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The Drugging of America

Walmart(!) Neutralizes a Day from Hell…

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A cold day in Hell…

Yes. Walmart, bless its corporate heart, managed to bring a quick, neat end to what started out as a Day from Hell, morphed briefly into a sad but real Day from Heaven, and then began to slide downhill again.

Cassie the (Ailing) Corgi had a pretty good day yesterday — at some moments possibly even rising to a 10 on a scale of 1 (about to expire) to 10 (back to normal). Foolishly, I thought, oh gosh! she’s gonna be OK!

You’d think I’d know better by now, wouldn’t you? 🙄

Beginning about 1 in the morning, she started coughing again. And coughed the rest of the night away. By morning she was so exhausted she was immobile.

I call the New Vet at 8 a.m., the instant they open.

In the interim between the time the dogs and I roll out of the sack and the time I can reach the vet, I pick up the laptop and, in the course of glancing at the news and waypoints, visit a complicated draft “page” at Plain & Simple Press where I store material waiting to publish it. Yesterday I spent HOURS updating and fully formatting it, an endless, tedious, mind-numbing job.

This morning? It was A.L.L. G.O.N.E.

Yes. Hours of brain-banging work, disappeared. And no, I couldn’t retrieve it for love nor money. But there wasn’t much time to fret about it…

The vet’s staff asks me to bring in the dog at 8:45.

This was pretty tight because I had to sing at a funeral at 10. And this was not one I was about to miss, since it celebrated the life (and presumed afterlife) of a lovely friend.

Okay. Brush teeth. Wipe off yesterday’s make-up. Throw on some fresh make-up. Lift the dog into the car, where she collapses in a limp pile. Fly through the rush-hour traffic, to the extent that one can fly through such a thing, and make it with eight minutes to spare. Time ticks by as the vet and I and her underlings discuss. It’s pushing 9:15. I still haven’t fed Ruby and still am not dressed in the requisite black duds and still have a half-hour or more to get back to the house and another 15 minutes to get down to the church. Nor, we might add, have I had breakfast or even so much as a swallow of coffee.

Seeing that I’m getting anxious, they suggest I leave the dog at their clinic, where they will test her again for the alleged, never-proven Valley fever and test for heartworm, which can cause the same kind of coughing, lassitude, exercise intolerance, and bloating. At this point, the new vets persist in the theory that the problem is not the diagnosed adrenal tumor but in fact is yet-to-be-provable Valley fever. This is entirely possible: dogs frequently test negative on the first try at Valley fever testing. It has, however, been more than 4 weeks (by far) since the first effort, so if she does have the disease, by now she should test positive. They want to put her back on fluconazole. I tell them I’d rather put her down, it made her so sick. They propose another concoction that has even worse side effects.

I fly out the door and arrive at the funeral rehearsal right at 10 a.m., to the director’s surprise (since I’d emailed her that I’d be late). On the way there, I reflect that she was also taking prednisone during the last go-round with fluconazole. Prednisone had some mighty baleful effects on the dog. It occurs to me that there could be some drug interaction.

The funeral comes off very lovely. Dear friend and leader on the choir who just had hip surgery showed up and, amazingly, managed to get up the stairs and participate in the whole ceremony. Old friends who have been off the choir, beautiful voices, also attended: a joy to sit with them and listen to them sing again.

Later, when I get back to the house, I look the drug interaction question up and discover — from Pfizer, the horse’s mouth — that discontinuing fluconazole causes increased metabolism of prednisone, which leads to adrenal insufficiency. Which would explain quite a lot…possibly we could try the fluconazole in the absence of prednisone to see if it will go down any more easily.

Along about 3 p.m., I get back to the veterinary. Cassie is barking and looking pretty perky. WTF? She was at Death’s Door in the morning…I had to carry her through the house to the car and then carry her from the car in the vet’s door.

They did another chest X-ray, since they never were able to extract the image I paid for from MarvelVet. They also did a heartworm test and sent off for another Valley fever titer.

However, it’s beginning to look like the dog probably does not have Valley fever. The white area around the lung and heart that MarvelVet cited as proof of his hypothesis was gone; the sound of her chest has been clear for several weeks, and still is. New Doc believes the problem is and has been a bronchio-pneumonia, probably of bacterial origin because the doxycycline we gave her for the UTI she developed seemed also to help clear up the cough…and doxy is the drug of choice for doggy pneumonia.

Unfortunately the doxy made the dog so sick I had to take her off it after 19 days (of 21 prescribed). She thinks, though, that the dog may be on the mend, and she’ll be OK if we can soothe the cough.

So she suggests Robitussin DM, in a dosage she specified.

 As for the adrenal tumor, this new intelligence just in:

  • New Vet doubts that any of the dog’s symptoms have been caused by the adrenal mass, which the sonogram doc believes to be nonmalignant. New Vet says most adrenal tumors in dogs have no symptoms (this is not altogether accurate, but let’s put our money on it for the moment.)
  • She thinks the bloat probably originated with the prednisone, which should not have been given in conjunction with fluconazole.
  • Other more classic fluconazole side effects, including anorexia and stupor and obvious misery and diarrhea and labored breathing, were caused by…yeah: fluconazole.
  • Taking her off the prednisone without titering her off even more slowly than I did would have caused adrenal symptoms, and giving fluconazole at the same time as prednisone can cause adrenal insufficiency that may or may not go away in the absence of the drugs.
    • Read: we’re talking about an iatrogenic problem aggravating a misdiagnosed ailment…
  • She doesn’t seem to have an explanation for the extreme swings in the dog’s well-being: yesterday Cassie was at a 9 or even a 10 on the 1-10 scale; this morning she was back down at a 1 or 2.
  • The dog does not have and probably never has had a collapsed trachea.

So…if our furry friend picked this up while nosing around in the grass during a doggy walk (which is how such infections spread among dawgs), I guess I should feel lucky Ruby didn’t get it, too. Actually, Ruby did cough some, very mildly and for just a few days; she may have had it and thrown it off because she’s so much younger.

This poses the possibility, though, that Cassie could recover. Maybe.

Now, as for that Robitussin DM: for veterinary purposes, the stuff has to have 20 mg of dextromethorphan and 200 mg of guaifenesin per 10 milliliters of sauce. Ohhkayyy…

So I figure I’ll trudge down to the Walgreen’s, stand in line till the cows come home, ask a pharmacist to direct me to the correct concoction, and…ugh, how awful does that sound?

Why do that when I can order it up from Amazon?

Right.

Right?

R-i-i-g-h-t.

Amazon offers approximately 87 gerjillion variants of Robitussin DM. The only one that has this particular proportion of active ingredient-to-active-ingredient-to-inactive-ingredients comes in “prepackaged spoonsful.”

Say what?

I do not want spoonsful, prepackaged in plastic waste or not. This stuff has to be hoovered up into an oral syringe so it can be squirted down the hound’s gullet.

Now in the middle of evening rush hour, whereinat you can not turn east out of my neighborhood because of the effing stupid “reverse lanes” the city has inflicted on us, I set out for the nearest Walgreen’s, which rests near the corner of GangBanger’s Way and Commuter Nightmare Parkway East. This, I dread, because I’ve been harassed in that store’s parking lot before and do not look forward to more harassment. The other nearby Walgreen’s is here in the ‘hood — couldn’t pay me to unlock my car doors in front of that place, especially not at dusk. The third Walgreen’s is way on down East Commuter Nightmare Parkway; though I can turn into its parking lot (where I also have been harassed), turning out of it in a direction that will bring me home is, shall we say, highly problematic.

O shit o hell o damn i do NOT want to do battle with any one of those dreary Walgreen’s.

But…right about then it dawns on me that I don’t hafta. There’s a Walmart on the way to Nearest Walgreen’s. It’s on my side of the road (no illegal or risky left turns across torrents of traffic) and its exit guides me straight to a left-turn lane that sets me on my way home, via Gangbanger’s way. Hot dayum!

Get into Walmart. It’s crowded — I have to park a long way from the front door. This — crowdedness — is a good thing, because drug-addicted panhandlers tend not to pester anyone when there are a lot of people in the parking lot. Into the store without incident. Quickly snab a fine young pharmacist; tell him the challenge. The kid is ready to rise to it. We sally forth into the cold nostrum aisle, and darned if he doesn’t find a version of Robitussin DM that comes close to the required proportions.

I say this is 20 mg of dextromethorphan and 200 mg of guaifenesin to 20 milliliters of sauce, not to 10. He points out that the solution to this is simply to give the dog twice the suggested dose.

Yeah. Well: we do have the possibility that a rushed vet could have the proportion wrong.

I say the solution is even simpler: give her the suggested dose and see if it works. Often OTC stuff like this will work with less than the recommended dose. If it does: bully. If it doesn’t, so then I just give the second half of it. He allows as to how this is an acceptable plan.

I grab the dope, head for the door, and in spite of a hectic scene find a cashier standing there all by his little self. Pay and shoot out the door without having to wait a minute.

Traipse to the far end of the crowded parking lot: not a single panhandler in sight. Yes!

Thank you, Walmart! Who’d’ve thunk it?

The Drugging of America: Lifestyle as Remedy

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In considering the plague of overprescription afflicting our country and many others, we’ve seen that huge numbers of Americans regularly take pills — prescribed or over-the-counter — that are unnecessary, inappropriate, redundant, or otherwise ill-advised. Many of these remedies, inflicted on patients for reasons both altruistic and self-serving, do not treat the chronic problem for which they are intended. Some of these people should never have been deemed “patients,” and their supposed problem is not a real problem at all. Often the drugs do not prevent future drastic health events, but instead inflict harm on the people who are persuaded to take them.

This is happening for a variety of reasons, ranging from doctors’ natural concern for patients’ well-being to the exploitation of these concerns by the spectacularly profitable pharmaceutical industry, which stands to gain many billions of dollars by putting the aging Baby Boom generation on long-term drug therapies. Two examples of this — among many — are the new vogue for diagnosing and treating scary-sounding “pre-conditions” and the campaign to lower the threshold for diagnosing “hypertension” to the point where some two-thirds of the American population are targeted for blood pressure meds.

As a result, more and more people are taking more and more drugs, often to no useful purpose. There’s even a name for it: “polypharmacy”– taking five or more prescription drugs to treat chronic conditions. By 2013, the Mayo Clinic estimated that 20% of Americans were taking that many drugs at a time; 70% were on at least one prescription. It gets worse as you get older: some 25% of people aged 65 to 69 are on five or more drugs, and that figure jumps to 46% for those between 70 and 79. This is not a benign thing: polypharmacy results in a wide variety of health problems and can lead to death.

The problem has become so pervasive that public agencies in the United States, Canada, Great Britain, and Europe have launched “de-prescribing” campaigns, efforts to inform the public of the risks of overprescription and to get people off unnecessary medications. These public-education schemes provide useful guidelines for identifying drugs that you might not need to be taking and for reducing the number and potential toxicity of drugs taken to treat real conditions.

Understand: I am not a doctor, and so what follows does not constitute medical advice. If you have a life-threatening ailment — or one that compromises the quality of your life and is unlikely to go away on its own — you need to see a doctor and follow a doctor’s advice. If you question that doctor’s judgment, get a second opinion; do not base your decisions on what you read on the Internet.

But here is what seems to be the case…

Some ailments, as we have seen with the “pre-condition” fad, are not ailments. They might (or might not) indicate a vulnerability to some ailment, but they are not the ailment. Furthermore, some real ailments can be treated with physical therapy,; by laying off the tobacco, the sugar, and the booze; and by building an all-around healthy lifestyle.

Yeah, I know: heard it on the Internet…

But a review at The NNT (“number needed to treat“) caught my eye and convinced me to look further into the “lifestyle change” gambit. This study showed that for people who have not yet begun to show signs of heart disease, the so-called “Mediterranean diet” does indeed work to help prevent heart attack and stroke. Say the researchers: “…based on a 30% reduction in events the Mediterranean Diet represents the most beneficial and least harmful intervention we have seen.” Even then: only 1 in 61 were helped; but none were harmed, contrary to the pharmaceutical approach.

Okay, that’s fine if you have no cardiovascular symptoms and you’ve never enjoyed a cardiovascular event. But what if you’re already sick with one or more  heart and vascular issues? Read on…

Way back in 1998, a five-year randomized study of heart attack victims (of whom 10% were women) showed that people who had already experienced a cardiac event were much more likely to stay well if they ate a Mediterranean diet rather than the diet then recommended by the American Heart Association — which, we might add, was far lower in cholesterol and sodium than the standard American diet. After about four years, 8% of the 303 people in the control group had died; but only 4.67% of the 302 Mediterranean dieters died. Got that? Thirty-four AHA dieters vs. fourteen on the Mediterranean eating pattern. That’s more than twice as many deaths!

Additionally, 33 members of the control group (8.2%) experienced nonfatal heart attacks, vs. 8  in the Mediterranean group (2.6%). Thirty-three? Forgodsake, that’s four times as many recurrences of cardiac events among the people who eat modified, low-fat American fare!

The reviewer of this study, Dr. Joshua Quaas, remarks that “The magnitude of this study’s results is astonishing. To compare saving a life post-heart attack with this diet (NNT= 30) and with statins (NNT=83) suggests that diet is nearly three times more powerful as a life-saving tool. A few factors make this particularly remarkable. Cancers were also reduced, while some authors have raised concerns about statins increasing cancer risk (without supporting evidence in the industry-sponsored trials to date). Imagine that the control group had been following a typical dietary pattern rather than the AHA recommended diet; the size of the effect could be even greater. Finally, the study suggests that cholesterol, which was not reduced by the Mediterranean diet, may not be as important a dietary consideration for heart disease prevention as currently thought and practiced.” In a 2010 update, Dr. Quaas observed, “Given the existing data and lack of harms the Mediterranean diet seems beneficial and should be strongly recommended at this time.”

The Mediterranean diet is one hell of a lot tastier than a fistful of pills. It will not make you dizzy. It will not make your head hurt. It will not cause you to feel so fatigued you can barely crawl from the bed to the toilet. It will not cause your hair to fall out. And it will not turn a profit for any huge pharmaceutical corporations. Combine it with exercise and modest weight loss, and you can bring your blood pressure down and improve your cardiovascular health without benefit of Big Pharma.

That latter contingency is probably the reason we don’t see every doctor in the land putting patients on a diet of veggies, fruits, fish, and modest amounts of meat swathed in olive oil. Once again we return to the old investigative reporter’s dictum: Follow the money trail. Nobody’s getting rich on it, so it’s not the “treatment” you’re going to get.

The Mediterranean diet also works against “pre-diabetes,” and it can be helpful for people who have actual, real diabetes. In 2009, results of a four-year study showed that people with type 2 diabetes who stuck to a Mediterranean diet with at least 30% of calories coming from fats (primarily olive oil) gained better control over the the condition without diabetes medications than those who ate a low-fat diet with no more than 30% of calories from fat (with less than 10% coming from saturated fat sources). In this study, 44% of people who agreed to follow the Mediterranean diet ended up having to take medications to control blood sugar. But 70% of those in the low-fat diet  group did.

The so-called “Mediterranean diet” is not exactly “health food,” at least not in the way most of us think of the revolting exotica favored by fanatics. It is, in a word, delicious. It is Italian food. It is French food. It is Greek food. With a backyard grill or a decent oven, it is ridiculously easy to prepare. And you can buy the ingredients in any grocery store.

It does require you to learn to cook, in a low-key way. But the labor involved has yet to kill anyone.

And it’s not what I would call a “diet.” No one is going to feel deprived if forced to stick to this cuisine:

  • abundant fruits and vegetables
  • olive oil as the principal source of fat
  • fish and poultry consumed in low to moderate amounts
  • dairy consumption is mostly of cheese and yogurt (less butter/cream)
  • red meat consumed in low amounts
  • red wine in low to moderate amounts

Compared to the wacksh!t diets some would like to put us on (remember when we all had to abandon our butter for margarine? Remember when we decided that oops! all that hydrogenated corn oil not only wasn’t helping you, it was harming you?), it’s strictly from cordon bleu.

If you need a guide to this, here’s a website devoted to hyping it. The Mayo Clinic has a shorter and less self-interested page describing the scheme, nicely organized in one place and easy to understand. And about two-thirds of the recipes in my cookbook, 30 Pounds/4 Months, fall under the heading of “Mediterranean,” as defined by these guidelines.

So, eat well, drink well. Do not smoke. And avoid eating and drinking things that are laced with sugar and other chemicals.

And also exercise well. Contrary to enthusiasts’ insistence, you do not have to go out and beat yourself to exhaustion: you can extract health benefits from ordinary, mild exercise. The trick is to do it regularly and not to hate it. A thirty-minute walk a day will do the trick. Walk the dogs. Go for a brisk stroll in your local park. Walk to shopping instead of driving. Climb the steps instead of riding the elevator one or two or three stories.

Whenever you can generate an opportunity to create some extra steps, do it. In a parking lot, park as far away from the store or office entrance as you can get. If you go into a Safeway and then need to visit the Walgreen’s catty-corner across the street, don’t move your car over there: leave your car in the grocery-store lot and walk across the intersection and back. Have a parking garage at the office? Park on the top floor and go down and back up by the stairs.

These very simple strategies will help you to avoid developing a chronic healthcare problem, and if you do, they can help you to control it or maybe even make it go away.

What about so-called “alternative care?” Will gulping supplements, for example, cure what ails you?

No.

Snake-oil salesmen come at you from all directions, not just through medical practices targeted by Big Pharma. Remember: those supplements are produced somewhere, and that somewhere is often Big Pharma. There’s as much money in over-the-counter nostrums as in the prescription varieties.

For some time, we were told that calcium, magnesium, and potassium supplements would work miracles for our cardiac health, for example. Not so much, as it developed. For managing hypertension, a 2006 study showed “no robust evidence to suggest that combinations of potassium, calcium or magnesium can reduce high blood pressure (BP) in adults.”

So convinced are we, though, that popping pills must be the key to good health that by 2013 more than half of Americans and 68% of those 65 and older were regularly swallowing vitamins.

The fact is, though, no conclusive evidence has shown that dietary supplements prevent chronic disease in most people. Nutrients that occur naturally in a healthy diet and protect from certain ailments may, when distilled into a pill, have exactly the opposite effect. For a long time, for example, we were told that beta carotene was going to protect us from “oxidation” and the subsequent damage to cells that would lead to cancer. Imagine the surprise, then, when several strong studies in the 1990s showed that ingesting beta carotene supplements increased lung cancer rates among hopeful smokers. We were told that vitamin E, another antioxidant, also would protect us from cancer. Well, no: a 2011 study showed that vitamin E and selenium not only did not prevent cancer, they actually increased prostate cancer rates among men — by 17 percent!

It does not seem to matter whether the pills come to you over the counter or through a prescription. If you do not have a life-threatening or pain-inducing condition — a real one, not one invented to sell drugs — don’t take pills.

There are better ways to maintain health and to treat the conditions (if “conditions” they can be called) that come naturally with living and aging. Healthy eating. Moderate drinking. Moderate exercise. Abstention from known toxins (such as tobacco and dope). None of these things are hard. And none of them cost you or your insurer anything like what a prescription costs.

Series:
The Drugging of America

The Drugging of America: Deprescribing

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Over the past couple of weeks here at FaM we’ve seen evidence that Americans have been sucked into a vortex of unnecessary prescription and nonprescription drug treatment. About all most of us have heard of this comes from the flap over the spreading addiction to opioids — largely blamed on the habit of prescribing addictive drugs for discomfort that could be handled with over-the-counter or nonaddictive prescription pain-killers. But in fact there is a larger, quieter movement afoot. It’s called deprescribing.

Its purpose is to bring a stop to putting everybody and his little brother and sister on handsful of long-term, sometimes redundant, sometimes conflicting drug therapies.

Deprescribing is “the process of tapering, stopping, discontinuing, or withdrawing drugs.” The goals are to reduce the widespread use of “polypharmacy” — in which a person regularly takes five or more drugs — and to improve health and outcomes for patients who actually do need medication. As polypharmacy has become an international problem afflicting most developed nations, so deprescribing is being taken up worldwide.

The Canadians in particular pursue the issue with some vigor. Two invaluable sites from that country are Deprescribing.org, operated by Dr. Barbara Farrell, a research pharmacist, and Dr. Cara Tannenbaum, a research geriatrician; and the Canadian Deprescribing Network, which explains the issue and what you can do about it in words of one syllable. As the latter site points out, overprescribing affects older people more acutely than younger ones: “…[E]ach year in Canada 1 in 200 seniors are hospitalized due to harmful effects of their medication. Seniors are hospitalized five times more often than people under the age of 65 because of harmful medication effects.” Nevertheless, overuse of medications affects everyone. Women, older men and women, and people with more than one chronic condition are at the greatest risk. The site, on two pages, offers a total of fourteen safety tips for people who have to take prescription drugs:

Track your meds. It’s up to you or your family to keep track of the drugs you are taking. Your medication list is unlikely to be available to all health professionals online! Electronic medical records systems often don’t “talk” to one another.

Keep a list. For your safety, carry your own UPDATED list and keep one on your fridge. Make sure to include over-the-counter (OTC) drugs. Make sure drugs prescribed by specialists that you see are listed.

Stick to one pharmacy. Try to fill prescriptions from one pharmacy so drug interactions are easily checked. Any pharmacy’s list will only show what their pharmacy has dispensed to you and won’t include everything you take.

Don’t start a new drug when you’re alone. It’s rare, but if you have a severe allergic reaction you’ll need immediate help. Never take a prescription drug that was prescribed to someone else.

Check your prescription. When you pick up your prescription order, check both your name and the drug name on the bottle. At times, people who have the same name have received the other person’s drug.

Be aware of side effects and adverse effects. If you have a new symptom after taking a new drug, don’t assume it’s a “new condition” or “old age”. Tell your doctor or pharmacist right away. It could be adverse effects from the drug itself or an interaction with another drug you already take.

Beware of the prescription cascade. Sometimes new drugs might be prescribed to deal with symptoms caused by a drug you are already taking. This is called the “prescription cascade” – a common example is being prescribed a new drug for stomach upset, which may be caused by a drug you are already taking. Ask your doctor to consider whether new symptoms could be the result of the drugs and whether you should consider stopping a medication or reducing the dose, also known as deprescribing.

Look out for changes. Tell your doctor how new drugs affect you and whether there’s been a change for better or worse. Doctors may be depending on you to report and may not be actively monitoring the effects. If you SEE something (or feel something), SAY something (just like at the airport!). You do not have to be “right” in order to bring forward concerns about adverse reactions from a drug.

Seniors are more sensitive to medications. Older people are more sensitive to medications because of changes in their liver and kidney function as they age. In many cases, drugs for seniors should be prescribed at a reduced dose. The more medications used, the greater the chance of drug interactions.  Drugs commonly prescribed to older adults can cause dizziness and loss of balance, leading to falls or fractures and hospitalization, as well as cognitive and memory problems. Adverse drug reactions can start even if you have been taking a drug for a long time. Your doctor depends on you to raise issues of concern and to begin to talk about deprescribing some drugs: www.deprescribingnetwork.ca/starting-a-conversation

Ask for a medication review. Ask your doctor or pharmacist to review all your medications, especially if you are taking several or if different doctors prescribed them. This means reviewing your complete medication list to make sure all are needed and not causing problems as you grow older. List drugs prescribed by specialists and over the counter drugs too. Often, doctors are able to give you an appointment that is longer than the usual 10 minutes to have a consultation about your medications. It is up to you to ask for a review of your medication: don’t assume that your drugs will be reviewed on an annual basis. Remember to ask your doctor if you can either stop taking some medications or lower the doses of others as a result of the medication review.

Medication issues in nursing home settings need to be addressed quickly. In a nursing home setting, get answers quickly if you have concerns about your medications or a family member’s. Patients can lose function and mobility if bedridden from a drug interaction. Delirium (a reversible state of disorientation, agitation or drowsiness) or unusual behaviour can be caused by medications and it may be mistaken for a serious chronic illness such as dementia. Alert your family members and be prepared to go, with your family, to management, if you have serious concerns or can’t get an answer. If you feel anxious bringing up medication issues, ask a family member to make an appointment with nursing home staff and have them accompany you.

Avoid anticholinergic drugs.* Older adults are often prescribed anticholinergic medications (medicines that affect acetylcholine, a neurotransmitter) for common conditions such as overactive bladder, allergies, gastrointestinal problems, Parkinson’s and depression. Seniors are highly sensitive to the harmful effects of anticholinergic drugs. These drugs can have a negative impact on the brain by causing delirium, confusion and memory problems as well as physical effects such as dry mouth, constipation and blurred vision. Recent research is exploring whether these drugs have a role in dementia. While this link is still being explored, seniors should avoid these drugs whenever possible or ask for a safer alternative.

Ask questions and be wary. When your doctor suggests a new drug, you have the right to ask what the drug is for, what its benefits are and the risks of harm. Is the drug being prescribed for prevention? How likely is it that you would become ill in the future if you didn’t take it? Could the side effects outweigh any benefit the drug may have? It may not be worthwhile feeling unwell every day because of a drug to gain a small chance of having a little less risk of future illness.

Ask if deprescribing is appropriate for you. If a drug is bothering you, ask your doctor or pharmacist about the possibility of a “drug holiday” or a trial of stopping or tapering the drug and carefully monitoring the results. It is reasonable to see if a drug is causing problems if it is not a life-saving drug. You may find more information here.

* Anticholinergic drugs include a wide variety of commonly prescribed and over-the-counter nostrums, among them Benadryl, Dramamine, Advil PM, tricyclic antidepressants, and a variety of smoking cessation drugs.

A major problem with trying to get off one or more drugs is that many medications — both over-the-counter and prescription — can cause uncomfortable and sometimes dangerous kickbacks if you stop taking the stuff abruptly. For this reason, you need to talk with a pharmacist and, ideally, with your doctor about tapering off the drugs you’re taking, or stopping altogether.

Getting people off these drugs can be a complicated matter. Some sites that provide potentially useful information hide that information behind paywalls or demand private data and an e-mail address in exchange for access. Criteria for limiting drug use and helping people ease off  drugs can be challenging. The STOPP-START set of criteria, for example, is extremely complex. However, unlike the 2003 Beers criteria, the STOPP-START criteria list medications that have been shown to have significant adverse effects, and the STOPP-START approach has been shown to improve outcomes.

The American Geriatric Society offers updated Beers drug guidelines in relatively easy-to-access table form. Note than many of these drugs are readily available over the counter: Benadryl and its generic versions, for example. Proton pump inhibitors? Those are the pills you take for real or supposed GERD: omeprazole, for example. Some people will drop one of these drugs for ordinary indigestion, easily amenable to a couple of Rolaids. Estrogen? Mercifully doctors have stopped trying to put every middle-aged woman in the country on that stuff, but it still is frequently prescribed for any number of real or imagined ailments. Run your eyes down the list and you come to aspirin, ibuprofen, naproxen, famotidine, pseudoephedrine (Sudafed)…holy sh!t!!! In the U.S., any of us can buy any or all of these drugs at any time, with no advice or feedback from a doctor or a pharmacist. So, even if your doctors are not guilty of piling med on top of med, you yourself could inflict any number of potentially dangerous individual drugs or combinations of drugs upon yourself.

Two useful tools  for consumers are Medstopper, a Web-based program that disgorges guidelines for quitting specific drugs, and Worst Pills, Best Pills, which exists both as a Website and as indispensable reference work.

So what can each of us do about this state of affairs?

  • First, and most obvious: question authority. When a doctor wants to put you on some drug now and evermore, look it up. Learn all you can about the diagnosed condition, about all the approaches to treatment, and about the available medications. Seek a second or even a third opinion before agreeing to go on a medication for the long term.
  • Second, choose a pharmacy and have all your prescriptions filled there. This will create a single file listing all the prescription drugs you’re taking in one place, accessible by a specialist in pharmaceuticals.
  • Third, ask. When filling a new prescription, always ask the pharmacist (not the pharmacist’s assistant: the actual pharmacist, who has an advanced degree in the subject) how it will fit with your existing prescriptions and with any over-the-counter drugs you have around the house. Ask whether it is incompatible or redundant with any OTC drugs.
  • Fourth, keep your own list of all the drugs you’re taking (Rx and OTC) . Carry it in your wallet, so that if you’re ever in an accident or have an acute attack that sends you to the emergency room, medical personnel can find it easily.
  • Fifth, unless a condition is life-threatening, don’t be in such a hurry to swat it with a drug. Most ailments go away on their own. Most aches and pains resolve themselves in time or improve more effectively with physical therapy than with drugs. Tincture of time is often the best medicine.
  • Assume any new symptom or strange health manifestation that develops after you start taking a drug may be a side effect. Look it up.
  • Sixth, ease off as many drugs as you can. You may find you don’t actually need them, or other approaches with less malign side effects may work as well. Educate yourself about the issue in general and about ways to get off any unnecessary drugs.
  • Finally, take care of yourself. As a matter of fact, you are the only person who can take care of yourself. Eat healthy. Kick the nicotine habit. Drink in (extreme) moderation. Get regular exercise. None of this is hard…but it’s the best treatment you can apply.

This is the sixth of seven planned posts on
The Drugging of America

 

The Drugging of America: Who Funds That Treatment?

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If indeed Americans are over-consuming medications to a ridiculous extent — so much so that some call it an “epidemic” of overprescription — why do doctors buy into it?

The reasons are varied and complex, some having to do with a doctor’s natural desire to cure and to save lives and to fend off future ailments; others associated with less altruistic impulses. But one reason almost certainly is the existence of and recommendations from disease-related organizations that emanate advice on how to treat and live with various ailments. Much of this advice is directed at doctors. You no doubt have visited the websites of such groups: the American Heart Association, Susan G. Komen for the Cure, the American Diabetes Association, the Alzheimer’s Association…. You name the ailment: there’s a group for it.

Many of these organizations provide valuable information and advice for patients and their families. But it’s worth noting that some do urge testing and treatment that may not be altogether necessary or even well-advised. The Komen group, for example, advocates and has persuaded most American women that every woman should undergo regular mammograms. This, despite the fact that a closer look at this practice shows no real benefit accrues (in terms of preventing death from breast cancers) but a significant amount of harm is done. The American Heart Association steadfastly advocates for widespread antihypertension treatment of people who have no symptoms, pushing its guidelines downward to the point where two-thirds of Americans are targets for prescription drugs. The Alzheimer’s Association tells us we must watch for and treat “pre-Alzheimer’s” — another entrant in the race to make patients out of people who are not yet ill and may never be ill.

One of the first lessons I learned as a beginning reporter was to follow the money trail. Always ask: “Who profits from this?” Often the answer leads you into some very interesting terrain.

That is the case here: When you take a hard look at these organizations, you find they receive a lot of funding from Big Pharma and from makers of medical devices.

Understand: I’m not saying any or all such groups are corrupt. But common sense tells you that when an organization receives funding from special interests, its objectivity and motives may be questionable. This means it is in our interest, as patients and potential consumers of the flood of prescription drugs in which we seem to be drowning, to stay aware of the money motive.

An investigative report by Pro Publica revealed that doctors who receive gifts and payments from pharmaceutical companies tend to prescribe more brand-name drugs.

Dr. Kim Allan Williams Sr., president of the American College of Cardiology, said he believes relationships between companies and doctors are circular. The more physicians learn about a new drug’s “differentiating characteristics,” he said, the more likely they are to prescribe it. And the more they prescribe it, the more likely they are to be selected as speakers and consultants for the company.

“That dovetails with improving your practice, and yes, you are getting paid to do it,” he said.

The Project on Government Oversight (POGO), a well respected investigative reporting group, found the FDA (Food and Drug Administration) itself is heavily funded and probably influenced by the pharmaceutical industry. Astonishingly, this is written into law: the agency receives about three-quarters of its funding from drug makers through required fees, which are renegotiated at intervals. In FY 2015, “The agency spent about $1.1 billion on prescription drug oversight—more specifically, those activities the agency categorizes as part of its ‘process for the review of human drug applications.’ Congress delivered 29 percent of that money—$331.6 million. Drug companies provided the rest—$796.1 million.” This represents a huge chunk of this supposedly public agency’s funding: “Over the past two decades,” POGO reports, “‘user fees’ paid by industry have climbed from 35 percent of the FDA’s spending on such oversight to 71 percent.”

The National Health Council — the so-called “voice of the patients” urging the FDA to speed approval of drugs, willy-nilly and without wasting time trying to determine whether new products are safe, effective, or even necessary — is heavily funded by Big Pharma, according to POGO: “National Health Council gets most of its funding from drug companies; its members include many drug companies, and representatives of drug companies and their main lobbying organizations serve on its board.” Some 93% of the “patient advocacy groups” the FDA is required to invite to discussion of drug approval procedures are funded by Big Pharma. More than a third of these groups “have executives, directors, or other personnel from pharmaceutical or biotech companies on their governing boards.”

In other words, what should be objective, science-based certification of new drugs’ effectiveness and safety is largely driven by Big Pharma interests.

The American Heart Association has come under fire more than once for questionable partnerships and endorsements of drugs and other products. In 2013 — a year after it had received $521 million from corporate and non-governmental donors (including contributions of around $1 million from pharmaceutical companies producing statins) — the AHA lowered its guidelines for cardiovascular disease to take in a vast number of people and recommended statins for about 44 percent of men and 22 percent of healthy women between the ages of 40 and 75. A look at the group’s self-reporting shows that for FY 2016-17, total cash received from pharmaceutical companies and device manufacturers came to $23,865,284, with another $8,539,525 in promised commitments.

In 2017 the Alzheimer’s Association reported that total corporate giving over five years came to $7,987,782.

The American Diabetes Association reports having received at least $500,000 from each of these corporate donors:

And that’s just the elite “Banting Circle” set. Colgate and CVS Pharmacies ponied up at least $400,000; donors of at least $100,000 included the Merisant Company (maker of Equal artificial sweetener), Quest Diagnostics, and Walgreens, among others.

The National Osteoporosis Foundation numbers among its 2018 Corporate Advisory Board members Eli Lilly, AMGEN, Bristol-Myers Squibb, AgNovos, Medtronic, Pfizer, Roche — and others. Take a close look at these links: I’ve made most of them to Wikipedia, where the content is not quite so self-serving as what you’ll see on the corporate sites. You’ll find some eye-popping scandals and controversies associated with some of these companies (check out Merck’s sham medical journal!). AgNovos, which is not covered in Wikipedia (why might that be?), produces products said to combat osteoporosis.

The American College of Cardiology, which on the surface appears to be a staid professional group for medical doctors, is listed by Open Secret as a PAC (political action committee). This is not quite accurate: the organization has a PAC. The ACC ‘s website does not provide a readily avaliable a list of its corporate donors. However, last year Boehringer Ingelheim and Eli Lilly and Company announced they would support an ACC drive to reduce cardiovascular risk and disease in people with type 2 diabetes. These are large, highly profitable pharmaceutical corporations with a vested interest in expanding the markets for their products.

Look hard at this stuff, and you find yourself wondering… Who’re you gonna trust? Ghostbusters?

This is the fifth of seven planned posts on The Drugging of America.

The Drugging of America: Hyped-up Hypertension

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Chances are very good that you’ve been told you have high blood pressure — or are about to get it — and so need to take pills to keep your numbers down. Some 70 million Americans — a third of us — have been told we’re suffering from hypertension, and another third have been diagnosed with “pre-hypertension.” That’s two thirds of the population of the United States who supposedly should be on blood pressure meds.

Really?

Well, maybe not. Let’s listen in on what an expert from the University of Massachusetts Medical School has to say on the subject:

Notice that this gentleman was speaking in 2014. What he advises has been known for at least four years. And yet if you go to your GP for a check-up — or even to a trained cardiologist — you are likely to find yourself added to the majority of Americans put on anti-hypertensive medications.

You will be told, as I was, that if you don’t start taking these drugs immediately — and stay on them for the rest of your life — you are going to have a heart attack or a stroke. This, even if your blood pressure is fairly low — my systolic BP averages around 123.5.

One reason for this is the steady pressure on practitioners to diagnose hypertension and prehypertension, a campaign to convince them that patients are at risk if their numbers are above a certain level. Within the past year, that level has been dropped by ten points. Until just a few months ago, “normal” blood pressure was defined as a systolic reading of 120-129, and “prehypertension” was 130-139. Now, lo! We’re told numbers in the 120s indicate “elevated” blood pressure — and need to be treated — whereas numbers in the 130s are now defined as “Stage 1 hypertension.” This rejiggering of definitions puts a large new cohort into the category of “patients” who must be medicated. Or, we might say more realistically, makes them eligible for overtreatment.

But how beneficial are these medications?

Let’s check the Number Needed to Treat. Among people treated with anti-hypertensives, overall 1 in 125 were helped in that they did not die. Strokes were prevented among 1 in 67. One in 100 were helped in that they did not have a heart attack. But 1 in 10 were harmed. Obviously, one would like not to experience a cardiac event. But do you really want to be one of the 1 in 10 who are harmed by the drugs?

None of these drugs is completely benign. All of the classes of antihypertensives have side effects, which affect different people in different ways. You may experience no side effects. Or you may have one or two side effects that are so minimal they don’t bother you. The most common is hypotension, the result of overtreatment, leading to dizziness, fatigue, tiredness, and anxiety. However, the potential for serious side effects is there:

Calcium channel blockers

Peripheral edema (swollen ankles)
Headaches
Palpitations
Flushing
Gum hypertrophy
Constipation
Hair loss
Abnormally slow heart action
Heart block

Diuretics

Abnormally low potassium levels (hypokalaemia), which can lead to heart failure
Low levels of magnesium (hypomagnesaemia)
Abnormally low sodium levels (hyponatraemia), also potentially life-threatening
Glucose intolerance (a risk factor for mortality)
Erectile dysfunction
High calcium levels (hypercalcaemia), which can lead to abdominal pain, bone pain, confusion, depression, weakness, kidney stones, or arrhythmia (an abnormal heart rhythm including cardiac arrest)
Gout
Glucose intolerance

ACE inhibitors

Dry cough
Swelling (angioedema), potentially life-threatening
Metallic taste in mouth
Low white blood cell count
Acute renal dysfunction (kidney failure)

Angiotensin receptor blockers (said to be the best tolerated of antihypertensive meds)

Low white blood cell count
Acute renal dysfunction (kidney failure)

Beta blockers

Bradycardia
Wheezing or asthma,
Masking of hypoglycaemia
Sleep disturbances
Fatigue
Exercise intolerance
Erectile dysfunction
Glucose intolerance
Worsening of peripheral vascular disease
Drowsiness
Raynaud’s phenomenon
Heart failure
Elevated triglycerides, cholesterol and/or fat phospholipids (dyslipidaemia)
Angina caused by sudden withdrawal.

Alpha blockers

Postural hypotension (sudden drop in blood pressure, causing dizziness or fainting)
Precipitation of heart failure.

Well, you think — as your doctor is telling you that if you don’t push your systolic blood pressure into the 110s, you’re going to drop dead of a heart attack or a stroke —  maybe it would be better to risk or tolerate these unpleasant ailments than to die.

Think again.

The fact is, despite the hype to the contrary, treating mild to moderate hypertension has not been shown to improve outcomes: it does not change rates of mortality or sickness. A recent study published by the widely respected Cochrane Group found that “No evidence of a difference in total mortality and serious adverse events was found between treating to a lower or to a standard blood pressure target in people with hypertension and cardiovascular disease. This suggests no net health benefit from a lower systolic blood pressure target despite the small absolute reduction in total cardiovascular serious adverse events. There was very limited evidence on adverse events, which lead to high uncertainty. At present there is insufficient evidence to justify lower blood pressure targets (≤ 135/85 mmHg) in people with hypertension and established cardiovascular disease.”

And that’s for people who have identifiable cardiovascular disease — not for the hordes of asymptomatic patients assigned to take these drugs.

Another effort to determine the benefits of treating low-level hypertension showed that “Antihypertensive drugs used in the treatment of adults (primary prevention) with mild hypertension (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) have not been shown to reduce mortality or morbidity in RCTs ” (randomized controlled trials; my emphasis). The authors continued, “Individuals with mildly elevated blood pressures, but no previous cardiovascular events, make up the majority of those considered for and receiving antihypertensive therapy. The decision to treat this population has important consequences for both the patients (e.g. adverse drug effects, lifetime of drug therapy, cost of treatment, etc.) and any third party payer (e.g. high cost of drugs, physician services, laboratory tests, etc.)…. Available data from the limited number of available trials and participants showed no difference between treated and untreated individuals in heart attack, stroke, and death. About 9% of patients treated with drugs discontinued treatment due to adverse effects.”

Note that this second study defined “mild” hypertension as 140-159/90-99 mmHg — and remember that today the American Heart Association would have us believe systolic readings of 120-129 are “elevated” and 130-139 are full-blown hypertension.

In 2017, another set of researchers found that treating people to lower blood pressure targets made no difference in cardiovascular outcomes: “We found and included three unblinded randomised trials in 8221 older adults (mean age 74.8 years), in which higher BP targets of less than 150/90 mmHg (two trials) and less than 160/90 mmHg (one trial) were compared to a lower target of less than 140/90 mmHg. Treatment to the two different BP targets over two to four years failed to produce a difference in any of our primary outcomes, including all-cause mortality (RR 1.24 95% CI 0.99 to 1.54), stroke (RR 1.25 95% CI 0.94 to 1.67) and total cardiovascular serious adverse events (RR 1.19 95% CI 0.98 to 1.45).” (My emphasis.)

As you can see, then, overtreatment of mild hypertension (or possibly of what we’re now told is serious hypertension) may be doing more harm than good. Even when “mild” or “stage 1” hypertension was defined as 140-49/90-99, there was no evidence that people at “low risk” (i.e., with no existing heart disease, diabetes, or kidney disease) are helped by going on antihypertensive medications. To the contrary, they are presented with a wide array of uncomfortable and even life-threatening drug side effects.

Meanwhile, for some years practicing doctors have been reporting rampant overprescription of these medicatons; one even called it “an epidemic” of hypertension overtreatment. Not to be left behind, the legal profession has noticed the phenomenon, too; one lawyer suggests, almost circumspectly, that Big Pharma and the money motive might be at the bottom of it all:

Unfortunately, big drugs are big business, and wherever money is involved, motivations can come into question when medications are prescribed to people who might not need them.“I think doctors are induced by pharmaceutical companies to use their products,” says medical malpractice attorney Andrew J. Barovick. “Whether they’ll acknowledge it or not, there’s often a quid pro quo.”

Whether or not doctors get paid for putting you on a given drug, there’s no question that the prospect of putting two-thirds of Americans on blood pressure meds represents a vast reservoir of profit for Big Pharma. That alone is reason to be skeptical.

Remember this principle: always get a second opinion.

This is the fourth of seven planned posts on The Drugging of America.

Still kickin’…

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Wildly hectic week! Today is the first time I’ve had a chance to attend to my own stuff all week, and tomorrow will be turned over to other activities again.

Honest: I will write the next installment in the Drugging of America series. This afternoon. Really. First, it’s off to buy some dog food — otherwise, it’s spend this afternoon in the kitchen, lest the pooches run out.

I’ve decided to add another post in the Drugging report: funding sources of the major organizations that recommend treatment, provide information for patients and doctors, and advise on guidelines.

The more you look into this issue, the farther your jaw drops...

Watch this space!