In the Internet age, medical care often begins with a free, instant, zero co-pay appointment with the Google search engine. Not all the information Dr. Google spits back at you is helpful, necessarily, and some may cause you undue anxiety, but the discerning patient may find useful first aid information for a cut or a sprained ankle or discover that the nasty pain down his leg may be due to piriformis syndrome.
Self-diagnosing may be on the rise, but self-medication is limited to over-the-counter drugs. For prescription medications, we rely on board-certified physicians and other medical providers to examine us and determine which drug, if any, suits our needs. Three new studies suggest we might think twice before trusting that doctors are always making decisions that are in the best interest of their patients.
#1 - “Off-label” drugs may work well for you or be cheaper than other options, but doctors are less likely to use them
A recent case in point is Lucentis, a dear drug used by ophthalmologists to treat macular degeneration. Many sufferers from this eye condition receive a monthly injection to the tune of $2,000 per shot. Lucentis, made by Genentech, works well. But here’s the rub. Another Genentech medication, Avastin, is highly comparable in effectiveness to Lucentis yet costs 40 times less—just $50 per dose. Why would any a doctor use Lucentis when a much cheaper alternative is available? Avastin was designed a cancer drug, not an ophthalmologic treatment. When eye doctors use it, they are prescribing it “off-label”—for a purpose other than its FDA-approved use. This is legal and common, but some patients are uneasy with off-label prescriptions. Why doesn’t the FDA approve Avastin for the treatment of macular degeneration? “Genentech could apply for that approval,” Bradley Fikes reports in the San Diego Herald, “but it declines to do so. Indeed, it goes to great lengths—illegal lengths, French and Italian regulators have said—to discourage Avastin’s use in the eye.” And it is not just pharmaceutical companies with perverse incentives to steer patients away from cheaper, equally effective medications. “For physicians who submit the bills,” Mr. Fikes writes, “greater expenses can turn into greater profits.” In 2012, one ophthalmologist in Milwaukee, Wisconsin brought in $7 million in Medicare reimbursements for Lucentis alone.
#2 - Your doctor may be more likely to prescribe more expensive drugs pushed by pharmaceutical company representatives
Have you noticed that your doctors are giving out fewer free samples of prescription and over-the-counter drugs recently? This may be because, as Kenneth Katz, Erica Reid and Mary-Margaret Chren report, “many private clinics” and “[n]umerous institutions have banned or sharply restricted drug sampling.” But a lot of samples ($6.3 billion worth in 2011) are still dropped in doctor’s file drawers and handed out to happy patients. It turns out there is no such thing as a free tube of Aquaphor or starter dose of antibiotics. A study published this month by Michael Hurley and three other researchers found that patients left dermatology clinics where sampling occurs with prescriptions for acne costing more than twice as much as those of patients attending clinics where sampling doesn't occur. And it's not just a matter of cost. As Dr. Katz and colleagues write, “[s]ampling can influence physicians to prescribe less appropriate medications” and “outcomes might be worse if patients ultimately are unable to afford or obtain sampled drugs.” By removing pharmacists from the equation and doling out drugs directly, doctors providing their patients with samples risk missing “drug interactions...safety issues...expiration dates, and information needed in case of product recalls.” And sampling can carry more profound dangers:
[Two] years after it gained US Food and Drug Administration approval, rofecoxib ranked as the most widely distributed sample in the United States. Only 3 years later, in 2005, the drug was withdrawn from the market because of increased risk of heart attack and stroke. Similarly, among the 15 drug samples most widely distributed to pediatric patients in 2004, 4 received new or revised black box warnings within the next 2 years. One of those drugs was pimecrolimus,10 a medicine frequently prescribed at the time by dermatologists. In 2006, topical pimecrolimus and tacrolimus both received black box warnings that noted a potential increased risk of skin cancer and lymphoma.
#3 - Because of a flawed federal law, your child’s pediatrician may not have consulted the latest research on the effectiveness and risks of certain prescription drugs
The Best Pharmaceuticals for Children Act was enacted in 2002 and made permanent in 2012 to encourage and fund better research into medications prescribed for children. But according to a disturbing new article by physicians Kenneth Katz and Glenda Swetman, the BPCA is hampered by a significant flaw: there is no requirement that randomized controlled studies requested and funded by the Food and Drug Administration are ever published in peer-reviewed medical journals. As a result, good data on the effectiveness and risks of pediatric drugs often lie fallow, hidden from the view of doctors treating patients. The example Drs. Katz and Swetman cite is harrowing. A relatively mild childhood skin disorder, molluscum contagiosum, has been treated for nearly two decades with the drug imiquimod. But two rigorous studies conducted eight years ago concluded that imiquimod was not only ineffective in the treatment of molluscum contagiosum but potentially harmful to children. These studies, along with the results of about half of the 253 pediatric trials held between 1998 and 2004, were never published and were therefore inaccessible to most pediatricians. Dr. Katz and Dr. Swetman rightly call on Congress to amend the BPCA to ensure that taxpayer-funded research is properly disseminated.
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So what should you take away from these tales of hidden research, perverse incentives and profit-hungry pharmaceutical companies? The takeaway is not, I think, profound mistrust of your doctor’s prescriptions. Most physicians are treating most conditions in responsible and medically sound ways, and it would be public health travesty to, say, reject childhood immunizations for your kids because you think the medical establishment is shot through with corruption. But neither should you invest blind trust in your doctor, particularly when he lobs you free samples, steers you toward a drug that seems unnecessarily expensive or prescribes a drug for your child without showing you evidence that it works. It pays to be a prudent consumer of health care. There is no harm in probing your doctor’s choice of medication before filling a prescription.
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