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If you believe that the latest blockbuster medication is worth a premium price over your generic brand, or that doctors have access to all the information they need about a drug’s safety and effectiveness each time they write a prescription, Dr. Jerry Avorn has some sobering news. Drawing on more than twenty-five years of patient care, teaching, and research at Harvard Medical School, he shares his firsthand experience of the wide gap in our knowledge of the effectiveness of one medication as compared to another. In Powerful Medicines, he reminds us that every pill we take represents a delicate compromise between the promise of healing, the risk of side effects, and an increasingly daunting price. The stakes on each front grow higher every year as new drugs with impressive power, worrisome side effects, and troubling costs are introduced.
This is a comprehensive behind-the-scenes look at issues that affect everyone: our shortage of data comparing the worth of similar drugs for the same condition; alarming lapses in the detection of lethal side effects; the underuse of life-saving medications; lavish marketing campaigns that influence what doctors prescribe; and the resulting upward spiral of costs that places vital drugs beyond the reach of many Americans.
In this engagingly written book, Dr. Avorn asks questions that will interest every consumer: How can a product judged safe by the Food and Drug Administration turn out to have unexpectedly lethal side effects? Why has the nation’s drug bill been growing at nearly 20 percent per year? How can physicians and patients pick the best medication in its class? How do doctors actually make their prescribing decisions, and why do those decisions sometimes go wrong? Why do so many Americans suffer preventable illnesses and deaths that proper drug use could have averted? How can the nation gain control over its escalating drug budget without resorting to rationing or draconian governmental controls?
Using clinical case histories taken from his own work as a practitioner, researcher, and advocate, Dr. Avorn demonstrates the impressive power of the well-conceived prescription as well as the debacles that can result when medications are misused. He describes an innovative program that employs the pharmaceutical industry’s own marketing techniques to reduce use of some of the most overprescribed and overpriced products.
Powerful Medicines offers timely and practical advice on how the nation can improve its drug-approval process, and how patients can work with doctors to make sure their prescriptions are safe, effective, and as affordable as possible. This is a passionate and provocative call for action as well as a compelling work of clear-headed science.
“Powerful Medicines is a must read for anyone interested in the use, abuse, and economics of prescription drugs. The issues it addresses are central to the ongoing debate about how to reduce the cost and improve the quality of health care in America.” —Statement of Senator Kennedy, sent by his health advisor David Nexon
“This is an authoritative, stunningly comprehensive, and beautifully written book about a subject that ought to interest every American. At last: a smart Harvard doc who knows drugs, understands FDA and regulatory policy, and has a sense of humor. Unbelievable!” —Donald Kennedy, Editor-in-Chief, Science, former Commissioner, FDA
“In Powerful Medicines, Dr. Avorn brilliantly demonstrates the corrosive effects of commercial influence over medical research, education, and clinical care. This impressive book demonstrates the adverse effects such privatization can have on the health care system and ultimately on patients.” —Bernard Lown, M.D., Winner of the Nobel Peace Prize, Professor Emeritus, Harvard School of Public Health
“Only Jerry Avorn, with his insider's penetrating vision, could show us the triumphs and travesties, promises and perils of today's prescription drugs. Refreshingly, he not only diagnoses the ills of our current system but proposes novel remedies that we are well advised to heed.” —Jerome Groopman, M.D.
“A book that is at once engrossing and definitive.” —Howard Gardner, Hobbs Professor of Education and Cognition, Harvard Graduate School of Education
TABLE OF CONTENTS
Prologue: Different strokes
Case studies of patients who had neurological catastrophes because of the drugs they took, or the drugs they failed to take.
PART ONE: BENEFITS
Chapter 1: The pregnant mare’s lesson
The prescription medicine most frequently used by American women didn’t work the way it was supposed to, and often caused more harm than good. How could this happen?
Chapter 2: Leaving the Dark Ages behind, mostly
It took western science thousands of years to figure out how to tell a good treatment from a worthless one, and only a decade to forget.
PART TWO: RISKS
Chapter 3: The fat is in the fire
A drug in the popular “fen-phen” diet pill combination was known to cause serious lung disease, but it was prescribed to millions anyway – until it was taken off the market.
Chapter 4: Too sweet to be true
A new diabetes drug looked like a breakthrough treatment until it was withdrawn in Europe because of unexpected fatalities. Why did it take two more years for U.S. authorities to reach the same decision?
Chapter 5: Cold comfort
Few would expect that an over-the-counter treatment for the sniffles, found in most American medicine cabinets, could lead to cerebral hemorrhage. But the evidence had been there for decades.
Chapter 6: Getting risks right
All drugs have downsides, but many of them aren’t discovered until a product is in widespread use. We could do much better at spotting these problems early.
Chapter 7: The most vulnerable patients
The elderly fill the most prescriptions, benefit the most from them, pay the biggest pharmacy bills, and have the greatest risk of side effects – many of them preventable. Yet they’re the least likely to be included in drug studies.
Chapter 8: Enter Doctor Faustus
Every prescription is a tradeoff between benefit and hazard. How can the good that a medicine does be fairly stacked up against its hazards?
Chapter 9: Imperfect measures
Scientists have developed ways to compare the relative “worth” of drugs to treat cancer vs. depression vs. erectile dysfunction. But how well do such measurements really stand up?
Chapter 10: Whose risk is it, anyway?
Legal, moral, and medical quandaries arise when doctors, patients, and society have different views on whether it’s worth taking a chance on a potentially dangerous treatment.
Chapter 11: A balancing act
Physicians and policymakers are routinely forced to make tough choices about whether a given medication is “safe enough” to use. Usually we get it right.
PART THREE: COSTS
Chapter 12: Live cheap or die
One New England state’s disastrous experiment in trying to save money by rationing prescription drugs.
Chapter 13: Filling the pipeline
Where do new drug discoveries really come from?
Chapter 14: What the traffic will bear
Americans pay more for their drugs than the citizens of any other country. How did we get into this fix?
Chapter 15: Navigating the third dimension
Philosophers have debated the value of a human life for centuries. When it comes to paying for medications, those debates become a central part of health policy
PART FOUR: INFORMATION
Chapter 16: Signals, noise, and the big void
How do we make sure that doctors and patients have all the information we need to make the right drug choices? We don’t.
Chapter 17: Informational kudzu
Madison Avenue succeeds in filling the informational vacuum for prescribers and consumers alike with a limitless flow of attractive factoids.
Chapter 18: Devising an antidote
Using the pharmaceutical industry’s own tactics to convince doctors and patients to use medications more sensibly.
Chapter 19: The emperor's fashion critics
Medicine has a long and depressing history of scientific whistle-blowers and their usually unhappy fates.
Chapter 20: Same language, different accents
Somehow Australia, England, and Canada have developed better systems than the U.S. for educating physicians and consumers about prescription drugs.
PART FIVE: POLICY
Chapter 21: Pulling the facts together
FDA requires only that a new drug must work better than placebo; we have to do a better job of comparing them with one another.
Chapter 22: Turning knowledge into action
An innovative proposal for getting the straight dope about drugs out into doctors’ offices and patients’ homes.
Chapter 23: Markets and medicines
Moving beyond simplistic ideas of commerce and profit as the guiding principles of drug use and medical care.
Epilogue: The triple-edged sword
We need a new way of thinking about benefits, risks, and costs to make the most out of the therapeutic revolution that lies before us.