Introduction:
I am what you call a disgruntled physician. I entered this
profession with the noblest of intentions, namely to please
God through helping the sick, the dying, and their families.
I entered this profession with a plan to change the world...
one soul at a time. Rather than finding a profession committed
to serving humanity, I found an industry prepared to destroy
it.
It should be said, from the very beginning, that what I say
in this article has little to do with individuals, and more
to do with systems. Your individual pharmacist, physician,
nurse, social worker, or other health professional is not
necessarily a willing contributor to the industry part of
things. But rather, they are its victims.
It should also be said that while the tone of this article
may be interpreted as pessimistic or even depressed, I do
not intend it to be so. I remain optimistic and indeed, I
have not lost that vigor, that fire, that energy which brought
me into medicine. I still believe I can change the world,
one soul at a time. And I have not lost hope. Indeed, it is
this drive which has led me to discuss the oppressive and
manipulative side of the pharmaceutical industry. And through
this discussion, I hope to demonstrate that the issue is not
one person, or one corporation. Nor is the issue something
which can be fixed with one law. No. We are dealing with a
system, and here are some of its components...
Tongue-Twisters & Empty Pockets:
Naming the medications...this is where the game is being
played with the slickest of hands and the most clever of minds.
During the research and development of new drugs, the pharmaceutical
company choses the name of the new compound that they have
developed. The name often resembles the name of chemicals
or substances found in laboratories. And, indeed, the names
of these compounds did once have significance. Not anymore,
however.
The drug company develops a new drug, chooses the name for
the compound, and then chooses their brand name for it. Once
the drug becomes generic, the generic company must call the
drug by the name of its compound. This means that rather than
calling their generic Prozac, they must call it fluoxetine
(flew-ox-ah-teen). As time goes on onecan see the names becoming
more and more complex, often involving more and more consonants
in a row which we tend to have difficutly in saying. Here
are some examples of brand names with their generics:
Prevacid - lansoprazole
Lantus - glargine insulin
Keppra - levetiracetam
Reopro - abciximab
Integrillin - eftifibatide
Xigris - drotrecogin alfa
The generic names of medications are intentionally difficult
to pronounce. This affects physician prescribing behavior.
Already strapped for time, do you really think that your doctor
is going to write "levetiracetam" instead of "Keppra"?
Of course not.
The patient too. Do you think you would remember that you
were taking "divalproex sodium" or "Depakote"?
Which one? Patients remember drugs by trade names, which are
much easier to pronounce and often even sound cool and stylish.
So when you go to the ER and list your medicines, which ones
do you think you will list? Your brand names. So, that's precisely
what they'll prescribe on your discharge.
Nike and Reebok cost more than no name brand sneakers purchased
at Target. Well, so too does Prozac cost more than fluoxetine,
even though they are the exact same thing.
The Formulary System:
Another subtle manner in which drug companies have manipulated
the delivery of healthcare is through the formulary system.
This is a system in which hospitals, pharmacies, and insurance
companies only carry specific brands of medications. In return,
they get discounts on the cost of purchasing that medication
from the pharmaceutical giant.
So, for example, the makers of drug-X will send their drug
reps to a hospital Pharmacy and Therapuetics Committee to
lobby (and even issue bribes) for their drug to be on the
hospital formulary. They usually sponsor lunch or dinner at
such a meeting where they then give a fancy PowerPoint presentation
on the latest studies about their drug and the competition.
They then offer a discounted price or some other "perk"
for the drug to be supplied to that particular hospital. Then
anytime a physician in the hospital writes for a specific
drug, such as Protonix, the pharmacist will do a "therapeutic
substitution" with Prevacid - Prevacid being the competition
which is on the formulary. These should more properly be called
"monetary substitutions".
While in the hospital, the patient continues to receive Prevacid
instead of Protonix, which medically is not a very big deal
because they are very similar medications. However, the problem
lies in the discharge orders. Upon discharge, most physicians
tend to give prescriptions for the medicines that the patient
was taking while in the hospital. This means that rather than
continuing on Protonix, the patient is prescribed Prevacid
since that's what he was taking as an inpatient. In this manner,
drug companies can get patients to switch brands, pretty much
against their will, especially if they are uninformed.
The other problem with the formulary system is with residents.
Residents are budding young physicians, being trained in their
basic medical discipline or specialty such as Internal Medicine,
Surgery, etc. Residents tend to stay at one hospital or in
one hospital system. In so doing, these impressionable minds
are subject to one formulary, often with only one drug from
each major class of drugs. So if Prevacid is on their hospital
formulary for their full three years of residency, guess what
they will prescribe when they are full-blown internists or
surgeons...Prevacid. And once Prevacid comes off of patent
(barring any loopholes), do you think that former resident
is going to write "Prevacid" or the generic name,
"lansoprazole", on their patients' prescriptions?
The Sarafem Deception:
(this section is an excerpt from Abu Aasiya's
In Search of a Cerebral Paradise)
The logo for Sarafem has two sides and this is quite appropriate
in that two tones, two faces, double crosses, and the like
all allude to deception. Sarafem is the pharmaceutical industry's
latest scam. Originally marketed as an SSRI under the name
Prozac, fluoxetine hydrochloride has returned to the drug
market, this time different in name only. This time the target
audience is different. Even the ailments aimed at are different.
Prozac, loaded with patient skepticism and a target for numerous
conspiracy theories, has come off of patent. In anticipation
of this, Lilly Pharmaceuticals launched the product again,
under the name Sarafem, this time with different indications.
The target audience is menstruating women with a newly described
condition called Premenstrual Dysphoric Disorder (PMDD). Here
is a quote from the Sarafem website (as of 9/7/01):
Irritability, sadness, sudden mood changes, tension, bloating.
If you suffer from many of these symptoms month after month
and they clearly interfere with your daily activities and
relationships you could have PMDD. PMDD, Premenstrual Dysphoric
Disorder, is a distinct medical condition that is characterized
by intense mood and physical symptoms right before your period.
Sarafem can help. Doctors can treat PMDD with Sarafem
the first and only prescription medication for PMDD.
"...the first and only prescription medication for PMDD,"
is a very deceptive statement and in fact, a downright lie.
If PMDD even really exists, or if it should be classified
as a "disorder", fluoxetine hydrochloride can be
used to treat it, whether it is under the name Prozac, Sarafem,
or the newly available generic. Now that Prozac is off patent,
it can be produced by generic drug manufacturers and offered
to patients at a substantially lower cost.
PMS and PMDD clearly refer to symptoms that men and women
have known about for centuries. Why, now, in the late 20th
and early 21st centuries, are these common symptoms being
classified as disorders? Could there be a biological mechanism
requiring these phenomena? Could there be another explanation?
In Islam and Judaism, sexual intercourse is not permitted
at the time of menstruation. Wouldn't it make sense that God
would equip us with a phenomenon that makes our observance
of His Law easy? In addition, sexual intercourse is painful
for many women during menstruation. Furthermore, some pathogens
are more easily transmitted during intercourse that occurs
at the time of menstruation than during times of no menstruation.
Medical texts are clear that this is the case with HIV transmission.
Also, we must remember that this society is obsessed with
efficiency. The consumer-producer process has little room,
if any, for the female biological processes, be they menstruation,
pregnancy, or breast feeding. Anything that disrupts efficient
production in this new worldly order must be a disorder or
a disease. So Sarafem's introduction into the market coincides
not only with the loss of Prozac's patent, but also with an
acceleration in our worship of progress, efficiency, production,
and consumption.
Patents & Priorities
That wasn't all for Lilly Pharmaceuticals. With the end of
Prozac's patent, they also launched Prozac SR which is a once
weekly dose of Prozac. Because its delivery system is different,
it affords it a new patent. Another 11.7 years of patent (and
revenue) protection.
Perhaps I would not find this concept so troubling if I did
not have to sit there and hear drug reps who look like they
just walked off of the set of Melrose Place, tell me that
Prozac SR was "developed to help with patient compliance."
no it wasn't. It was developed to make money. Period. And
its timely release, coinciding with the fall of the patent
also serves that end. Money.
Again, the individual scientist behind the development of
the drug may have the best of intentions. Not so, with the
corporation however. It is money. And I have little tolerance
for the wax models who try to convince me otherwise.
Another interesting tactic, is the use of loopholes built
into patent law. The Hatch-Waxman Act (passed in 1984 - how
Orwellian) requires generic companies to wait until the drug
goes off patent to begin sale of the generic drug. There have
been numerous lawsuits issued by brand name pharmaceutical
giants against generic manufacturers for allegedly violating
the Hatch-Waxman Act. What this then does is tie the two companies
up in a lawsuit, during which time, the generic company stops
the production of the drug. Essentially, this frees up more
time for the sale of the brand name medication in the absence
of generic competition.
Denying the Poorer Nations:
Now this is where their true intentions are shown... It is
well known that the poorer nations of Asia and Africa are
in the depths of an AIDS epidemic, much of which is transmitted
mother-to-child either before birth or during breast-feeding.
These countries are poor. Their populace is even poorer. Where
could they possibly get the funds to purchase expensive new
antiretroviral agents to combat AIDS? Wouldn't it make sense
to allow those companies to violate the patent laws and make
cheaper medicines for their people?
Of course it would, if you were a caring member of the human
family, or if you were one of those altruistic types, like
myself, when entering your health profession. Of course it
would make sense. But do you know the industry's argument
against this? They argue that allowing countries to produce
their own medications would produce a black market for the
cheaper medicines and would steal profits from the pharmaceutical
giants. This would then stifle AIDS research, because producing
antiretrovirals would be a losing venture, or at least not
as profitable.
So where are the priorities? Improving the human condition?
Saving the lives of innocent children? Preventing the spread
of horrendous diseases? Or is it profits?
Ads & Gimicks:
While I was completing my chief residency in Internal Medicine,
I spent time on a rotation in orthopedics. I saw lots of patients
with arthritis, sports injuries, and workman's comp issues.
In most cases, they required some sort of pain and anti-inflammatory
medications. There was one doctor in particular, a superior
of mine, a mentor, who while filling out a prescription for
one of his patients, burst into song. He started bouncing
his knee back and forth while he rhythmically wrote on his
prescription pad. "Celebrate! Celebrate! C'mon and celebrate!"
His pen was an air guitar as he recounted the song for Celebrex.
Within the week, I heard my three year old daughter singing
the same song. And mind you, we rarely have the television
on. So, really...is there any difference between that physician
and my three year old daughter as they sang that song? Was
there much difference in the ease with which they recounted
the lyrics, or even mentally replayed the commercial of grandparents
running through the field chasing after their grandchildren?
My guess, is not much.
Conclusions:
Rather than attempting to change the system, most healthcare
professionals are so bogged down by its bureaucracy and paperwork,
that they cannot find the time nor the energy to confront
the system as a system. Instead, they wage their individual
battles for the patients (and for their own peace of mind)
on small, isolated fronts - a guerilla warfare of sorts. They
"stretch the truth" on diagnoses so that precriptions
can be paid for by insurances. Or they exert extensive efforts
to secure drug samples from drug reps, so as to provide free
samples to their patients. Sometimes they give the higher
dose or prescribe a higher frequency of dosage than the patient
needs so that the patient receives more drug for their money
(at least for the ones which cost the same at varying doses).
There are many small ways of "bucking the system"
or finding tiny, often barely significant loopholes.
But the problem is that this is a secondary form of resistance.
Secondary forms of resistance use the existing system to fight
the system. This is problematic because it only ends up generating
more bureaucracy and more laws to combat the loopholes. Secondary
resistance is also limited in that it indirectly supports
the system, and affirms its existence.
What we need is a primary form of resistance, if possible,
and thus far I am unable to conceive of one. A primary form
of resistance confronts the existing system or paradigm with
a completely different and unique one. Essentially, it says,
you no longer make the rules. We are playing by new rules.
We need to wake up. We need to recognize the enemy in the
corporate world order. We are not here to make money. We have
a higher calling. In fact, as a physician, I have seen a lot
of people die. Not once did I hear someone say, "I wish
I had more money," or "I wish I had lived life a
bit more extravagantly." Nope. Every time I have conversed
with a dying soul, they have mentioned God and family. Nothing
else. We need to return to the way of the prophets (peace
be upon them all). It is their way that calls us to sacrifice
for our fellow humans, to help the poor, to visit the sick.
And their way is the one about which we will be questioned.
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