Monday, June 9, 2008

Doctors and Drug Companies

From the New York Times comes this troubling story: child psychiatry experts who pioneered the diagnosis of bipolar disorders in children and who recommended the use of powerful antipsychotic drugs in pediatric patients failed to disclose just how much money they were being paid by the drug companies:
In 2000, for instance, Dr. Biederman received a grant from the National Institutes of Health to study in children Strattera, an Eli Lilly drug for attention deficit disorder. Dr. Biederman reported to Harvard that he received less than $10,000 from Lilly that year, but the company told Mr. Grassley that it paid Dr. Biederman more than $14,000 in 2000, Mr. Grassley’s letter stated [...]

In the past decade, Dr. Biederman and his colleagues have promoted the aggressive diagnosis and drug treatment of childhood bipolar disorder, a mood problem once thought confined to adults. They have maintained that the disorder was underdiagnosed in children and could be treated with antipsychotic drugs, medications invented to treat schizophrenia.

Other researchers have made similar assertions. As a result, pediatric bipolar diagnoses and antipsychotic drug use in children have soared. Some 500,000 children and teenagers were given at least one prescription for an antipsychotic in 2007, including 20,500 under 6 years of age, according to Medco Health Solutions, a pharmacy benefit manager.

The Times article points out that the diagnosis of these types of disorders in very young patients remains a subject of controversy, and that the drugs in question are known to have more severe and lasting side effects when used by children. However, the Harvard researchers mentioned in the article were operating under an "honor system" of reporting income from drug companies; few safeguards are put in place to make sure that income from sources that might show a conflict of interest are openly disclosed.

One of the doctors the Times article mentioned is Dr. Joseph Biederman, who is on the staff at MassGeneral Hospital for Children. In addition to his work with bipolar children, Dr. Biederman is known for work with children with ADHD as well. An article on the MassGeneral website quotes Dr. Biederman as saying the following:

“Early diagnosis and appropriate treatment are essential so that ADHD can be managed, giving patients and parents a sense of control and peace of mind,” emphasizes Dr. Biederman. The American Academy of Pediatrics recommends stimulant medication to treat core symptoms combined with behavior therapy to improve functioning. Although some parents worry that medicating a child for ADHD may only encourage that child to use illicit drugs later on, Dr. Biederman and his MassGeneral colleagues have conducted studies suggesting the exact opposite. They authored one widely quoted 1999 paper in Pediatrics, for instance, which showed that children with ADHD who were treated pharmacologically in childhood were three times less likely to develop substance abuse four years later in adolescence than those who were not treated. In the years since, they have published additional research—including a 2003 meta-analysis in Pediatrics— documenting how treatment for ADHD significantly reduces the risk of alcohol and drug abuse later on.
It's unclear at this time whether Dr. Biederman was underreporting grant money from ADHD drug manufacturers when he recommended the above course of action.

Frankly, the problem of the financial ties between doctors and pharmaceutical companies is one that is largely undiscussed in the mainstream media. While an egregious conflict of interest like the one displayed by the Harvard researchers might be noticed, lesser perks doctors receive for giving Big Pharma reps access to them--and thereby to their patients--is just part of how modern American medicine works. Pharmaceutical companies spend staggering amounts of money each year in their efforts to convince doctors to push their products; patients generally have no idea that the great new drug their physician seems so enthusiastic about paid for his dinner last night or his vacation last month.

But patients trust their doctors to be ethical in their recommendations for new drug treatments, and would likely be troubled by the conflicts of interest between doctors and major pharmaceutical corporations if they understood the extent to which these conflicts exist. The Harvard researchers' behavior may involve greater sums of money than most doctors will see from a BigPharma corporation in a given year, but to some extent most if not all doctors are accepting some sort of compensation from drug companies, and are then quite likely to turn around and prescribe a medication with little information other than the pharmaceutical company rep's glowing report. This isn't just wrong; it's dangerous. An estimate of the number of deaths due to prescription drugs puts the number at more than 100,000 a year. Granted, not all of these adverse events and deaths were caused by doctors prescribing new products based on a rep's sales pitch without having researched possible side effects and complications their specific patients might experience--but just how many deaths do occur for that reason is likely to remain unknown.

The reality is that Dr. Biederman and the other Harvard researchers were behaving no less unethically than most American doctors do; the difference in their behavior is one of degree, not of kind. The extent to which our doctors are in cahoots with major pharmaceutical corporations is part of the American medical landscape--but the fact that it's common makes it no less troubling.


lwestin said...

Good post.

Unfortunately, the motives of doctors and hospitals cannot be assumed to be in the best interests of the patients. The CMA is currently supporting a case where the Winnipeg 'Grace' hospital is fighting for the right to decide whether and when to withdraw 'care' from a patient, care being defined as including food and water. The CMA hopes to set a precedent of doctors and hospital having exclusive say - regardless of the family's, or even the patient's view.

Irenaeus said...

And people wonder why I'm sceptical Big Science.

Sarahndipity said...

I'm sure this is how birth control pills are pushed, too, and why they're prescribed for every female problem imaginable, even if they don’t treat the underlying condition. Where is the feminist outrage over this?

freddy said...

Sadly, patients are also complicit in this mentality as well. How often to expensive ads ending with "...ask your doctor about..." permeate the public psyche with the attitude that there's a drug out there for every problem, if we only ask our doctor. How often do people approach doctors expecting to receive a magic illegible prescription & a handful of samples? How angry people get when a doctor refuses medication and prescribes a lifestyle change or a "wait-and-see" approach! And how quickly they change doctors! The problem is systemic, and has been for a long time.

Anonymous said...

Was about to write something long and tedious, but essentially agree with Freddy.

Drugs are a pervasive part of our society, somehow inexorably linked to the word 'healthcare'.

As a pharmacist that reads 'Our Daily Meds' one day and attends a pharmacy seminar the next wherein physicians describe use of antipsychotics in autistic children for control aggressive outbursts and hostility, I realize that the real picture is somewhere between the sensationalism of what journalists observe and arguments waxed by those that think the question of medications and health is a simple clearcut issue, even in comparing greed vs. altruism or decency (such as the issue of why physicians can be paid speaking fees and other monies and not disclose it when publishing research).

For one thing, there are an awful lot of people that don't even try to understand how their own body works, others don't seem to trust their own eyes when the emperor is running around naked. Pharmaceutical sales reps for the most part are those people that are in drug sales; they aren't actually doing the art, but they're part of the ad campaign. They know nothing beyond the pitch they've memorized. Generally, they are not experts on anything except selling their product.

But, back to the ultimate consumer, it seems from a dispensing standpoint, that patients don't even want to know how to best make a medication work for them. I see it every day any time day or night, for the most part people using emergency facilities needing urgent treatment don't even know what medications they are taking, let alone for what reason.