I’ve been reading a brave book that I wanted to like but I don’t. It is called Drug Truths: Dispelling the Myths about Pharma R&D. The author is John L LaMattina, who is the retired president of Pfizer Global Research and Development.
The pharmaceutical industry has had a bad press over the past couple of years, and nothing would have given me greater joy to report that all was now good; that there was no more overselling of drugs and no more inappropriate advertising. But instead, I am seriously worried by this book. It seems to imply that there was no such overselling in the first place and that industry has always behaved well.
For example, let me quote a piece about disease mongering. “The view that the pharmaceutical industry sits around dreaming up new diseases and then convinces people that their minor ailment urgently needs drug treatment is absurd. First of all, a company cannot simply declare a new disease and market a drug to treat it. A disease must be recognised by global regulatory agencies who set up criteria that a drug must meet in order to have even the most remote chance to be approved. Second, payers must believe that the condition is serious enough to warrant reimbursement of the cost of the drug to treat it. Third, physicians must believe the disease is serious enough to be willing to prescribe a drug to their patients to treat it. And finally, patients must be concerned enough about their pain or discomfort to be willing to seek treatment in the first place.”
From a perspective of unfiltered primary care, I think I’m in a reasonable position to comment. Why do patients go to their doctor? All kinds of reasons. The ecology of what goes on in the consulting room is dependent on numerous external influences; advertising – or let us call it “disease awareness”, where people are encouraged via “educational campaigns” to see their doctor if they have symptoms of various diseases or disorders, is one. Expectation of medication is introduced with ease. One example is the “awareness campaign” a couple of years ago encouraging men to attend their doctors if they had erectile dysfunction. On the value of seeing one’s doctor, I could not disagree. However, ED can have a variety of causes, from the psychological to vascular disease. Medication can be useful, however it may not be appropriate, and further tests may be needed. But by creating expectation of medication, the process of proper medical care is short circuited. LaMattina has not considered that some physicians will simply give in to the expectation and pressure to prescribe. Similarly, LaMattina describes irritable bowel syndrome (IBS) as another disorder where the pharmaceutical industry cannot be accused of disease mongering: “This is clearly not a disease invented by a pharmaceutical sales executive.” What he fails to do is to appreciate the spectrum in the disorder. Like depression, anxiety, and pain, there will be some people who are entirely or heavily disabled by their symptoms. And then there will be others who have minor symptoms, who are only occasionally bothered by them, who may find that taking medication is more hassle than not, or who have other non-pharmacological ways of dealing with their symptoms. But “disease awareness” advertising threatens to make these people “patients” with all the problems that this delivers.
Similarly, with cholesterol, LaMattina says, of a particular senario, “…should you take a statin? Given that statin use lowers your risk of a heart attack by as much as 35 per cent, the answer should be a resounding ‘yes’! This type of treatment is not disease mongering – it is preventative medicine.” But actually, it’s not just disease mongering but also scaremongering. It is almost impossible to make a realistic decision about risk based on relative risk alone. What you need to know is your absolute risk – there is no point knowing what per cent you can reduce your risk by until you know what your risk was to start with.
Now, if the pharmaceutical industry were able to say: actually, we won’t get involved with “awareness campaigns” anymore because the best health information is independent health information, I would be happier. If there was an acknowledgement that funding patient groups was fraught with difficulty, I might be sympathetic. The recent report from the Royal College of Physicians on Physicans and the Pharmaceutical Industry . makes it clear that the pharmaceutical industry wants to rehabilitate itself. There are some things all are agreed on – industry shouldn’t be offering “gifts” to doctors, and doctors shouldn’t be accepting them. But the RCP report argues for “co-operation” between doctors and pharmaceutical firms especially with regard to research. I think this is premature and potentially dangerous. Pharmaceutical companies simply do have a different agenda to doctors. Any relationship has to be under constant and open scrutiny; and I am not sure that there has been a proper appreciation of the past problems such that they have disappeared and will cause us no problems in the future.