Pharma Companies Suck...But Doctors Suck More

Several years ago a bunch of policy wonk-type doctors started thinking to themselves: How do we encourage patients to take generic drugs? For several common chronic conditions these doctors felt that generics were at least as effective as their super effective fresh-from-clinical-trials counterparts at a fraction of the cost. Specifically, they wanted to test their hypothesis that diuretics (or as I have learned in down-home NC speak, "water pills") are just as good as more expensive alternatives including ACE inhibitors and calcium channel blockers in the treatment of high blood pressure (hypertension).

What came from this hypothesis was the ALLHAT study, an NIH effort (subsidized by some pharma funding) which pitted several anti-hypertensive drugs against one another in a long term trial intended to prove which one best thwarted future cardiovascular death. The real story of the shenanigans surrounding the study and its aftermath is brilliantly detailed here in a NYT piece from a few weeks ago. The bottom line: diuretics work just as well as the alternatives and cost pennies compared to its still-patented competitors, some of which also were shown to cause or worsen heart failure.

The results were supposed to validate the expansive work and expense of the study and save both the government and individuals millions in drug costs. As it turns out, aside from a small initial bump in the use of diuretics, not a damn thing has changed. Once again the greed of pharma companies has won out over the realities of both medicine and economics. The drug company spin machines actually twisted ALLHAT results to imply that they demonstrated the effectiveness of their given products. This is a story many of you are probably familiar with, and you can read it for yourselves above in gory detail.

Do I think drug companies are actually evil? Well sometimes, but I don't blame them at the end of the day. When Toyota comes out with its next new mid-sized sedan, do I think they should compare it to the 2003 Camry; and when they conclude that the Camry is a better car, have the ethical sense to suggest that consumers go to the used car lot and skip this year's hot addition? No. Drug companies are first and foremost, profit-making enterprises. I believe that this pursuit of profits has led to many wonderful breakthroughs in medicine. Do I also believe that pharma companies are a negative force in medicine? Absolutely, but it's not totally their fault.

So who's fault is it? Should the government intervene to prevent sketchy advertising and marketing practices and to make transparent the clinical trials process? Maybe, but what makes my blood absolutely boil is that physicians across the country are in a position to police big pharma but they have become vulnerable to the spell of the pharma witches. Doctors should know better. They should read the studies and do what's best for their patients, not for the commissions of the 28-year old leggy blonde rep who brought lunch to the entire office last week. I don't think pharma companies should be allowed to direct market to patients, but somebody has to give them a prescription for whatever slick marketing job they got sold on by a 30-second television spot. I'm embarrassed to conclude that this is a just another example of physicians as a cog in the health care wheel, not captains of the ship. They can be played just like any other professional in any other sector. All it takes is dollars and an effective strategy.

I don't know where we go from here. Shockingly, comparative trials (looking at new drug X versus current standard of care drug Y; compared with the much more common drug X versus placebo) are fairly rare, and they are extremely expensive and time consuming. The spectacular failure of the ALLHAT results to change clinical standards will only discourage future important efforts at comparative evaluations of drugs. Effectiveness and safety are our first concerns with any new drugs, but we should care about cost-effectiveness too. And to do that we must have comparative trials. I just wish I knew who exactly to be mad at about this whole mess.