Some commenters raised interesting questions after my last post so I thought I'd continue the discussion. Maxedoutmama suggested we should halt all advertising for drugs, in part because early users are close to being research subjects without much in the way of informed consent. USAF_Linguist wondered about offering testing of new AIDS drugs to people in the third world who have no access to such drugs. And Dymphna told of her own experience of responding to a medicine that was used off-label (which means her insurance will not pay for it, and she has been using samples and buying drugs in Canada to continue getting access to the medication.)
All raise interesting and valid points.
In terms of stopping all advertising for medications by drug companies, I must respond with a definite "its a good idea but I probably wouldn't do it." My ambivalence stems from the existence of a condition known as "Medical Student's Disease". This is a common illness among medical students, which occurs among them especially when they are studying Psychiatry. Psychiatric symptoms are often exaggerations of normal experiences. Who hasn't felt depressed at times, or anxious? Who hasn't had insomnia at some point in their lives? Who hasn't felt that their thoughts and speech were disorganized on occasion? Most medical students self diagnose as having Depression, social phobia, various psychoses, not to mention all the medical ailments they come down with in their first few years of medical school. The fact is that when people who are stressed hear about the often non-specific symptoms and the wonder drugs that cure them, the temptation is strong to obtain relief via chemistry, especially in a population that has been trained since childhood to treat every discomfort with medicine, and has been taught that to avoid frustration and pain is an American birthrite. The reality is that most drugs work, for specific indications, for most people some of the time; some work for most people most of the time, and some work for a few people, infrequently. Furthermore, not everyone should be treated with drugs for every condition: not everyone who gets anxious at a party should be put on a drug for social anxiety. The drug companies are trying to create a market and people are highly susceptible to such manipulations. On the other hand, where do we expect them to get the money they need to justify their investment in new medications, which, pardon me for repeating myself, can cost $1 Billion to bring to market (that's a 1 with 9 zeros behind it, which is a lot of money to my way of thinking.)
So, in answer to Maxedoutmama, I would have to say I don't know what would be best, but curtailing free speech is already a problem with McCain-Feingold, so lets not make it worse. (Sorry for the editorializing.)
USAF_Linguist mentioned testing drugs on impoverished people and I think it is likely to continue but I have some problems with the idea. Informed consent is a bit of a fiction. Every time people take part in a study, have a run of the mill medical procedure, agree to a treatment of anlmost any kind, they are expected to sign an informed consent. Sadly, when people are undergoing procedures or taking medications, they can never really make an informed decision. If you are in distress,and I tell you you need an operation that could kill you or maim you, or can give you a drug that could help you but could also kill you, and I assure you the risk is low, very few people can actually make an accurate risk assessment.
Look at a real world example of risk assessment: When our vaunted FDA announced that certain pain medications double the risk of a heart attack, what was the response? The lawyers salivated at the opportunity for a class action suit, people who had had heart attacks rushed to contact those lawyers after hearing their ads, and the company involved panicked and pulled the drug. In our sophisticated country we could not expect people to make a risk assessment of a 1-2% increase in the risk of a heart attack brought about by using a medicine that for some people was the only thing that could allow them to function pain free.
As far as testing in the third world, I suspect people there are even less likely to understand the risks they are taking. Plus, if there is a problem, their medical system will be much less likely to be able to respond appropriately. That argues against such testing, but on the other hand, we want as many test subjects as possible to minimize the chances of treatment emergent side effects and testing in Americans costs a lot more than testing on poor people in the third world, so we have a quandary. I do not know how to square that circle.
Finally, Dymphna describes the common experience of a person responding to an off-label use of a medication. Since or bodies are extraordinarily complex, and our brains and related minds are the single most complex structures yet discovered in our universe, it is no surprise that there are individual variations in responses to medications, or that medicines often act in surprising ways. In Dymphna's case, she cannot take the usual first line medicines (the SSRS's, like Prozac, Zoloft, etc) for depression and anxiety (I must add I do not know what she is taking medication for, but those are the two most common indications) yet she found a medicine, Provigil, a novel medication whose mechanism of action is not well understood, but which increases alertness in patients with certain types of sleep disorders, and found it relieved her distress. When our patients are suffering, we are always on the look out for new ways to help them. I planned on writing about a couple of new Sleeping pills and my experience with them (and may yet get to it) but Dymphna has met up with a couple of the difficulties with the situation. She cannot use her insurance to pay for the drug because it is not approved for her problem; she has to obtain it from her Doctor (by way of samples, which leads to the kinds of trouble I alluded to yesterday with the Drug Reps) or from Canada, which is not a real solution (though I will not get into that today because it requires a longer response); for the Doctor there is an additional risk in that if Dymphna develops a serious side effect, he is open to a lawsuit for using a drug in a non approved fashion.
Drugs are marketed as if we understand why and how they work. SSRI's supposedly raise the level of available Serotonin in the brain. People with depleted Serotonin stores tend to be depressed (though even this is not as certain as you might suppose). Obviously, by raising Serotonin levels people become less depressed and feel better. Yet, since the first anti-depressants came on the market 30 + years ago, patients have typically responded in the same way: one third do very well, one third have a moderate response, and one third find no relief at all. This does not include those who can not tolerate the side effects and have to stop the drug (and the tolerance of side effects generally is proportional to the intensity of their depression in conjunction with their character structure [again, another very long discussion].)
Consider this, when thinking about Neurochemistry and psycho active medications: we have identified somewhere north of 100 natural substances found it the brain that can act as neurotransmitters; furthermore, there is evidence that individual brain cells can act as independent signal processors (another name for a computer, if you will) and have much more processing power than a simple transister which is how they have been described by many who favor a "biological comuter" description of our brains. Now try to explain to me how the Serotonin theory of depression can account for all the variations of human experience we see.
Recent Comments