Jan 28 2011

Polypharmacy

To quote a very popular science blogger, “I get e-mail.” I wish I could respond to every one, but there is just not enough time in the day. I do read every e-mail – it is a great source of feedback and ideas. I especially enjoy responding to e-mails that are criticizing my position on something or that defend a position I do not agree with. Responding to specific arguments is a good way to organize an essay.

I also look for patterns in the e-mails (and in other venues) – arguments that tend to occur over and over again. Clearly there is something compelling about such arguments, or their “meme” is in the popular culture or at least within a certain subculture. I give high priority to responding to those questions that I see frequently, that are representative of a common belief. Here is one such e-mail about doctors prescribing drugs (unedited):

could you please comment on why MD,s now proscribe reams of “take another pill” and never say “let us fix this” when you visit your MD you always leave with another drug, as a former MD of mine said it is better to drive under a 18 wheeler, than to stop taking these pills. an 18 wheeler will only hurt you ,stop taking these pills and will DIE.  UNLESS i am the only dead person with an email address i am NOT dead. we need more MD,s who will accept the fact that natural is many times as good as, if not better than a bunch of money grubing DOCTORS who see $ signs not patient welfare
david

There are a few themes in this e-mail that are very typical anti-science-based medicine propaganda, and a kernel of a legitimate concern. The concern is over polypharmacy (combing different drugs) and overprescribing (giving patients too many, inappropriate, or bad combinations of drugs). The e-mail states this issue in a rather propagandistic style, combined with a false dichotomy – prescribing medication vs fixing the problem. Medications have many different purposes in medicine. Sometimes they are curative, like antibiotics for a bacterial infection – and so are a way to fix the problem. Sometimes they are preventive, like aspirin for preventing strokes and heart attacks. In such cases medications can prevent or at least reduce the risk of serious disease. Ironically I often hear people advocate preventive medicine instead of medicine, not realizing that in many cases medications are effective preventives.

Medication can also be symptomatic – meant to reduce symptoms, but not necessarily alter the course of the disease or prevent complications. Again, it is a common theme among medicine critics to criticize “just treating the symptoms.” This is also a false dichotomy – you can simultaneously give curative, preventive, and symptomatic treatments. And symptomatic treatments should not be dismissed. Ask anyone with an incurable chronic pain syndrome how symptomatic therapy has affected their quality of life. The notion that symptomatic treatment should not be given instead of disease-altering treatment, and using powerful symptomatic drugs to mask the symptoms of a serious illness, and therefore complicate the ability to follow the course of that illness, is a basic concept taught to every medical student.

It is further true that pharmacological treatment is just one medical modality, and others should not be neglected. Physicians should (and often do) encourage lifestyle changes – such as a healthful diet and regular exercise – to prevent disease and promote health. But this is often not adequate.

Non-pharmacological (and non-surgical) interventions are well integrated into standard medical care. I routinely prescribe specific vitamins for specific conditions, refer patients for physical therapy for chronic pain and other ailments, review lifestyle factors such as diet, exercise, sleep, and substance use, and counsel patients to use moist heat,  wrist braces or other conservative modalities to treat common problems. And no, I am not the exception – these are all accepted standard practices. The cartoon picture of the average physician as a greedy pill pusher is just propaganda.

And of course, there is a bell curve of competence among physicians. Some physicians do overprescribe or neglect non-pharmacological interventions. But that’s not the standard of care, nor is it typical.

Overprescribing is also an issue that the medical community wrestles with themselves. There are many studies and articles discussing this issue – which is often complex and requires an evidence-based and balanced approach. There are specific areas in which a lot of introspection, research, and quality control has been done – like overprescribing antibiotics for viral infections, or hypnotics in the elderly. This is mainly a quality-control issue – getting the word out to practicing physicians so that they follow the best evidence-based guidelines. I do think we need to do a better job here, but it’s important to recognize what the problem is. It is not with philosophy, or in many cases even evidence – but rather with physician education.

The “greedy” doctors argument is a non-sequitur. Doctors do not get paid for prescribing drugs. Kickbacks for doing so is actually illegal and unethical. Doctors generally bill for their time, or for specific procedures – not prescribing.

The final very common argument that the e-mailer puts forward is that “natural” interventions are better than medicine. This is simply the naturalistic fallacy. There is no useful definition of “natural”, nor is there any reason to think that a natural remedy is safer or more effective than a manufactured one. Many herbal products sold as natural alternatives, are just drugs themselves – unpurified and poorly controlled drugs – but make no mistake, they are drugs, with all the pharmacological activity of regulated drugs.

While the issue of polypharmacy is a real one, it is a complex issue that is being addressed within the medical community, including the relationship of doctors with the pharmaceutical industry and their promotional activities. But we do need to move beyond the simplistic propaganda-style arguments used by the e-mailer. Unfortunately, that is the general level of the conversation in the public, which is a shame. There are many legitimate issues that can and should be addressed in the public forum.

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