looking sales folks selling them stuff, and none of this carnival-sideshow stuff.
http://www.kevinmd.com/blog/2006/10/how-to-get-doctors-attention-or-how.html
Be sure to read the comments-- they are very insightful. Especially one commenting that the surgeons, at their conferences, have MUCH more professional looking sales folks selling them stuff, and none of this carnival-sideshow stuff.
Tuesday, February 20, 2007
Ads in Medical Journals: A Serious Problem?
In HOOKED, I spent relatively little space discussing pharmaceutical ads in medical journals. I did this in part because I figured that ads are less worrisome as a source of influence over physicians, due to the fact that they are very clearly labeled as "ads" and no one tries to pretend that they are education, etc.--unlike other practices such as continuing education, visits from drug detail people, etc. Had I seen a paper that appeared last summer, I might have devoted more attention to the issue.
Fugh-Berman and colleagues (writing in PLoS Medicine, an internet journal that accepts no advertising) dug deeper than I had, especially in spotlighting the ways that medical journals go fishing for ad business. They had the good sense to check out some of the medical journals' own websites in which the abjectly plead for advertising revenue, putting forward an image that is pretty far removed from their "public" image as dispasionate, incorruptable purveyors of scientific truth. The authors conclude that the near-total reliance of the journals on ad revenue from the pharmaceutical industry cannot help but bias the editorial decisions. They make the interesting suggestion that it has long been thought "professional" that top-notch journals only advertise pharmaceuticals and things that are part of direct service to patients; they do not run ads for cars, or things that have to do with the physician's own lifestyle. Fugh-Berman et al argue that this "professionalism" actually undermines professional values in medicine and that if the advertising in medical journals was more diversified, it would at least be a help.
Fugh-Berman A, Alladin K, Chow J. Advertising in medical journals: should current practices change? PLoS Med 3:e130, 2006. http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371%2Fjournal.pmed.0030130
Fugh-Berman and colleagues (writing in PLoS Medicine, an internet journal that accepts no advertising) dug deeper than I had, especially in spotlighting the ways that medical journals go fishing for ad business. They had the good sense to check out some of the medical journals' own websites in which the abjectly plead for advertising revenue, putting forward an image that is pretty far removed from their "public" image as dispasionate, incorruptable purveyors of scientific truth. The authors conclude that the near-total reliance of the journals on ad revenue from the pharmaceutical industry cannot help but bias the editorial decisions. They make the interesting suggestion that it has long been thought "professional" that top-notch journals only advertise pharmaceuticals and things that are part of direct service to patients; they do not run ads for cars, or things that have to do with the physician's own lifestyle. Fugh-Berman et al argue that this "professionalism" actually undermines professional values in medicine and that if the advertising in medical journals was more diversified, it would at least be a help.
Fugh-Berman A, Alladin K, Chow J. Advertising in medical journals: should current practices change? PLoS Med 3:e130, 2006. http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371%2Fjournal.pmed.0030130
Saturday, February 10, 2007
More Teen Suicides Due to Less Medication?
According to CDC statistics, teen suicides rose from 2.2 per 100,000 to 2.6 per 100,000 in 2004, an 18% increase. This was the first increase seen in more than a decade:
http://www.medpagetoday.com/tbprint.cfm?tbid=5005&topicid=138
The article reporting this finding (which had originally appeared in the journal Pediatrics) quoted several experts claiming that a likely cause of this rise was the new black box warning that the FDA required to be placed on SSRI antidepressants (selective serotonin reuptake inhibitors), warning of the increased risk of suicidal behavior in children and teens.
In HOOKED, I reviewed some of the evidence on how the pharmaceutical industry tried its best to hide and to deny this risk, which is a small but real concern. (See post below on the BBC program "Panorama" from last month which looked at this story.)
There has been a standard response from many child psychiatrists, most often those in bed with the industry--that it's terrible to impugn the SSRI drugs, because it will prompt physicians to stop prescribing them for teens, which will lead to untreated and worsening depression among teens, which will cause many more suicides than would ever be the case had SSRIs been widely used. (This response came only after the first industry ploy failed--that kids who engaged in suicidal behavior did so not because of the drug, but due to the underlying depression. That has been shown to be false since non-depressed teens given SSRIs have been shown to display the same sort of behavior.)
So when I saw psychiatrists claiming that this increase in suicide is due to the mean old FDA beating up the poor drug companies, I naturally wondered about the money trail.
Two major authorities are cited in the MedPage article: Dr. Charles Nemeroff of Emery University, and Dr. David Fassler, affiliated with the University of Vermont. Dr. Nemeroff is probably Exhibit A for unrepentent conflict of interest in high places in American medicine. He was exposed last year in the Wall Street Journal after he was forced to resign as editor of a psychiatric journal, due to the journal publishing a paper that he wrote advocating an implanted electric device for treating depression, without disclosing that Nemeroff was a shareholder in the company that makes the device. That led to a maudlin letter to the editor from 40-odd psychiatrists, all protesting that their colleague was a person of the highest integrity and how dare the WSJ impugn his honor.
Dr. Fassler has published much less in scholarly journals lately and so I was unable to see if he has direct financial ties to drug companies. He is a member of the board of Mental Health America. This is a legitimate advocacy organization, with numerous local chapters, which is supported in part by the MacArthur Foundation. But it also boasts among its donors most of the major drug companies, to the tune of $500K to $1M each.
So: did decreased use of SSRIs lead to this increase in teen suicide? Well, first one would like to know if there are any data that fewer SSRIs were in fact prescribed. Studies in the past have shown that physicians are actually pretty good at ignoring black box warnings. Second, to make the claim plausible, one would need to believe that the SSRI drugs are really very effective in treating depression in teens. But the available studies in fact show either no effect or very little effect. The relatively poor performance of SSRI drugs generally, not to mention their risks, is one of the better-kept secrets in drug industry marketing.
MedPage, to its credit, indicated skepticism as to whether the black-box-warning claim was the true reason for the rise in suicides.
What is perhaps saddest about this dispute is that it probably never had to arise at all. I am not a child psychiatrist or an expert in the use of SSRIs. But as best as I can understand, the behavioral syndrome that is related to SSRIs, and that prompts the suicidal or occasionally homicidal behavior, is a very specific syndrome called akithisia. It typically occurs in the first few weeks of starting therapy with an SSRI. Most patients have oppressive, intrustive thoughts of harming themselves or others, and had they immediately stopped taking the drug when those thoughts occurred, the harm would probably have been prevented in almost all cases.
Now, suppose the drug companies had been interested in science and patient care, instead of marketing and sales. As soon as this risk became known, it might have been widely publicized. Doctors could have been told by the ubiquitous drug sales reps: Watch your patients like a hawk for the first few weeks of treatment for this specific syndrome. Make sure that they and their family members know to stop the drug right away if it occurs. If after those first few weeks you haven't seen this--and thankfully it is rare--you are probably home free. This warning would have reduced the risk of anyone being harmed by this side effect by perhaps 90% at least, while still allowing physicians to prescribe SSRIs widely (assuming that they really work--see above). But no, the companies had to let their marketing concerns override quality medical care.
http://www.medpagetoday.com/tbprint.cfm?tbid=5005&topicid=138
The article reporting this finding (which had originally appeared in the journal Pediatrics) quoted several experts claiming that a likely cause of this rise was the new black box warning that the FDA required to be placed on SSRI antidepressants (selective serotonin reuptake inhibitors), warning of the increased risk of suicidal behavior in children and teens.
In HOOKED, I reviewed some of the evidence on how the pharmaceutical industry tried its best to hide and to deny this risk, which is a small but real concern. (See post below on the BBC program "Panorama" from last month which looked at this story.)
There has been a standard response from many child psychiatrists, most often those in bed with the industry--that it's terrible to impugn the SSRI drugs, because it will prompt physicians to stop prescribing them for teens, which will lead to untreated and worsening depression among teens, which will cause many more suicides than would ever be the case had SSRIs been widely used. (This response came only after the first industry ploy failed--that kids who engaged in suicidal behavior did so not because of the drug, but due to the underlying depression. That has been shown to be false since non-depressed teens given SSRIs have been shown to display the same sort of behavior.)
So when I saw psychiatrists claiming that this increase in suicide is due to the mean old FDA beating up the poor drug companies, I naturally wondered about the money trail.
Two major authorities are cited in the MedPage article: Dr. Charles Nemeroff of Emery University, and Dr. David Fassler, affiliated with the University of Vermont. Dr. Nemeroff is probably Exhibit A for unrepentent conflict of interest in high places in American medicine. He was exposed last year in the Wall Street Journal after he was forced to resign as editor of a psychiatric journal, due to the journal publishing a paper that he wrote advocating an implanted electric device for treating depression, without disclosing that Nemeroff was a shareholder in the company that makes the device. That led to a maudlin letter to the editor from 40-odd psychiatrists, all protesting that their colleague was a person of the highest integrity and how dare the WSJ impugn his honor.
Dr. Fassler has published much less in scholarly journals lately and so I was unable to see if he has direct financial ties to drug companies. He is a member of the board of Mental Health America. This is a legitimate advocacy organization, with numerous local chapters, which is supported in part by the MacArthur Foundation. But it also boasts among its donors most of the major drug companies, to the tune of $500K to $1M each.
So: did decreased use of SSRIs lead to this increase in teen suicide? Well, first one would like to know if there are any data that fewer SSRIs were in fact prescribed. Studies in the past have shown that physicians are actually pretty good at ignoring black box warnings. Second, to make the claim plausible, one would need to believe that the SSRI drugs are really very effective in treating depression in teens. But the available studies in fact show either no effect or very little effect. The relatively poor performance of SSRI drugs generally, not to mention their risks, is one of the better-kept secrets in drug industry marketing.
MedPage, to its credit, indicated skepticism as to whether the black-box-warning claim was the true reason for the rise in suicides.
What is perhaps saddest about this dispute is that it probably never had to arise at all. I am not a child psychiatrist or an expert in the use of SSRIs. But as best as I can understand, the behavioral syndrome that is related to SSRIs, and that prompts the suicidal or occasionally homicidal behavior, is a very specific syndrome called akithisia. It typically occurs in the first few weeks of starting therapy with an SSRI. Most patients have oppressive, intrustive thoughts of harming themselves or others, and had they immediately stopped taking the drug when those thoughts occurred, the harm would probably have been prevented in almost all cases.
Now, suppose the drug companies had been interested in science and patient care, instead of marketing and sales. As soon as this risk became known, it might have been widely publicized. Doctors could have been told by the ubiquitous drug sales reps: Watch your patients like a hawk for the first few weeks of treatment for this specific syndrome. Make sure that they and their family members know to stop the drug right away if it occurs. If after those first few weeks you haven't seen this--and thankfully it is rare--you are probably home free. This warning would have reduced the risk of anyone being harmed by this side effect by perhaps 90% at least, while still allowing physicians to prescribe SSRIs widely (assuming that they really work--see above). But no, the companies had to let their marketing concerns override quality medical care.
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