A good decision is based on knowledge and not on numbers. Plato
Medicine by the Numbers: Statistics
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Medicating Childhood Behavior: Caution Ahead
In Hannibal Missouri, Huckleberry Finn’s house sits next door to Mark Twain’s. Tom Blankenship, the real boy who lived in the tiny house, was the model for the wild and fictional Huck, as Mark Twain was for the impish prankster Tom Sawyer. In the sleepy little town set on the banks of the Mississippi River, it is easy to imagine the two real boys living the lives Twain created for his characters. And it is just as easy to imagine what would happen to two such boys in the modern world. Twain and Blankenship would be disruptive children, seeing the school psychologists and being medicated for attention deficit disorder. Is this progress, or are too many children today labeled with psychological disorders and taking drugs to modify behavior?
Reasons for psychoactive medication use in children
The most legitimate reason for identifying and labeling children as disordered is that some psychological disorders that appear early in life express themselves more severely in adulthood than later onset versions do. Early treatment helps prevent more dysfunction later, especially in problems like autism. Other reasons may be less admirable. Prescribing drugs to treat emotional and behavioral symptoms is easier and less time consuming than dealing with the psychological problems that lie beneath the symptoms, problems which do not reflect abnormal brains.
How did we get to medicating behavior?
Attempts to treat psychological symptoms with drugs began in earnest with the serendipitous discovery in the 1950s that certain drugs, used for treating infections and high blood pressure, appeared to elevate mood. They seemed to have a direct effect on behavior. Pharmaceutical companies then began to develop drugs specifically targeted to brain function. Later, scientists discovered that these drugs led to changes of levels of chemicals in the brain that transmit information between nerve cells and they developed the neurochemical theory of psychological disorders. The drug age of treatment of anxiety, depression and psychosis took off on the assumption that the drugs treated some native chemical imbalance in the brain. Because there is no direct evidence for such imbalance, some respected psychiatrists now question the neurochemical theory. Additionally, careful review of many drug studies show their effects to be little better than placebos (sugar pills). Nevertheless, drug treatment of psychological symptoms has ballooned in all age groups, particularly in the late 1900s and early 2000s. Between 1987 and 1996 the use of psychoactive drugs in children from ages 6-17 jumped 2-3 times. By 2000, 8.8% of 6-17 year olds were taking some kind of psychoactive drug. By 2017 the number of children medicated for behavior was over 7 million.
The diagnoses that prompt drug treatment in children
The behaviors of modern children that prompt treatment are divided into diagnostic categories: attention deficit disorder (ADD or ADHD); mood, anxiety and disruptive behavioral disorders; autistic spectrum disorders and childhood schizophrenia. The latter two categories reflect distinct disorders of brain function, but the first four are defined by behaviors that are often related to age and circumstances. But even autistic spectrum disorder diagnoses capture many children with behaviors that were once considered part of the normal range of human personality and behavior – social ineptness, obsessional interests and unusual styles of learning and communicating.
Non-medical factors involved in the rise in psychoactive drug prescriptions
Non-medical factors which have added to the enthusiasm for drug treatment of behavioral symptoms have been the tremendous changes in society since World War II –in family structure and values, leisure time activities, employment patterns, the educational system and in the non-governmental institutions like churches and community groups that used to provide moral and structural support. While schools once neglected girls’ needs, boys are now immersed in an educational system geared to girls, who are more verbally adept at younger ages than boys are. Sitting still and learning to read is a task that boys confront several years earlier than they used to, and many lack the required maturity. When they fail and act out, they are thought to be inattentive and impulsive, garnering them ADD evaluations and drug treatment significantly more often than girls.
Changes in the practice of medicine
Changes in the practice of medicine, with more emphasis on tests and drugs now than on time spent in direct contact with patients and families, also contribute to the ease with which drugs are used as the primary approach to all kinds of medical problems, not just psychological ones. Another problem for children is “off-label” drug use, a term applied to the perfectly legal practice of prescribing drugs for reasons other than those used in the trials that determined their safety. It is estimated that 70% of all pediatric drug use is off-label, and for most of the psychoactive drugs used in children, testing has been done only in adults. In addition, the majority of psychoactive drugs used in children are prescribed by family practice or general pediatricians, not by psychiatrists. Pediatric psychotherapists, whose help might supplant the need for drugs or improve the outcome of drug treatment, are in short supply. For children without private insurance, psychoactive drug prescription rates are higher than for the privately insured.
Long term concerns
The concerns about widespread use of psychoactive drugs in children extend beyond the many side effects such as decreased appetite, insomnia, cardiac problems, and sudden death (stimulants used for ADD), and weight gain, sleepiness, liver problems , diabetes, and increased suicide rates (antidepressants , antipsychotics and mood stabilizers). Some neurodevelopmental biologists think we may be trading one set of problems for another delayed and potentially more troublesome set, because psychoactive drugs have long term effects on the immature brain that are not seen in the adult. The developing brain is meant to learn from experience and modify its behavior in a process we call maturation and it is not at all clear that interfering in development with drugs that change behavior passively is superior to helping the child learn without drugs, by improving the social environment and providing competent psychological help. We should remember that role models for Huck and Tom grew up to be a judge and a famous writer.
Over the Counter Pain Relief
Pain stayed so long, I said to him today
“I will not have you with me any more.”
I stamped my foot and said, “Be on your way,”
And paused there,
Startled at the look he wore.
“I, who have been your friend,” he said to me.
“I, who have been your teacher,
All you know of understanding love,
Of sympathy and patience I have taught you.
Shall I go?”
Author unknown
Pain is a friendly messenger, carrying news from the frontiers of the body to the command center of the brain. Like the messages traveling across telephone wires, pain is just a series of electrical impulses traveling up nerves. The brain sorts the electrical impulses and presents them to you, the conscious mind inside, as a coherent story about what’s going on down below. Sometimes the message triggers an immediate reflex action, like pulling a hand away from a hot stove, even before your mind grasps the problem.
How is pain relieved?
Relief from pain depends on stopping the electrical impulses carrying the pain message or on altering the way the brain puts the message together. Every drug or procedure used in pain treatment works on either the simple electrical message, or on its complex interpretation by the brain. Ultimate relief comes when the conscious mind disappears into sleep, which is of course the great achievement of general anesthesia. Consciousness is the barrier to complete relief of severe pain.
Most pain, however, is not the severe unremitting variety that requires treading the fine line between consciousness and oblivion. Most pain comes in an acute form that gets us to the doctor for treatment of a sudden illness, or in a chronic form related to our heads or our skeletons. Thousands of years ago Cicero made the distinction: “All pain is either severe or slight; if slight, it is easily endured; if severe, it will without doubt be brief.”
Willow bark – the first pain medicine
Time and chemistry have given us surgery, anesthetics, antibiotics and narcotics – life-savers for diseases heralded by severe pain. They have also given us lesser drugs for lesser pains, a long process beginning in the 5th century BC when Hippocrates recommended chewing the bark of the willow tree to relieve pain and reduce fever. A long line of chemical derivatives of the willow bark’s salicilin culminated in a stable powder patented and marketed in 1899 as aspirin, the world’s first synthetic drug. Aspirin launched the world’s pharmaceutical industries.
Anti-inflammation and pain
Inflammation causes pain and the purpose of the pain is to get you to attend to whatever is causing the inflammation. Pain relief from aspirin is best understood in terms of its anti-inflammatory effects, but the drug has multiple other biochemical properties, many still being discovered. One effect, on an enzyme involved in the production of chemicals that produce inflammation, led to the development of ibuprofen and its cousin naproxen. These newer drugs, non-steroidal anti-inflammatory drugs (NSAIDS), are mainstays in the treatment of the aches and pains of daily life. Anti-inflammatory steroids like prednisone are far more potent and used only when their risks are balanced by the seriousness of the problem under treatment.
Tylenol is not an anti-inflammatory drug
Tylenol, or acetaminophen, is commonly thought to be just like aspirin, but it is chemically unrelated, has no anti-inflammatory effects, produces no gastric upset and doesn’t affect blood clotting. It reduces fever by a direct action on the brain, but no one knows how it reduces pain. The pain-relieving properties of aspirin and the NSAIDS, apart from their anti-inflammatory effects, are also poorly understood. It is possible that they decrease pain perception in the mind, but if so, no one understands how. They are most effective after an acute injury, after simple surgical procedures, or with infrequent headaches (relief here is also of unknown mechanism).
Frequent analgesic use can increase pain problems
But what about pain of chronic conditions like osteoarthritis and frequent “tension” headaches, in which inflammation plays a lesser role? Much arthritic pain is from tightness and muscle imbalance. Gradual activity warms up joints and removes some of the discomfort. Exercise, heat, ice, massage, weight loss, stretching, Pilates, and yoga help minimize drug use in these chronic conditions. Frequent use of analgesics for headaches (more than once a week) actually lowers the threshold for headache triggers (like lack of sleep, alcohol, lack of exercise, stress, etc.) and for pain perception, and often leads to a cycle of increasing drug use producing increasing numbers of headaches. This phenomenon is known as rebound headache and it highlights the importance of other methods of headache prevention and relief (adequate sleep, stress management, attention to diet and exercise, etc.).
Selling pain relief like candy
Since 1915, when aspirin became available without a doctor’s prescription, the sale of over-the-counter (OTC) pain relief has achieved the heights late Merck chief Henry Gadsden aspired to when he wished aloud 30 years ago that he could sell drugs to healthy people just like Wrigley’s sells candy and gum. These days, OTC pain medicines are so readily available that they seem as harmless as the candy next to them on the shelf.
Side effects
Unlike candy, OTC pain relievers have to be processed by the liver and kidneys. Chronic use can produce liver and kidney impairment, even failure of these organs. Chronic analgesic use damages hearing. Aspirin and other NSAIDS may erode the stomach lining; all but Tylenol impair blood clotting. Recent statistical studies resulted in withdrawal of two newer NSAIDS from the market because people taking them had more heart attacks than those on placebos. The problem also appears in statistical analysis of those on high doses of the older NSAIDS.
Don’t kill the messenger – heed it
Because no drugs are risk-free and pain is just messenger telling you about a problem, try to reserve the pill option for pain that interferes with sleep or truly inhibits you from carrying out the activities that are important to you. Attend to the causes of the message in as many non-pharmaceutical ways as possible. And remember that an analgesic “virgin” or infrequent user gets more out of a painkiller than an analgesic veteran.
A Primer on Steroids
Ask around among your friends and you will find that many of them, at one time or another, have been given “steroids” by their doctors. They have taken pills, inhaled the drugs, had injections, smeared creams on their skin, dropped liquid into their eyes, or received the drugs in an enema. They may have been treated for pain, swelling, rashes, cancer, slipped discs, vision problems, arthritis, colitis or vasculitis. At the same time, you hear stories of athletes “doping” with “steroids” to enhance athletic performance and losing titles they won for having done so. You read ads for body building “steroids” and see the results in pictures of massively muscled men – and women. And sometimes you hear that testosterone, widely advertised for aging men, is a “steroid.” Are these all the same drugs? Yes, and no. They are all manufactured versions of human steroid hormones.
What makes a steroid hormone?
All steroid hormones begin as molecules with the same core structure made from cholesterol. Various carbon, hydrogen and oxygen combinations added to the core make different chemical structures with different functions in the body. Those steroid hormones made in the testes and ovaries are called sex hormones. Those made in the adrenal glands are called corticosteroids and mineralocorticoids. Steroid hormones trigger a large number of different and vital chemical responses throughout the body.
Which steroids are used for which problems?
The steroids you hear about most frequently are synthetic versions of some of the adrenal glands’ corticosteroid hormones. Because they block immune system function, they are very powerful anti-inflammatory agents, commonly prescribed for allergic responses, autoimmune diseases, catastrophic situations involving trauma and shock, some cancers, and pain problems in which inflammation is thought to be the culprit. The steroids used for body building and performance enhancement are usually derivatives of the male sex hormones, or are nutritional supplements which are thought to increase the body’s own production of the male hormones.
Catabolic and anabolic effects: breaking down and building up
The first corticosteroids used in humans were animal adrenal gland extracts. They were lifesaving treatments for shock in people who had lost adrenal gland function. Incidental observations about their powerful anti-inflammatory effects propelled their widespread use and the Nobel Prize in Medicine in 1950 went to the men who elucidated their physiologic effects. With increased use, however, corticosteroids proved to have many serious long term effects because they are catabolic hormones, achieving their results by breaking down the body’s proteins and diverting them for different purposes.
The male sex steroids are anabolic hormones because they signal the body to build proteins. They have much narrower medical applications than the adrenal corticosteroids do. Anabolic steroids are useful in patients who have impaired male hormone production for reasons such as pituitary gland (the master gland) failure or testicular failure. But anabolic steroids are not medically needed in healthy people, and their use in amounts required to increase muscle mass above the body’s natural endowment courts significant risks. They are not medically available for healthy people. The male hormone testosterone is sometimes prescribed for men who have low testosterone levels later in life, with the aim of restoring libido and maintaining muscle mass, though there is some controversy about the risks versus benefits of this practice.
Powerful drugs with powerful side effects
Side effects of adrenal corticosteroids are related to the dose, delivery mechanism and especially to length of time used. With oral and intravenous delivery, changes in glucose metabolism shift the pattern of fat storage in the body to the trunk, the neck and the face, producing the characteristic “moon facies” of someone treated with steroids over long periods of time, in relatively high does. Skin thins. Muscles shrink. Bones lose calcium and may fracture. Cataracts commonly develop. Insomnia and sometimes a form of mania signal brain effects. Suppression of the immune system, the source of the powerful anti-inflammatory effects of the corticosteroids, allows some infections to blossom. And very soon after steroid treatment starts, the adrenal glands begin to curb their own production of steroids, making stopping the drugs dangerous unless they are slowly tapered, a process that sometimes takes months.
Injections of corticosteroids into painful, presumably inflamed areas cause breakdown of the collagen structure of in connective tissue. Injections directly into tendons can cause enough degeneration at the site to lead to tendon rupture, causing some orthopedists to ban steroid injections anywhere near the Achilles tendon. Steroid inhalation for asthma and chronic obstructive lung disease is similar to topical use for skin problems – very effective at relieving inflammation, and not associated with much absorption into the body, so not as likely to produce adverse effects.
Some of the side effects of anabolic, male hormone steroids are related to their androgenic properties – the ability to produce and enhance male characteristics, and at the same time to shut down the body’s own production of testosterone in the testicles. Female users have deepened voices and develop acne and facial hair, but lose scalp hair. Males develop decreased sperm counts and shrunken testicles and also get acne and lose scalp hair (remember how many bald cyclists there were in the Tour de France during the height of the doping scandals?) But the most dangerous side effects are not visible: they include heart disease, liver cancer, anger, aggression and irritability and depression, as well as abnormalities in liver and kidney function.
Exercise caution in legitimate use of steroids and avoid illegitimate use
Alternate day dosing schedules for corticosteroids may help prevent side effects, as will the development of newer, more targeted versions of the drugs. But steroids should always be approached with caution, and used with great care. The most important things for doctors and patients to consider are the certainty of the diagnosis and likelihood that the condition will improve with less risky treatment. For instance, if orthopedic pain comes from muscular imbalance and not from inflammation, steroid injections will not help. If the condition being treated – say a bad case of poison ivy – will resolve with other types of care, steroid risks are unnecessary. Always remember that some severe steroid side effects can occur with just a few weeks use.
Sidebar: Case History illustrating Risk/Benefit Judgment in Corticosteroid Use
A 60 y.o. woman undergoes successful surgery for a benign brain tumor, but awakens with a paralyzed facial nerve, a well-known and feared complication of surgery in this type of tumor. She has a severely drooping mouth and lower eyelid. High dose steroids over the next week reduce the swelling in the nerve, resolving the facial nerve paralysis. But the treatment also causes degeneration of the tops of the hip bones – a well-known steroid complication called aseptic necrosis. She then needs two hip replacements. Was the side effect worth the treatment result? In this case, most people would say yes. But if the steroid treatment had been for something that would have resolved with other treatment, the hip complication would have been much harder to accept.
The Opiate Epidemic: Why Now?
In the 1970s, doctors in inner city hospital saw many patients suffering complications of heroin use, but outside those communities there was no talk in the media about an epidemic of opiate abuse. Now, four decades later, the state of Kentucky is suing Purdue Pharma for the devastating effects of its opiate drug OxyContin on its citizens, the Governor of Vermont devoted his 2015 State of the union address to the problems of prescription opiate and heroin abuse in his state, and a California doctor was recently convicted of second degree murder in the narcotic overdose deaths of three patients. And these just a few of the news stories related to our current “opiate epidemic.” Is this a new problem, and if so, how did we get here?
What are opiates?
Opiates are psychoactive substances that have been used for over 5000 years. They are derived from the poppy plant and ingested, smoked or injected to produce relaxation, pleasant euphoria and mild hallucinations. Medically speaking, they also alleviate pain, coughing and diarrhea. Opium, the general name for poppy plant extracts, is a complex mix of substances which include the alkaloid chemicals morphine and codeine. Morphine was isolated and named in Germany in 1805. Though very effective as a pain remedy, morphine was, by the end of the Civil War, termed a “hydra headed monster” that was “wrecking lives and home.” In a search for a non-addictive opiate, an English pharmacist created heroin in in 1874. Synthetic offshoots like Vicodin, Percodan and Percocet followed in the 20th century, and OxyContin debuted in the mid-1990s.
Dependence and addiction
Opiates alter the brain’s structure and chemistry. Normally, the brain produces “endogenous opioids” in response to activities that are pleasant and rewarding. In response to opiate drugs, the brain promptly lowers its own opioid production. If the drug supply is interrupted, the lack of internal production of opioids causes withdrawal symptoms – agitation, nervousness, high blood pressure, pain, nausea, vomiting and seizures. Opiate use has produced dependence on an external source. Its severity depends on dose and length of time opiate drugs have been used. When the next dose preoccupies thinking and drug seeking interferes with routine life, causing medical and social ills, dependence has become addiction.
Withdrawal symptoms are relieved by taking more opiate drugs, but over time the dose required to keep withdrawal symptoms at bay increases. This is called tolerance. At the same time, however, the opiate dose that causes respiratory depression does not change and one of the side effects of progressively larger doses of opiates is respiratory depression – failure to breathe. Respiratory depression is the usual mechanism for death in someone who has overdosed on an opiate drug.
The road to heroin addiction
Since 1999, opiate overdose deaths have quadrupled in this country. Prescriptions for opiates have skyrocketed, as has heroin use. The US accounts for eighty percent of the opiates consumed in the world and an estimated 2.1 million Americans have opioid related substance abuse problems. Medically speaking, though, this is not an epidemic and it is not a new problem. The reasons for the hyperbolic use of epidemic language in the media are sociologic. We have entered a new era in which the pattern of use of heroin has changed dramatically, moving out of the lower socioeconomic strata into smaller cities, towns and wealthy suburbs and into the lives of children. In this story, the medical profession and pharmaceutical industry have played roles as large as those of innovative drug dealers from a small town in Mexico.
In the modern history of the poppy plant derivatives, heroin was a street drug and heroin users were typically found in decaying inner cities. The other opiates remained under the control of physicians, who were constrained in their prescription writing by the fact that these drugs fell under federal controlled substance laws. Use was restricted even in terminally ill cancer patients because of fear of addiction, a view that changed only after the advent of the hospice movement in the 1970s.
By the 1980s, buoyed by the good feelings of providing relief for cancer pain, doctors who dealt with other forms of chronic pain – typically orthopedic in nature, but also nerve pain and headaches – began to change their views about the use of narcotics. A short letter in the prestigious New England Journal of Medicine in 1976 stated that a review of hospitalized patients who had received opiates showed no evidence of significant risk of later addiction to the drugs. Though it was nothing of the kind, this letter was later described as a “landmark study” and used to support the view that, when used to treat pain, opiates did not cause addiction.
By the 1990s powerful opiates were flowing into the community in large quantities for routine treatment ankle sprains and dental work. In hospitals, pain became the “fifth vital sign,” measured subjectively by the patient on a 1-10 scale, and used in hospital satisfaction surveys used for quality control. Opiates flowed much more freely because patient satisfaction surveys counted for insurance reimbursement and discharge medications often included narcotic prescriptions.
OxyContin appears
While medical prescribing practices were changing, Purdue Pharma developed OxyContin. Heavily marketed as a product that could not cause addiction because the patented timed release would prevent the initial high and euphoria associated with the conventionally produced pills, the drug came in large doses. But people seeking a high soon learned to crush the continuous release pills. OxyContin quickly became a popular street drug, sold by the people who were getting prescriptions for the myriad pains that bring people to doctors’ offices. Pill mills popped up where drug seekers could find unethical doctors willing to write prescriptions with no requirements other than money.
Heroin is cheaper than OxyContin
Heroin requires no doctor’s prescription, is far cheaper than stolen OxyContin sold on the streets, and satisfies the dependence, tolerance and addictions of people who have slipped into those traps with prescription drugs. Heroin overdoses are claiming teenagers in wealthy suburbs of Midwestern cities and in New England – because heroin has arrived there with young men who deliver small amounts directly to customers who contact them by phone. These dealers are salaried non-users, they provide reliable quality heroin, and they disappear back into Mexico after short term stays.
Rethinking
Solutions will have to come from objective study of the results of loosening the standards of prescribing addictive and mind-altering drugs for self-limited problems that can be adequately treated with lesser drugs. And while the care of the terminally ill and some patients with severe nerve pain may require opiates, there have been no controlled studies on risk vs benefit for the treatment of other chronic pain problems, ones which may benefit more from a comprehensive approach combining lifestyle changes, exercise and counselling such as had been provided in pain clinics in the past. Last but not least, doctors and patients could all benefit from a widespread educational campaign about signs of increasing tolerance to and dependence on brain altering drugs.
Risky Business
pharmaceutical
From Gk. pharmakeutikos, from pharmakeus “preparer of drugs, poisoner,” from pharmakon “medicine, drug, poison, charm, spell, enchantment.”
As the ancient Greeks saw it, drugs, poisons, spells and enchantments were all in the same family. Over the centuries, science separated useful treatments from the occult relatives, but injected and ingested chemicals have always retained a mystical ability to inspire faith and hope. Because we now live in a world of non-stop, sophisticated, and ubiquitous marketing of drugs to healthy people, faith and hope have to be tempered by some healthy skepticism about the products being pushed by the new shamans.
Seeking expanded markets for drugs
Drugs companies do much superb work and save lives of people who are desperately ill. Without them, our children would die of simple infections and surgery would be, at best, unsafe and very painful. But beyond the pharmaceutical laboratories stretch marketing departments, an enormous sales force, and corporate board rooms that seek expanded markets. Television, magazine and newspaper ads show sincere, dedicated researchers seeking cures for debilitating diseases, but the primary goal of advertising is to convince doctors to prescribe the company’s drugs. Direct advertising to consumers enlists the general public in the task.
The project is wildly successful. In 1993, around the time marketing drugs directly to consumers became legal, patients filled 2 billion prescriptions for medications. By 2003, after a population increase of only thirteen per cent, the prescription rate was up 70 per cent to 3.4 billion, or 11.8 prescriptions medications a year for every man, woman and child in the country.
Expanding disease definitions expands markets
Dig into the pharmaceutical company culture and you will find policies that push expansion of disease definitions to include more and more people who are not actually sick. Drug marketing highlights selected risk factors for future illness, and converts them into “diseases” in their own right, to be measured by tests and managed by drugs. Examples? Cholesterol levels and bone density measurements. High cholesterol and osteoporosis are not diseases since they do not impair functioning and cause no symptoms. Among many other factors, they are simply correlated with illnesses that appear later – heart attacks and fractured bones.
Other risk factors such as inactivity and poor diet – the ones unresponsive to drug magic – fade in importance as marketers seek to convince potential customers that the risk factor that responds to drugs is the primary cause of a potential illness. Scratch the surface of “awareness campaigns” and you are very likely to find drug companies behind them, ready with easily packaged solutions for the problems they’ve brought to your attention.
Keep track of the ads you see, and you’ll notice other “illnesses:” depression, anxiety, pain, sexual “dysfunction,” gas, bloating and other non-specific stomach ailments. Some people suffer significant medical problems in these arenas, but the marketing is aimed at the far larger numbers who have minor and temporary complaints that fix themselves, or can be fixed by facing problems and adjusting lifestyles. The blossoming Type II diabetes epidemic is a great new opportunity for pharmaceutical marketing of drugs – the focus will be on controlling blood sugar rather than on the weight control, diet and exercise needed to prevent the disease.
The molding of the therapeutic mindset by the drug industry
Most doctors report that they are not influenced by marketing, even if they attend industry-sponsored seminars and meetings set in luxurious vacation spots, or meet with drug company representatives who dispense free samples. But there is a much more insidious and effective corporate influence on physicians: the molding of the therapeutic mindset by continuing education. The pharmaceutical industry recruits influential physicians in respected academic institutions to oversee the studies that get new drugs through an arduous approval process. Results are reported in prestigious medical journals, under the authorship of highly respected investigators. Nothing but pure scientific interest appears to motivate the research.
But pharmaceutical sponsorship produces gray areas: reports are very often written by drug company employees who extract results from data provided by the researchers; negative results sometimes escape reporting; statistics have a way of making very modest results look impressive, especially to consumers reading the simplified translations drug companies provide as press releases.
Doctors rely on a constant stream of reports of advances by medical researchers to chart the best course of treatment for their patients. Like consumers, they need good information untainted by commerce. Professional journals now require publication of their author’s affiliations with pharmaceutical companies along with any articles involving the company’s products. This is a step toward much needed transparency. Other steps have to come from the audience. More than ever we need to be educated and to be aware of fear tactics and manipulation.
Statistics color perceptions
A good, educational starting point is a rudimentary understanding of statistics, because the benefits of drugs must outweigh their risks to justify treatment of any condition. The use of “relative” numbers to inflate trivial differences in risks and benefits is psychologically misleading and happens all the time. Reporting something as a 33% or 50 % improvement in risk may only mean the difference between one and two or three cases in the 100 people studied over however many years the study ran.
Vast numbers of people, including children, take daily medicines that target behaviors and moods, or single risk factors for a disease. Based on short term studies, the drugs appear safe. But there are no long term studies yet to guide us in this new era of perpetual drug use aimed at optimizing behavior and preventing disease.
Be wary; ask what statistics really mean, and pay attention to drug-free ways of preventing disease and modifying behavior.
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