Compassionate Use of Cannabis in PA

Many years ago while walking the vendor isles at an American College of Emergency Physicians Scientific Assembly, I passed a booth that was collecting signatures in support of medical use of cannabis. Knowing its extremely low toxicity, both from detailed study in undergraduate pharmacy and years of clinical medicine, I signed. They also asked if I would be willing to come forward and publicly express my opinion. I almost always answer yes to that one.

A few years later, I got a call the NJ coalition supporting compassionate use legislation and after some discussions ended up the featured physician speaker in a Video called “Marijuana is Medicine”, featuring many patients who benefited from medical use. It was featured at the Trenton Film Festival and a copy presented to each legislator in the state. Subsequently, compassionate use legislation passed.

Several years later, in 2009, I was called again, this time by Jewish Social Policy Action Network asking if I would testify for compassionate use before the House Subcommittee on Health and Human Services. I did, but in the 5 1/2 years since, nothing changed in PA.

Recently, I got another call to speak in PA. Not that I mind being called again, though it sure seems (especially considering recent polls) that very few have been willing to speak publicly.

This time was much different for me. I spoke at a press conference in the capital rotunda organized by State Representative Ed Gainey on behalf of a bipartisan coalition of legislators. They claim to have the votes to pass legislation but Rep. Matt Baker refuses to let it out of committee for a vote. I was a last minute addition to the speakers list (they wanted a physician/expert to speak), which also included TV personality Montel Williams, legislators, and a number a patients. I had no idea how the day would play out, but I prepared a statement and went to Harrisburg. I arrived to find that a local grassroots group was there in significant numbers. The group, Campaign4Compassion, is composed mostly of parents of children with resistant forms of epilepsy, but also a host of other maladies for which there is now much more than anecdotal evidence for efficacy.

I was brought to tears more than once during the press conference. A mother of a child who was having hundreds of seizures a day that just stopped with CBD. The child has now spoken her first words. A state trooper, whose child sat in the front row, testified to seeing similar results and is now faced with competing promises to protect his family and to uphold PA law. He said he will probably become a medical refugee, up-end his family, and move to CO. And Montel Williams, who has MS, told his compelling story of facing deep depression and near suicide, until he discovered cannabis could alleviate many of his symptoms.  It was just the start.

The press conference was a preview for a town hall meeting set up by local TV Station, CBS21 in Harrisburg, for that evening. (90 minutes and available on the web for those interested). The network had arranged for a local panel that included the chief of pediatric neurology who cared for many of the children I mentioned, and he left no doubt about the apparent effectiveness of CBD for many of his patients. We heard from a wife of a vet with PTSD. The VA had him on 17 different medications without improvement. Then he heard about other vets smoking pot to relieve his insomnia, night terrors, etc. It worked, but the VA drug tested him, found THC, and locked him up for 21 days. Shortly after his discharge, he killed himself.

Most emergency physicians have seen plenty of chemo and HIV patients who have benefited, but I have never been so moved by the stories, deeply personal, that were shared that day. I know how often emergency physicians see patients that have become addicted to opioids, who have legitimate pain and few alternatives. Many of these patients were there too. Some now successfully using cannabis to reduce or eliminate their opiate use.

Between the noon press conference and the Town Hall that evening, I was invited to an open house sponsored by one of the mothers of an epileptic child. Her child had a dramatic response to CBD. After hundreds of seizures daily, the child was started on CBD and has had only a few seizures in the last year. She was playing with the dog and now speaks a few words.

Yes, this time was different for me. It is time that ACEP take a formal position in support of medical cannabis use.  I will never leave the side of these patients. Legislators are still plagued with bad information. Medical organizations have been slow to speak up and their silence is used as an excuse by both physicians and legislators to not move the issue.

Opponents often point to the long discredited concept of cannabis as a gateway drug and to the risk oF rising use by teens. And no one needs to tell emergency physicians about the what drug problems are in the community.

According to the CDC, In 2008, prescription opioid pain relievers (oxycontin, hydrocodone, etc) — were responsible for over 15,000 overdose deaths — more than the combined death count attributed to cocaine and heroin. A recent study in JAMA showed that availability of medical cannabis was associated with significant reduction in opioid related deaths. There are 2 messages there : 1)We need to educate doctors and patients about proper opioid use; and 2) we need to give doctors and patients as many alternative options as possible.

A new Lancet study on adolescence use over 20 years concluded “the risk of marijuana use in states before passing medical marijuana laws did not differ significantly from the risk after medical marijuana laws were passed”.

Last year there were some opinions on the pages of ACEPnow, our College newsletter. The “opposing view” was from a Colorado emergency physician, up close to the front line, but it seemed the only issue that arose in Colorado was unintentional exposure by children, and uneducated use by tourists. I fully agree with the authors conclusions : “The medical community should be actively involved in regulations. State legislators and health care providers must remain vigilant and follow the public health effects of such laws to determine best strategies and interventions (eg, child-resistant packaging, dose limitations, education, and counseling) for public health and safety.”

However that is really not a position against medical use, but rather focuses on responsible implementation. Absolutely, by all means, learn from experience and legislate accordingly, but it’s time to legalize compassionate use without delay everywhere.

As an emergency physician, I have always prided myself in being a patient advocate. The patients and families I met this week have inspired me. I hope you will join me and let your voice be heard in support of Compassionate use.

 

MONEY -The Ultimate WMD

 

Money- The Ultimate WMD

We have heard many references to WMD in recent years. Initially, we used the term to speak of nuclear weapons. Chemical weapons were added to our list. While they are clearly not quite as devastating as nuclear weapons, they are still sufficiently dangerous to qualify as included in the category. The basis for this classification obviously would be the large-scale effect on a population. Now consider the whole new class of threats encompassed by cyber-attacks. Imagine the havoc that would be caused by corruption of our banking and finance systems. Imagine your banking accounts compromised, or drained, credit cards rendered useless, ownership evidence of registered assets like cars and houses destroyed and those assets placed in jeopardy. What if attacks such as these could be routinely accomplished without victims’ knowledge?
What if a substance existed that could allow an evil conspiracy to “brainwash” the governing bodies to follow there instructions as if just zombies with pre-programmed agendas.
Now consider the effect of money. It does all these things with impunity because the population has become conditioned to such a system. The attacks are considered just part of life, not an outside force at all.

Lets go down the list of “effects”. Chemical weapons affect large populations poisoning everything it contacts. Imagine a foreign power poisoning the water system of a community and people dying after drinking their water. Who would not consider this a major attack? What if the poison worked slowly? Such poisoning of water and air is taking place at an increasing rate and money assures that no one can stop it.

Even overt toxic spills that cause immediate death and destruction are met with lukewarm resistance. Pay off some people, maybe even a fine, but never seen as a continued threat or met with “we will bring those responsible to justice” remarks from our leaders.

Big Pharma has been pushing dangerous drugs and paying off regulators to allow shady practices, pushing drugs for unproven uses causing immense harm to patients, and looking the other way while massive quantities of dangerous prescription drugs are diverted to black markets.

A major cyber attack, like I described above would generate a massive response if it came from China. However, a parallel “attack” is alive and well and part of everyday life. Compromised financial systems. rigged LIBOR, stock market fraud, insider trading, obscene “fees” charged to consumers, illegal mortgage practices, etc. have already compromised the financial markets and are allowing a continuous stream of money to be siphoned from the general economy. (read everyone’s bank account).

As to control of our leaders in government, this needs no further comment. Money talks and it rules globally. More money equals more power and as more money concentrates in fewer hands, so will the power it creates.

Something that I rarely hear discussed is that money demands more money. Every investor wants a return on their investments. The uber-wealthy are no different except they have come to expect substantial returns even in bad markets. Managing wealth for clients demanding 10% or more return on their money in the current economy is no easy chore. And these investors are not interested in excuses. Not surprisingly, ethics and legality go out the window. Sure we want these managers to face jail not fines to their companies, but they are in fact the middle level, their clients demand their efforts, but remain protected at arms length. Further, the more they have, the more they demand to remove from the economy for their own benefit (as percent of their growing wealth). Aside from the ethics and devastating effects on society at large, this is also totally unsustainable in the long run.

Our leaders may not be truly “brainwashed”, but they are under no less control of their financial support systems (political contributors).

There are innumerable other ways that money (big money not local transactions) disrupts and corrupts our system. Local businesses go bankrupt daily under pressure of “big store” competition pulling local wealth out of the community and “redistributing” that wealth to distant “investors” leaving only low wage jobs in their wake. Many of these employees are just a step above indentured servants. Most live day-to-day, never save enough to provide any security and are often a paycheck away from financial disaster. Slowly, many of these people succumb, their homes are foreclosed, their savings drained. They fall prey to the numerous “traps” set for them by the system. Bad mortgage, job losses, credits problems, medical bankruptcies, etc. and their assets are moved from their “pile”, out of the local economy, to that of the distant uberwealthy. This must stop.

Step one is getting money out of politics and amending the constitution making clear corporations are not people and their money is not welcome in the political process. Public finance of elections is needed. Next is severe limits on the passage of wealth through generations creating a new class of “royal families”. Does anyone think that these families will not ultimately produce a finite number of truly evil, sociopathic individuals, with virtually unlimited power. People who would make the Koch Brothers seem like do-gooders.

Money it would seem is the ultimate weapon of mass destruction. Viewed from such a perspective, perhaps a limit on personal wealth and the uses permitted is no different than restricting individual (or corporate) access to chemical weapons.

Medicine as Business

I have previously voiced my support for a Medicare for All national single payer system. I have many reasons for this but one is the slowing and perhaps even the reversal of the transition of the practice of medicine to the business of medicine. There are implications and costs to the privatization and conversion of healthcare to income producing equity.

While Medicare is still overpaying for many services and being defrauded or exploited by many providers, the centralized nature of the beast has enabled it to turn some of the screws to reverse those growing trends. The actual practice of medicine is generally limited to physicians, and other trained providers, but they are increasingly in the employ of for-profit entities.
A simple search for statistics on cost versus outcomes shows there is little correlation in many areas. This is not surprising given the sophistication of the local vendors of care in terms of their ability to focus on profit over outcome. For example, Medicare expenditures per person in the Fort Myers area are about half as those in the Miami area. In Minneapolis, they are a third of what they are in Miami.
That Florida regulations and enforcement are lax, and that it is heavily endowed with Medicare beneficiaries, is no secret. So it should not be surprising that Florida is a haven for exploitation of the system ranging from outright fraud and abuse, to “well run” (from a business perspective) medical practice and supporting industry. High cost comes in two flavors, Old school “medicine as business” was independent doctors doing unneeded procedures and small timers overcharging or submitting fraudulent claims. Bad medicine, bad practice. New school high costs are seen in those areas that have “evolved” in the “medicine as business” model, and it comes in many varieties. But the bottom line is current medical business models have learned how to extract megadollars from the system in many niche area. Sometimes “legally” and sometimes not. This is good business, bad medicine and patient outcomes are not even in the formula. Make no mistake. their methods will continue to spread, because the profits can be enormous. If you are in the business, there is likely already a conference telling you how to cash in for more bucks in your chosen niche. If you already have something working, a larger entity might be interested in acquiring it for their equity partners and leveraging it even further.
The ACA makes a few changes trying to realign incentives toward rewarded better patient outcomes, instead of provider income. Medicare for all would give them further power and leverage but we have a long way to go to change the culture.

TEXAS and the Cruel Social Experiment

We may be in the middle of a huge social experiment and one that will likely reveal the effects of right wing social engineering. A number of states are threatening to opt out of Medicaid expansion. It will be a hard sell to the public as hospitals and health systems gear up to avoid losing billions of federal Medicaid dollars. Once election politics are over, it will be a hard sell to leave scores of uninsured with no option and state taxpayers, health providers, and insurance buyers holding the bill.

There are some states that might just “opt out” through. Texas is probably a likely candidate. There is an interesting irony playing out in Texas. Texas had the worst prior coverage in the US, dead last, so they have the most to gain. The comparative dollars per capita of new federal dollars going into an expanding the Texas Medicaid program would be very high because there are so many uncovered Texans (estimated 2 million new people would quality for expanded Medicaid). But the cost to implement the changes also rises (the feds pay everything for 3 years but starting in 2017 Texas would have to pay 10%). So while Texas has a potential huge windfall, the unfunded costs are also huge. A lot more than many states. Some states, like Maryland, have done such a good job in the past, their costs will actually go down. They will reap the benefits of all the federal expansion with a net savings. Those benefits should quickly trickle down to local agencies, governments and taxpayers. Local funds that previously made expanded coverage available will be freed up by the federal coverage dollars.

Further, while Texas cost-cutting has left programs at absolute minimums (Texas has the lowest per capita budget in the nation), no surpluses accrued to the state government because they also cut taxes so much to their corporate friends that their state budget remained underfunded. They have no income tax, only sales tax, corporate taxes and a host of fees to support revenue. They are legitimately broke. They passed last year’s budget with a 4 billion dollar underfunding of Medicaid (http://sunshinereview.org/index.php/Texas_state_budget). That bill has been kicked down the road. Texas also has $280 Billion in debt and unfunded liability, so paying the State part of expansion would definitely be a problem.

This creates an interesting, if cruel, social experiment. Some states will opt out, not many, but a few. Some states will find the money to expand. Some states will put up nothing, because they already addressed the issue and are already laying down a track record and database. I predict that hindsight will finally cast a true light on the detrimental effects of the poor care in American terms. No doubt more American lives will be lost due to lack of insurance. Previous studies suggest 45,000 deaths a year are attributed to lack of insurance (http://news.harvard.edu/gazette/story/2009/09/new-study-finds-45000-deaths-annually-linked-to-lack-of-health-coverage/). With that previous data and improvements likely to show in states that “opt in”, one has to wonder how the GOP will justify the such losses.  I am sure Fox will figure out something.

Texas Healthcare at the Bottom – the Irony

If you live in a “Red” state, it is likely that your state government has been cutting services. Texas is a model of such policy, ranking at the bottom of healthcare in the US according to federal agencies. http://www.dallasnews.com/news/state/headlines/20120705-federal-agency-ranks-texas-at-bottom-for-health-care.ece

The results of conservatives slowly starving governments at all levels are the continued erosion of vital infrastructure and social services. Just how bad is Texas? Texas is the worst place in a country that the WHO ranks 37th  in overall national health (America’s current ranking). This is a crime in progress.

The irony of this cannot escape me. Texas hospital systems provide some of the best cardiovascular surgical services in the world. In the days when I went to medical school, their University System was one of the best and attracted top tier physicians along with patients seeking their care. And like many western states, tuition was dirt cheap, bordering on free at state universities. In Arizona (yes, that Arizona) residents of the state gained easy acceptance to state universities and if they had the need and maintained high GPA’s, tuition was waved under a general resident scholarship program. Being broke and otherwise without support, I qualified and owe my current life to that program.

In Texas, and other states, such investments in education and state talent bred a great system. The remnants of those investments now stand as islands in a rising sea. Still providing the best, but being starved of the resources on which they once depended. Priorities have changed, sacrifices must be made, and resources rationed (oh that “R” word). What stays is high dollar paying services like open heart surgery, and what goes is charity care, ancillary services, community programs, long term health investments, and then actual hospital clinical staff as ratio’s of patients to nurses in hospitals and nursing homes rise.

What is missing is the previous generous federal grant programs that paid for top tier professors to engage in basic sciences research in aerospace, medicine and other technology. The states themselves are broke and are unable to provide the subsidies they once did, let alone make up the missing federal money.

 

America’s Biggest Wasted Resource

This nation has lost its focus on what made us great. I read today about Norway’s current ranking as the most mother friendly nation. As I delved deeper into the issues, I began to think about the tragedy of America’s biggest and least talked about waste of national resources, that of our people. In a country of more than a quarter billion people it is more than a statistical probability that there are a lot of very smart people in all avenues of the nation.

Many of these people would be destined to be quite successful given reasonable opportunities. A smaller percentage (but still a large number) might be destined to be the nation’s, or the world’s, greatest scientists, entrepreneurs, politicians (as in leaders, not today definition), artists and philosophers. However, such potential can only manifests itself when the individuals obtain the education and social support needed to learn and mature.

We often talk of how great America is, and the huge accomplishments that have been part of our history. A closer look at the successes in the 20th century reveals that we produced much of those achievements after large scale education of the population. Support of public schools became the rule. The GI bill after WWII resulted in a heavy GOVERNMENT investment in education and unleashed a wave of technology that drove our nation forward.

The labor movement brought millions of Americans up to the middle class and raised middle class family standards to a level that made it possible to send their kids to college. Even if our parents could not quite afford to send us, low interest student loans applied toward tuition at heavily subsidized state universities made college financing quite manageable.

A look at the civil right movement is another clear example of bringing more of the population along with it’s locked-up talent into the mainstream though education. Absent the advances made during those years, it would likely be a rare sight to find an “intelligent” (educated) person of color either in middle or upper levels of society in America. All the current success stories could be just a list of wasted minds and lost productivity.

Every time we educate a population, we release its previously hidden “people resource”. It is kind of like mining. If you want to release the buried treasure or energy resource, you have to painstakingly mine it and separate it from the lower value resources. The only way to mine the American population for our national treasures, our best scientists, leaders, entrepreneurs, artists, musicians, etc., is to cast a broad net of education over them so the most important, and currently most wasted American resource can be recovered before it is forever lost.

If we could turn the conversation to this kind of mining, you would have my support for “drill, baby drill”.

 

Justice Roberts “Conversion”

There has a lot in “news” about Justice John Roberts alignment with the liberal side of the bench declaring the ACA constitutional. The Right has called him a traitor. The left is scratching their heads, but smiling. What was his thinking and what are the implications of Justice Roberts sudden conversion?

First, we progressives should be thankful. However, is this thankful as in ‘a beggar given a small bit of food’, or as in ‘Thanksgiving thanks’ for all that is good? We might also ponder what motivation and thinking is behind his decision to part with his usual company and accept his unpopularity within his own previous support group.

In the long run, this decision matters little to the monied interests who have taken control of the political Right. Those guys get their healthcare with VIP access and at a cost that does not even constitute pocket change. Healthcare access is about social justice, not financial power over democracy. I am fairly certain that most of the concern generated in this corner of the universe will be focused on financial implications and opportunities to exploit for financial gain to guide their next investment or hedge. They want to know who the winners and losers are so they can place their bets and be winners, regardless of which sectors win or lose. That is way their game is played. Consequently, I doubt they brought their full influence to bear. So it is not likely that this decision, despite all the rhetoric, is a big deal to them. It does, however, play into the storyline of Obama the Socialist, and for that they give thanks and raise money.

This decision was also certain to be one of the greatest legacies for the Roberts Court. One might ponder for a moment the historical notations attached to the Roberts Court if it had continued the regular issue of 5-4 decisions, appearing partisan in their outcomes, and culminating with this one. There has been an increasing perception of the SCOTUS as just another partisan piece of our broken system. After the Bush v. Gore and Citizens United decisions, a decision against the ACA would likely have cemented the perception of this court as partisan and no longer respected as an independent third branch of government.

Restoring credibility to the Roberts Court may not be very good for progressives. At some level the Court will gain additional credibility to the past and future decisions. From a court that brought us Bush v Gore and Citizen’s United, that is not good news.

I also think Justice Roberts must deal with his own ego. This is a very powerful man. Not only is he the Chief of the SCOTUS, he will likely remain so for a very long time. He is a young man with no possibility of being defeated in an election later down the line.  That kind of power has to be an ego booster. I say this only to suggest that feeling that mojo may help him be more independent, and to act to save his name and that of the Court. I would be think that perhaps Justice Roberts will mark this decision as his time to take command of the court as a more independent voice, but I would not hold my breath.

The ACA is Constitutional, but it is no Panacea

As the SCOTUS ruling on the ACA reverberates down through the ranks and implications become better understood, many problems will remain. Controversy will continue around the dominance of insurance companies and the cost to the public. The ACA may limit the profits by requiring insurance companies to spend 85% of your premium on healthcare, but they still retain a firm hand and today’s Wall Street reaction (Health insurers up) means they see it the same way.

Many people talk about reducing healthcare costs through a competitive market. The problem is the healthcare market would be better described as a manipulated marketplace. ACA provisions will make an incremental step in the right direction, but it will not fix the problem The entire market is opaque and dominated by cost shifting. If some people don’t pay their fair share, others must make up for it. In the simplest form, this might mean you pay a little extra at the local Walmart to make up for losses from shoplifting. In healthcare, it rises to epic proportions and the effects.

Here is an example of how this works in my field of emergency medicine. Let’s look at a sample of typical real-world bills, covered costs and payments. If you have had any recent medical care, this may look a bit familiar. You have surely seen those hospital bills for thousands somehow reduce to a few hundred dollars by insurance discounts.

Payments for the same type visit by different payers (insurance companies, Medicare, Medicaid or individuals) will vary immensely. Medicare patients represent about 30% of patients in a typical ER. The feds will pay about $170 under Medicare (varies by region) for high level physician services (for the sickest patients). That sum will come in a little below the actual cost or what a retail store might call a reasonable retail price. That cost includes physician reimbursement, plus the cost of malpractice, health and business insurance and typical business expenses, another 10 plus percent to cover the cost of billing, and the burden of cost shifting. Since Medicare pays less than that, some cost shifting will have to applied to the remaining 70% of patients.

For a typical practice, another 20% of patients will be Medicaid. State Medicaid rates for emergency physicians vary tremendously from merely below Medicare to outright abusive exploitation. Some states will pay less than $50, others over a $100. For many years in NJ, I received $12 per patient visit regardless of the service provided.

They get away with this because emergency physicians cannot opt out of Medicaid. The law requires they provide care to all comers in the ER. Obviously, the difference between the cost of care and payments will be even larger for Medicaid patients resulting in even larger cost shifting that is added to the cost shifting from the Medicare patients. This leaves a large burden on the shoulders of those remaining patients.

Patients covered by Insurance will comprise another 30 percent of visits. Insurance companies work hard to avoid paying for cost shifting. In hospitals and regions where they dominate the market and have the necessary leverage, they may pay Medicare rates or even less. Mostly, they pay about 150% Medicare if they have contracts. Most insured patients will be treated in places where their insurance is “accepted”. This means discounted contractual rates will prevail for those patients, although the actual payment may be have to be paid as a deductible by the patient.

This leaves a small group of patients, who are uninsured, or who seek care in a hospital where the physicians are not contracted. These visits will bear the full burden of all the other cost shifting. Insurance companies deal with these high costs shifts by passing the cost through to the those who buy the insurance. This is a major cause of the high cost of insurance, the need to pay for not just your care but those not paying a fair share. Realize that the insurance company executives are just fine with this as it justifies increasing premiums. The “bill” generated for the above visit may be anything from perhaps $350 to as much as a $1000. Yet in a fair and transparent system devoid the system costs, the cost might be under $100. (that is why socialized medicine is so much cheaper).

That bill is only the beginning as it only covers the physician charges. Hospital billing practices are exponentially worse. Their billings profiles are nothing less than insane. The hospital will bill charges for the ER usage(room, nurse & supplies), x-rays, labs, drugs, etc. The total emergency “charges” can easily top $10,000 although the cost of providing such care might only be $500 (again devoid system costs). The problem is unlike Walmart that increased its price to account for shoplifting to all of its paying customers, hospitals must collect all their cost shift from only about 10% of payers. Therefore, they may send bills totaling $10,000 knowing the amount of the bill is irrelevant to contracted payers and will only apply to  non-contracted patients. Mostly they only collect from patients with non-contracted insurance companies. However, caught in this mess will be uninsured patients who become responsible for the whole bill.  In many or most cases this places insurmountable debt on those who can’t afford insurance making medical debt the number one cause for bankruptcy fillings. Also lost in this conversation is the coercion to buy insurance at whatever price to avoid such a fate.

Imagine if BJ’s or Sam’s Club could arrange for prices in your local grocery to rise 10 times. Everyone would flock for memberships. That is what we have in the Healthcare marketplace. No, healthcare it is worse. To improve this analogy, the big box stores would also have to sell their memberships at a huge discount to wealthy members of country clubs, while doubling prices to average local residents. This is what insurance companies have traditionally done. Discounts to big employers. Higher rates to small businesses, and nothing short of grotesque exploitation of individuals. Individuals in most markets have no options to cover pre-existing conditions. They are generally offered limited coverage, with large deductibles, low lifetime limits, and loads of exclusions, at astronomical prices. It has also created a huge scam opportunity to sell “insurance” that pays for essentially nothing. Offers for cheap insurance abound. Most provide little or no protection. The myth of cheap insurance from buying across state lines has mostly to do with offers to buy worthless coverage in states without regulations to prevent such unethical business practices.

Yes, the ACA is a huge step in the right direction. It is also likely to shine a light onto other inherent problems in the system. America has now recognized healthcare as a right and can now begin the larger process of fixing the problem. My prediction is that it won’t be too long until it is recognized that we can only reach our goals with a single payer system.

BigPharma Strikes again… and again

Link

In Documents on Pain Drug, Signs of Doubt and Deception (click for full article)

A research director for Pfizer was positively buoyant after reading that an important medical conference had just featured a study claiming that the new arthritis drug Celebrex was safer on the stomach than more established drugs. “They swallowed our story, hook, line and sinker,” he wrote in an e-mail to a colleague.

There is a school of thought in medicine that goes “You don’t want to be the first or last to jump on the bandwagon of new dugs or treatments”. This is in large part due, not to the original reason the statement was offered, but to deception of the part of researchers and their employers or sponsors, i.e. BigPharma.

When I first learned this “rule” in pharmacy college, the concern was speculation about the possibility of unknown or less common problems that would only surface after the use of the drug or treatment became more widespread.

Sure we knew that the drug representatives frequenting physician offices would downplay any such possibilities and put the best light on their products, but we did not think that data was fudged. Cherry-picked a bit sure, but not outright deceptive. We thought drug reps purposely lived in the safe harbor of gray data that was open to some “interpretation” and walked the line allowing a walk back if overtly contradictory evidence surfaced.

The “new” reality is different however. I say “new” only because the reality of deceptive corporate policy as part of “business as usual” has only recently been accepted. IT has likely been this way forever. Drug companies spend huge sums developing and testing new drugs. They want a return on that investment.

In this case, Pfizer was faced with the choice of being honest and losing any advantage the drug might enjoy in the marketplace versus lying and enjoying dominance in a huge market.

I personally came to terms with this overt dishonesty fairly early in my career as a physician.During pharmacy school, I learned that pharmacists have much more education on drugs than physicians, by a wide margin. In the real world, most physicians get the bulk of their education about the evolving drug market from drug reps, not independent legitimate educational sources.  (New drugs are released at a rate of almost 1 per week.)

Once in practice, the stream of drug reps pushing their wears is never ending. Their “educational sessions” always came with freebies, food, gifts, outings etc. Even free starters packs of drugs for patients to get them hooked on the most expensive version of what was out there.Visits to my office were always a bit challenging to the reps as I critically reviewed their references and challenged their conclusions. The success I had over the years in shooting down the materials presented cemented in my mind the new reality that I speak of. Drug Rep visits were a rehearsed dog-and-pony show, which had no ethical boundaries in its preparation. Many of the drug reps were much too unsophisticated to even know they were speaking garbage. Many were nurses who have even less real pharmacology background. And virtually no experience in scientific review of study methodologies and critique. The companies provided a script. They learned it, assumed they were given honest data, representative studies, and legitimate conclusions to present. BUT IT JUST WAS NOT TRUE.

In this case, they were promoting a drug for one of America’s largest markets, arthritic pain, without the very serious known side-effects of stomach bleeding and ulcers. All of its competitors in that market had that downside. This was obviously a huge step forward that potentially offered real benefits to patients. It was promoted that way.  And physicians believed it and in many practices literally stopped prescribing all competitors. What a coup. Just one problem, it was all a lie, and they knew it. As the article states “They swallowed our story, hook, line and sinker,” the head researcher wrote in an e-mail to a colleague.

The truth was that Celebrex was no better at protecting the stomach from serious complications than other drugs. It was just a new, very expensive option, still under patent, with no benefit over older dirt cheap drugs like ibuprofen. Oh, and it also is associated with increased risk of cardiovascular death and they sort of knew that too. It took years for that part of the story to emerge.

Healthcare system is cash cow being bled, not just milked

Aside

This is one of those eye-popping graphics. Just consider the some of the implications of this data. I should make a list, but it would be too long. The Healthcare system is not just being milked as a cash cow, it is being bled by the extraordinary greed of he corporate establishment. Sure there is plenty of fraud and abuse, and plenty of inefficiency, but that pales in comparison to the built-in syphoning of mega$$$ by health insurance & BigPharma for shareholder payouts and ridiculous executive compensation packages. Not to mention the conversion of hospitals and other medical services from providers of care to public for-profit companies. Not even the not-for-profits have escaped the “become a business and prosper” mentality. The community hospital where I spent my career got infected with that mentality. Unfortunately, they picked bad investments (it was a healthcare institution, after all, not a venture capital group) . It cost them control and the hospital was acquired by a larger system. Business has bled this this cow to the absolute edge. If Americans want healthcare, we will likely eventually end up with single payer because we HAVE to, just too bad we have to suffer so long to get there. But until there is no more blood to suck, we are stuck.