Over-medicated? Why most pills are less useful than we assume.
Date: 27th Nov 2017 Speaker:Dr Justin Coleman (Brisbane GP, producer of GP Sceptics podcast, editor of Diabetes Management Journal, medical writer, senior lecturer Griffith University)
We as consumers need to be skeptical of the reported evidence for medicines and should be provided with information regarding treatment benefits, effectiveness and potential harms.
During November's GC Skeptics in the Pub, we heard Dr Coleman's views on why the effectiveness of medications may be over-represented to the public, and more importantly, to GPs and other prescribes. Justin puts this enthusiasm down to three "M's": media, medicos and money.
In order to sell the news, the media is usually tends to reporting medication news in a more exciting and positive light. Unlike studies on "coffee, chocolate, sex and alcohol" which are inherently sexy, when it comes to medications, it is difficult to make an unbiased journal article appealing without putting a spin on the story. I mean, who really wants to read the article entitled "researchers find a protein that interacts with one biochemical marker known to have a role in hay-fever and believe that this could be a potential drug target but they're not 100% sure"? (Well I do but I'm a bit weird like that...)
In reality, it is difficult to get studies that find no effectiveness published in peer-reviewed journals, let alone reported in the media. In addition, researchers (those working at universities and in pharmaceutical organisations) are less likely to publish, report or provide press releases if their results if their study finds no significant difference (or that the "favoured" therapy had done worse) between two treatment options. Publishing mostly "positive" studies leads to positive publication bias . This has two major consequences.
When systematic reviews of all the literature are conducted, researchers will mainly find positive results - thus the "meta-analysis" of the studies will be overestimate the treatment effectiveness; and
The media outlets will not even be aware of negative findings and, although the chances of reporting negative findings was already low, the likelihood of the media reporting on something the researchers themselves have not reported on fast approaches zero.
Having said this, we suggest that if you want help with deciding whether an media outlet has appropriately reported on the effectiveness of a treatment, to use the Media Doctor Australia - Student Rating Tool.
While potentially harder to sway than the media and general public due to their training, prescribes are able to be influenced by the media and pharmaceutical reps to change their prescribing habits, presumable because they have become convinced it will benefit their patients.
And while pharmaceutical companies are vital to the health care system and have provided society with treatments that have substantially improved quality and quantity of many of us, their interest is to make money by sell drugs. In Australia, medico prescribing is the main determinant of drug sales. Unsurprisingly, pharmaceutical companies invest a large amount of their resources in trying to persuade medicos to prescribe their drug, and not the competition's.
Some of the efforts go to advertisements; however, as there is no direct-to-consumer advertising for prescription drugs in Australia, this technique has a fairly low impact in driving drug sales.
Pharmaceutical or drug reps on the other hand are very effective, which is why pharmaceutical companies use them, despite their high cost. While drug reps need to adhere to guidelines when providing information to Drs, including what "perks" they can give medicos, the information they provide medicos is most likely to have been sponsored by pharmaceutical companies, which are not are more likely to report positive results. In addition, pharmaceutical reps are unlikely to be carrying around trials which show negative results. These two factors is likely to lead to over-representing the potential benefits of the drug, and understating the harms.
Just hearing about the newfangled drug can lead to what is called availability bias. This is a mental short cut that we take where when we are asked to give an example of something, we are more likely to think of recent examples. This means that if a prescriber has just heard about a drug to treat X from a rep or advertisement, they are more likely to prescribe it, even if they thought it wasn't necessarily the best option.
This can happen to any human natured medico (or other health professional), because at the end of the day, they are just human. This is why Dr Coleman and a group of other medicos started the "No Advertising Please" program, and encourage prescribes to say no to seeing drug reps.
While pharmaceutical companies need to make money to invest in new drug development research, what is maybe less known but not surprising, is that most of the profits created from medication sales go to marketing rather than research. What is even more unfortunate is that the research done often is skewed by marketing- i.e.: research is conducted that will increase sales, rather than provide clinically meaningful findings.
Advice from Dr Coleman
Use the 5 questions to ask your doctor or health care provider developed by Choosing Wisely Australia:
Do I really need this test, treatment or procedure? Tests may help you and your doctor or other health care provider determine the problem. Treatments, such as medicines, and procedures may help to treat it.
What are the risks? Will there be side effects to the test or treatment? What are the chances of getting results that aren’t accurate? Could that lead to more testing, additional treatments or another procedure?
Are there simpler, safer options? Are there alternative options to treatment that could work. Lifestyle changes, such as eating healthier foods or exercising more, can be safe and effective options.
What happens if I don't do anything? Ask if your condition might get worse — or better — if you don’t have the test, treatment or procedure right away.
What are the costs? Costs can be financial, emotional or a cost of your time. Where there is a cost to the community, is the cost reasonable or is there a cheaper alternative?
(I recommend reading Testing Treatments if you want to have a better understanding of how treatments are tested and how to decide whether there really is evidence a treatment works)
Contact Dr Justin Coleman
Phone: +61 433 824931