Drugs

I just recently found this hilarious picture via Kevin, MD, which is a shot of Pharmaceutical Rep Barbie. And it reminded me (since, thankfully, neurosurgery is over and I don't have to think about it this evening) of a lecture I had a while back from one of the cardiologists I have worked for. Great guy, ridiculously intelligent, and coiner of some of the all time greatest hospital aphorisms. Anyway, he was talking about drug reps, and how they get doctors to prescribe their medications. Strategy number one, said he, is the "Catherine Zeta-Jones Approach." I'll attempt to recall the way he described his first exposure to this phenomenon:

"So, I'm working as an intern, horrendous hours, I haven't seen the sun in weeks, and all of a sudden, this, vision, appears out of nowhere and says "Doctor, have you heard about the efficacy of [drug X]?" Now, no, I hadn't, but it really didn't matter. This beautiful creature, she called me doctor. I stared, open mouthed, as she gave me the paper discussing the drug and said some things I barely recall. And I prescribed [drug X] several times after that before really thoroughly reading that paper."

Once he read the paper, he discovered that the techniques used to show the efficacy of the drug were almost unheard of. The study used a variety of complicated statistical tricks to evidence Twain's quip about three kinds of lies. And when he did further research, he found that the study's problems were noted before publication, and the only way they got the article published was by calling up the editor of the New England Journal and telling him they would purchase 10,000 reprints of the article, enough to cover the Journal's operating costs for a year.

The story did more to change my opinion of drug companies than anything has. I tend to be fairly reserved in my opinion about them. Some drug reps are nice, some are obviously salesmen (actually, usually saleswomen, see above) and I take everything all of them say with a shaker of salt. I know from my chemistry background how difficult and expensive drug design is, so I find the arguments the average "bring down those on high" politician makes to be completely laughable. I still do. But hearing this story of subversion in the foremost academic medical journal in the world made me reconsider a bit.

Thankfully, the editor responsible for that fiasco is gone. But the story demonstrated the lengths some companies will go to in order to sell drugs. Scarier still is the direct marketing to consumers, something which almost certainly leads to abuses in the system.

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During the whole process of thinking about this post, I was listening to my iPod, shuffling away random selections, and oddly enough, the Rolling Stones "Mother's Little Helper" which has the line "And though she's not really ill, there's a little yellow pill..." came on. The song recalled a factoid I memorized during my psychiatry rotation: fully one third of people in developed countries are depressed at some point in their lives. Which of course brings up two questions: one, is there something about our lives that makes us this way; and two, are we just giving a name to something natural in order to sell something? These questions can (and should) be broadened to include most diseases, in the mind of the doctor.

I think ADHD is almost certainly over diagnosed, in a culture averse to the time commitment involved in raising children. It was frightening on my peds rotation to hear mothers say (and I heard it twice, in two weeks of clinic): "I just want you to give him something so he'll sit still." Um, hello, you have a 5 year old boy, sitting still is the last thing on his mind when he's not in school. Why don't you take him to the playground and let him run around instead of giving him an XBox to teach him that immediate gratification is a universal, and drugging him up for the occasions when he finds that isn't true? Sometimes I think the surest case for our culture being locked in a death spiral is the fact that we spend millions of dollars on getting children addicted to amphetamines.

A long time ago, the ending of a Choose Your Own Adventure novel I read had the protagonist wind up attached a machine that kept him warm and comfortable, but trapped, for the rest of time. Periodically he would be lowered into a warm pool and forced to swim, keeping his muscles from atrophying, but otherwise, the warm, senseless oblivion was all he would know forever. For the majority of people, this vision, I am afraid, seems less like a nightmare and more like a paradise every day.