Always a Mystery: Why do Drugs Come and Go?

Jill Littrell, PhD
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I’ve been teaching a course on substance abuse for about 30 years now.  In this course, I cover a new drug class each week and always review the history of the drug.  All of the drugs of abuse, cocaine, alcohol, marijuana, opiates are not new on the human scene.  They date back to the Sumerians and the Greeks.  The question for me is what accounts for epidemics?  All of a sudden, cocaine is epidemic in the 1980s.  (What, no one remembers that Cole Porter wrote “I get no kick from cocaine” around World War I and Edison loved the stuff?)  Outside of Baltimore, there really wasn’t much heroin around in the 1990s in the east.  In a study of 230 homeless men in Atlanta I conducted in 2000, I encountered only one person whose drug of choice was heroin and he was from the north.  However, now we have a nation-wide opiate epidemic.  So why the sudden discoveries?  I have come to believe that epidemics are supplier driven rather than a function of consumer demand.  For the current opiate epidemic, the suppliers were the pharmaceutical houses, in particular Purdue Pharma.

Sam Quinones has written a fascinating account of how Purdue Pharma effectively created the current opiate epidemic.  Quinones begins with the Sackler brothers who started Creedmoor Psychiatric Institute in the 1950.   Arther Sackler began as a researcher but became a marketer.  He founded Williams, Douglas, McAdams, which after Sackler was no longer with the company became the marketer for Purdue Pharma and its product OxyContin.  Sackler developed the practice of having drug reps visit individual physicians and having doctors market to other doctors.

According to Quinones, several publications appeared in the literature which Purdue Pharma capitalized on to promote  OxyContin.  First, a letter to the editor of New England Journal of Medicine in 1980 by Jink & Porter reported on very low rate of addictions observed in 11,882 hospitalized patients who had been treated with opiates.  The report was not a study, but rather a paragraph long letter.  It did not provide information on the patient characteristics, the conditions for which they were being treated, nor the duration and dose of the opioid treatment.  However, physicians at Continuing Medical Education events accepted the findings without questioning.  Later, a 1986 study by Portenoy & Foley of 38 out-patients with non-cancer related pain, about a quarter of whom were back pain patients, found that only 2 patients exhibited drug seeking behavior.  These “studies” became the lynch pins in the case that pain patients would not be addicted if treated with opiates.  Later, the FDA approved Purdue Pharma’s claim that OxyContin, because of its extended release formulation, was less addictive than other opiates.  These studies and the FDA approved characterization were broadly cited in Purdue Pharma’s marketing efforts for OxyContin.

Coincident with development of marketing of medicine, the specialty of “Pain Management” developed. The past assumption that opiates should be employed cautiously was supplanted by the idea that patients had a right to have their pain treated aggressively.  In 1996, James Campbell, president of the American Pain Society, in a speech characterized pain as the fifth vital sign.  In 1998, the VA made it mandatory for pain to be assessed along with other vital signs.  The Joint Commission for the Accreditation of Healthcare Organizations, the agency which accredits hospitals, added assessment of pain to their criteria for accreditation (Quinones, 2014).

With reassurance from the leaders of the profession that aggressively treating pain constituted good treatment, prescriptions for OxyContin took off.  In 2010, opiates were the most frequently prescribed drugs.  Many unscrupulous doctors began taking a liberal view on assessing pain.  Pill mills emerged in the east.  When the pills became too expensive, addicts switched to street heroin.  As Quinones documents a new system of marketing had emerged for delivering heroin.  Dealers, many of whom were Mexicans, did not carry guns, would not go to the inner-city, and prided themselves on customer service.  They made home deliveries and were always polite.

Only later, the downsides of the new approach became apparent.  Opiate overdoses were epidemic.  Opiate deaths climbed among Workmans Compensation clients being treated for carpel tunnel and back-pain.  75% of new heroin addicts had become addicted through pharmaceutical opiates rather than street heroin.  Requests for maximum dosage recommendations from the medical community were heard but were protested by Purdue Pharm.

As discussed in my last post, the US government’s response to the current heroin epidemic is to promote more methadone clinics and more buprenorphine providers.  Unfortunately, this paradigm shares many characteristics with the campaign that led to the epidemic in the first place.  The pain people wanted to promote the idea that people in pain could not be addicted.  SAMSHA tells us that methadone and buprenorphine are not opiate substitutes but rather are “Medication Assisted Treatment” and buprenorphine is characterized as a partial agonist at mu receptor although this is true only on some but not all measures.  There were no maximum dose guidelines for pain clinics and there are no maximum dosage guidelines for methadone or buprenorphine.  Private docs set up pill mills and the incentives were to “treat”.  The same fee for service model obtains for methadone and buprenorphine.  Beyond needing an MD as medical director, anyone can operate a methadone maintenance clinic and again the more you treat, the more you earn.  There are no criteria for determining what level of pain is required for opiate treatment; there are no criteria for deciding who is really an addict and is therefore appropriate for methadone or buprenorphine treatment.  While J. David Haddox suggested that a pain patient who appeared to be drug seeking was really under medicated,  now, Nora Volkow (see Knopf, 2014) tells us that the current street market in buprenorphine is because addicts are in withdrawal and not receiving adequate levels of treatment.  It should be noted that Quinones suggests that the bad economy and lack of living wage paying jobs contributed to the opiate epidemic in Ohio.  Nothing has changed here.  So will we just be repeating the past?

In the next couple of years it will be interesting to determine which criteria will emerge for evaluating whether the expansion of methadone maintenance programs is a good for the society.  Given the barrier to becoming a methadone client have been lowered (you no longer need to be addicted for a year), will more young people become patients?  Will the society be in any way impaired if high rates of the population are methadone maintenance clients?  (I do believe the data that methadone clients can sustain productive employment.)  Will overdoses from opiates increase or decrease overall?  Perhaps these questions will be answered in the near future.

Lest I be misinterpreted, I am not categorically against methadone or buprenorphine.  In my next post, I’ll consider the pharmacological upsides and downsides of opiates.  (In my opinion, they are certainly better than antidepressants.)  My concern is how much of the society on drugs can any country sustain?

* * * * *

References:

Cicero T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P.   (2014).  The changing face of heroin use in the United States:  a retrospective analysis of the past 50 years.  JAMA Psychiatry, 71(7), 821-826.

Franklin, G. M., Mai, J., Wickizer, T., Turner, J. A., Fulton-Kehoe, D., & Grant, L.  (2005).  Opioid dosing trends and mortality in Washington State workers’ compensation, 1996-2002.  American Journal of Industrial Medicine, 48 (2), 91-99.

Knopf, A.  (June 23, 2014).  Congress and administration look at ways to expand buprenorphine treatment.  Alcoholism and Drug Abuse Weekly.

Leece, P., Cavacuiti, C., Macdonald, e. M., Gomes, T., Kahan, M., Srivastava, A., Steele, L., Luo, H., Mamdani, M. M., & Juurlink, D. N.  (2015).  Predictors of opioid-related death during methadone therapy.  Journal of Substance Abuse Treatment, in press.

McCance-Katz, E. F., Sullivan, L., Nallani, S.  (2010).  Drug interactions of clinical importance among the opioids, methadone and buprenorphine, and other frequently prescribed medications: a review.  American Journal of the Addictions, 19(1), 4-16.

Meier, B.  (May 10, 2007).  In guilty plea, OxyContin maker to pay $600 million.  New York Times, http://www.nytimes.com/2007/05/10/business/11drug-web.html?_r=0

Portenoy, R. K., & Foley, K. M.  (1986).  Chronic use of opioid analgesics in non-malignant pain: report of 38 cases.  Pain, 25(2), 171-186.

Quinones, S.  (2014).  Dreamland: The True Tale of America’s Opiate Epidemic.  New York:  Bloomsbury Press.

Volkow, N. D., Frieden, T. R., Hyde, P. S., Cha, S. S.  (2014).  Medication-assisted therapies—tackling the opioid-overdose epidemic.  New England Journal of Medicine, 370, 2063-2066.

Weissman, D. E., & Haddox, J. D.  (1989).  Opioid pseudoaddiction—an iatrogenic syndrome.  Pain, 36 (3), 363-366.

Zedler, B., Xie, L., Wang, L., Joyce, A., Vick, C., Brigham, J., Kariburyo, F., Baser, O., Murrelle, L.  (2015).  Development of a risk index for serious prescription opioid-induced respiratory depression or overdose in Veterans’ Health Administration patients.  Pain Medicine, in press.

Zedler, B., Xie, L., Wang, L. Joyce, A., Vick, C., Kariburyo, F., Rajan, P., Baser, O., & Murrelle, L.  (2014).  Risk factors for serious prescription opioid-related toxicity or overdose among Veterans Health Administration patients.  Pain Medicine, 15, 1911-1929.

91 COMMENTS

  1. I think that an important aspect of this issue is that the widespread use of drugs, whether prescription or street drugs, is evidence of social dysfunction. One could say that governments and corporations prefer to encourage drug use in many ways rather than have people vocalize social discontent. Our society has not shown the courage to attend to serious fundamental problems, and has allowed drug industries to flourish.

    • I wonder whether our society needs to get over the idea that there is a pill for every mild discomfort. I watch the commercials for antibodies to TNF-alpha directed to people with arthritis. One of my students who does not appear to be in pain said she had a hard time resisting her physician’s advice to take antibodies to TNF-alpha for her mild discomfort. Turns out that TNF-alpha antibodies are associated with a failure to myelinate axons. This seems like a major league side effect to experience for some relief from having stiff hands in the morning.

      • This is insane. TNFalpha is a very important signalling molecule in immune system and beyond and sure as hell Abs against it have many side effects. It should not be prescribed willy-nilly…
        This is another problem – zero accountability for doctors prescribing stuff, often off-label. While forbidding such prescriptions may not make sense maybe injecting some regulations and accountability could help?

    • I think you hit the nail on the head, Norman. Not only are the drugs used to evade examination of massive social dysfunction, but the entire DSM is designed primarily for that purpose. As long as those in power can blame any adverse response or objection to the status quo as a “disease of the mind,” they don’t have to think about the actual impact of their policies and activities, and meanwhile can continue to enrich themselves at our expense.

      —- Steve

    • Norman,

      I can see how having more folks on drugs would be a plus for the government; zombies are easy to manipulate. But corporations? Why the pre-hire and mandatory drug tests in so many industries? Employers don’t need more zombies. They have choices in who they hire… Why should they hire someone who is addicted to street drugs?

      I fail to see the logic.

      Duane

      • Hi Duane,

        It is intoxicates they don’t want you on.

        Any drug to get you to be positive, shut up questioning their ridiculous practices, and not notice how they abuse you is all good.

        I am positive that if Prozac came in an aerosol room spray, they’d be piping that stuff through the ventilation system.

      • The drugs are for the throwaways of society. “Superfluous population” that nobody needs or cares about. No matter that in reality the problem does not stop there, all classes are affected but psychopaths at the top are not well known for their thoughtfulness and concern with collateral damage and long-term outcomes.

  2. “My concern is how much of the society on drugs can any country sustain?”

    Unfortunately Jill I think we’re going to find out. I recently finished Bob’s latest book and there seems to be an intransigent ethic among those either directly/indirectly involved in the drug prescribing business. Looking forward to your next post

  3. I wouldn’t trivialize the importance of treating pain.

    There is an important difference between pain patients and drug addicts. The pain patients for the most part are not actively complicit in their condition. By comparison, almost everyone who is addicted to a prescription painkiller made the choice at some point either to lie to their doctor about having lost their prescription, to go “doctor shopping” to gain multiple prescriptions, or to purchase drugs illicitly on the street rather than seek treatment for their dependence.

  4. I think that pain patients become drug addicts through their physicians. With regard to opiates before they were made illegal, country doctors making their rounds on horse would leave the vial of opiate with the arthritic persons with directions to use every day. By the time the doctor came back, the patient was addicted meaning he/she would experience withdrawal without the drug. The same thing has happened with regard to prescription OxyContin. Taken according to doctor direction, people were becoming addicted. The same thing occurred with valium. Taken as directed, people do get addicted. When I worked at CIGNA in the Alcohol and Drug Dependency Department, we would regularly ask psychiatrists in the Mental Health Department not to provide prescriptions for valium. The valium detox came out of our department’s budget. We were never successful in changing physician behavior.

  5. I would say that my comment was a bit harsh, and that the truth lies somewhere in between.

    Senior officials at the CDC have decided to make the “prescription drug abuse epidemic” a frontline issue, and they have issued many reports with graphs showing the explosion in Rx drug deaths between 2000 and 2012. What these graphs don’t show is that heroin overdose deaths were exploding from 1980 to 1999, and that the growth in heroin overdoses ground to a halt with the advent of the era of prescription drug abuse. With the passage of increasingly strict laws to control Rx drug abuse, we’ve seen growth in prescription drug overdose deathsn grind to a halt fom 2012 to 2014. This halt has been accompanied by a doubling in heroin overdose deaths over just 2 years.

    In the parlance of economists, heroin and prescription painkillers are clearly “interchangable goods” to those who use them recreationally or to satisfy an addiction. Unfortunately they are not to those seeking legitimate treatment of pain, and draconian efforts to restrict addicts primarily end up affecting those who seek to use opiates for their legitimate medical purpose.

    After 40 years of the War on Drugs, the price of a hit of heroin on the streets of San Diego is about $5. I don’t mean any disrespect here for your article, knowledge, or experience, but to me it seems that supply-side efforts to control illicit drug use are a proven failure. Demand will always be met when there is money to be made, and the demand ultimately arises from the injustice and hopelessness that many in our society face on a daily basis.

    I have no doubt that some of the cases of addiction and overdose death are arising from people who initially started using these drugs for their medically appropriate purpose. But if I’m in severe, life-altering pain on a daily basis, I think I have the right to choose whether to take that risk myself rather than having the decision made for me by some paternalistic government agency. If I get dependent, I’ll seek help. And I especially don’t think my choice should be limited because of statistics that conflate addiction that started out with appropriate pain treatment with that which started out with deliberate abuse for recreational purposes.

    The whole supply side approach to drug abuse just doesn’t seem to work.

    • For example, Slide 7 here
      http://echo.unm.edu/wp-content/uploads/2014/10/LHHS-091012-Michael-Landen-State-Epidemiologist-Prescription-Drug-Overdose-Deaths-in-NM.pdf
      shows that illicit drug overdose deaths in New Mexico rose over 3-fold from 1990 to 2002, during which period Rx drug overdose deaths rose by about half. From 2002 to 2009 illicit drug deaths remain flat at 10 per 100,000 population, while Rx drug deaths rise 2.5 fold. (I have not used the 2010 data because of the large proportion of “unspecified” drug deaths).

      Is it a coincidence that the annual growth in illicit drug deaths ground to a halt in 2002, and the growth in Rx drug deaths increased such that the growth rate of total narcotic drug deaths remained constant across the entire 20 year period? Or that the plateauing of Rx drug deaths in 2012 was accompanied by a doubling of illicit narcotic drug deaths?

      The issues are complicated by an interplay between pain patients becoming addicted and what I suspect is a much larger population of recreational drug users who go back and forth between oxy and heroin depending on availability. The growth in Rx drug deaths overall does not seem to have been greatly affected, in New Mexico at least, by the availability of oxycontin beginning in 1995. Indeed almost a decade passed between the commercial availability of oxycontin and the beginning of the Rx drug epidemic.

  6. I don’t have a problem with anyone choosing to take an opiate for pain or for recreation. I do have a problem with lack of informed consent. I think the government needs to regulate the way those who make money off of drugs portray their products. I think if people knew the consequences of bisphosphonates (bonivia), entanercept (Enbrel), and statins, they would be far less likely to accept these remedies for what are usually minor aliments. When it comes to chemicals, there’s no free lunch.

    • Well, as a chemist, I would say that here is no clear dividing line between chemicals found in natural sources and those found in synthetic products in terms of health effects. Tomatoes contain methanol, which is metabolized to carcinogenic formaldehyde in the body. Aflatoxin, one of the most carcinogenic compounds known to man, is found naturally in peanuts. Methycarbamate, another carcinogen, is found naturally in fermented beverages. I could go on at great length, but overall I’d say that for most people who don’t smoke, their biggest exposure to dangerous chemicals comes from eating grilled meat. Heating proteins to 600 degrees results in an array of carcinogenic heterocyclic amines that makes my head spin.

      With respect to informed consent, the patient information leaflet that the FDA requires be provided to every patient recieving an oxy prescription says the following:

      “A long-acting (extended-release) opioid pain medicine that can put you at risk for overdose and death. Even if you take your dose correctly as prescribed you are at risk for opioid addiction, abuse, and misuse that can lead to death.”

      Seems fairly explicit to me. No one gives you a leaflet stating that peanuts may give you liver cancer or that barbequed meat is associated with increased risk of cancer of the bowel, breast, pancreas, liver, and testicles when you buy them.

      • It’s true that somewhere in the 3 full page handout that statement is written. But the industry knows that few people (I’m one of the nerds that does) actually read those inserts. They are more likely to believe that their prescriber wouldn’t give them anything that could actually harm them. Let’s face it, if they have already bought the idea that there is a pill for everything, they probably aren’t likely to invest the time to research what they are putting into their bodies. This isn’t a dig on anyone but it is a fact of life and a result of deceptiveness and an acceptance of ignorance.

        • I’d say that if someone hands you a 3 page safety brochure with your new prescription, that’s a pretty good red flag that you are being given something that has important safety issues and you should read it.

          I’m a little unclear on how you reached the conclusion that “deceptiveness” is involved when you give someone a warning and they decline to read it. I’d say handing someone a written warning is pretty direct.

          • Nice theory, except it never works in practice. In other developed countries opioid prescription are highly regulated and the addition problem does not exist on the same scale as in US.

            Or you maybe just want to put your head in the sand and tell people to read the leaflets.

      • John, I’d like to clarify some things from the perspective of Naturopathy which has been proven to me and is not common knowledge but truth never the less . Modern AMA medicine is so enamored of the isolate the active ingredient idea . My teacher Joseph Liss ND the single most accomplished healer I have ever known to whom helping nature cure cancer was a routine event in humans and animals used to say concerning the active ingredient idea.They say a person has a shortage of one vitamin say C . I can’t believe they are only short just C. If there is a shortage of C there are other shortages as well. If you take an organic tomato there are those things in it that occur together which are presently known about and some things which have yet to be discovered . Things occur in nature in combination and foods generally certainly the foods which we still can get that were used since Biblical times that are organically grown can sustain the human without side effects occurring . To isolate or make one part synthetically and then ingest it will have side effects in the human.That is the problem when isolating ingredients that are not even foods that are called drugs . They have side effects. In proper combination whole organic foods have evolved along with the human being for millennia as well as herbs in their entirety. Synthetics are relatively new and besides the human thrives best on live food which cannot be created in a test tube . I mean from dead stuff synthetic you cannot create an orange in a test tube. There is a difference between the ability of live foods and synthetic foods as far as providing for the ongoing health of the human being because live organically grown foods are compatable with living people thriving. Yes soils have been depleted air quality is not the same it’s harder to find clean water . The assaults on the human are many times coming faster then the human can evolve and yet we are very adaptable and resourceful. I’m not certain I have been clear or complete enough in this comment .

  7. I’d like to point out I find it problematic that the mainstream medical community is handing out opioids under names other than opium, and not giving patients informed concent regarding the fact they are being prescribed opioids. I believe this should be illegal. And, the mainstream medical community is seemingly unaware of the fact that the synthetic opioids can cause odd thoughts. At least I personally told four different doctors I was having odd thoughts and was being prescribed Ultram, a synthetic opioid, not one of those four doctors explained that Ultram was an opioid. Every doctors claimed my prescriptions couldn’t be the problem. And I ended up with a bipolar misdiagnosis.

    • “”Every doctors claimed my prescriptions couldn’t be the problem.””

      SE, sadly that seems to be the mantra of most doctors and not just psychiatrists. Many years ago, there was no doubt in my mind that Allegra was causing insomnia. When I told the allergist, who had top credentials, his response was that wasn’t supposed to happen. I wanted to say, “you —–, I am telling you it occurred and I don’t appreciate you minimizing my experiences.” I bit my tongue.

      • Thanks, AA. And I agree with you, it does seem to be all doctors who are denying ADRs. It’s bizarre, perhaps it’s a cognitive dissonance problem, although there is also a lot of misinformation being given to doctors.

        Even my current doctor, who does seem to be a decent guy, argued with me initially when I told him Wellbutrin can cause increased libido (I had also been given the “safe” Wellbutrin prior to the misdiagnosis, for smoking cessation, then was abruptly taken off it, so also had symptoms of antidepressant discontinuation syndrome).

        GSK was in the midst of a lawsuit when I had this discussion with my new doc, because they’d been illegally marketing Wellbutrin as the “happy, horny, skinny drug.” And this doc is telling me Wellbutrin doesn’t cause unusual sexual side effects. Although I understand why, drug.com and I would imagine PubMed, or wherever doctors get their information, still doesn’t list increased libido as a possible side effect of Wellbutrin – despite the lawsuit!

        The truth is you can’t trust any doctor any longer, not because they’re bad people, but because they’re being given a lot of bad information. Now my doctor lets me teach his students about how some patients are quite well researched in the medical arts.

      • I actually had to educate my doctor that this was extremely inappropriate to prescribe along ANY psych meds…..

        And the thing is here, because it’s not “codeine” (the pain drug of choice in Australia) – it’s PREFERRED by docs, because it’s “non-addicting.”

        Sometimes I think “non-addicting” just means NASty!

      • Thanks, JanCarol, didn’t know that. But it does have a major drug interaction warning with the Wellbutrin – so any doctor with a brain in their head should know better than to prescribe these drugs together is right.

        The truth is my PCP was paranoid of a malpractice suit because, unbeknownst to me at the time, her husband had been the “attending physician” at a “bad fix” on a broken bone of mine. It’s my understanding, from others, that unethical and incompetent doctors frequently cover up their malpractice by mismedicating innocent patients, then shipping them off to the psychiatrists to misdiagnose and tranquilize. My pastor called it “the dirty little secret of the two original educated professions.”

  8. “My concern is how much of the society on drugs can any country sustain?”

    Yes, I think this is a very important question that few are asking. It is certainly true of psychiatric drugs, where I am seeing a huge increase in the nasty exchanges between people related to the disinhibition caused by antidepressants.

    Our culture is being changed for the worse by these drugs, and even the most thoughtful critics of psychiatry are not talking about this.

  9. Another aspect related to why drugs come and go is why diagnoses come and go. I have seen many fad diagnoses in psychiatry, such as the present emphasis on diagnosing “bipolar” in anyone who has up and down moods, but there are also fad diagnoses in general medicine, such as diagnosing hypercholesterolemia, and giving statins even when there is no evidence of arterial disease. In psychiatry, many of the fad diagnoses that I’ve seen through the years have similar symptoms: variable moods, insomnia, periods of lower functioning. The diagnoses that are given, are often driven by the mental health industry’s need to create a niche to treat, as well as by Big Pharma’s need to create a market. So, the use of street drugs, prescription drugs, and diagnoses is so often industry driven, and not responsive to actual social problems.

    • I don’t think statins are a “fad”. They’ve been shown in randomized clinical trials to reduce cardiovascular events and mortality both in primary and secondary prevention. This is not a conclusion reached merely by a treatment guideline group made up of paid speakers for pharma, but by groups such as the Cochrane Collaboration (of which Peter Goetz is a part), AHRQ, and NICE.

      There may well be room for continued scientific debate, but to suggest that the vast amounts of expenditures and personal career investment that have gone into investigating these issues add up to a “fad” is unduly dismissive and fails to engage with the substantial body of research that has been done in this field.

        • This may be a bit overstated; however, when you consider the fact that drugs are often nothing more than slight alterations of naturally-occurring nutrients, and/or herbs, with a patent (and fallout from the slight alterations)…. It is food for thought:

          “For every drug that benefits a patient, there is a natural substance that can achieve the same effect.” – Carl Pfeiffer, MD

          Duane
          discoverandrecover.wordpress.com

          • Oh boy. Perhaps Dr. Pfieffer could join us and present the results of randomized double blind trials demonstrating the impact of some of these natural substances on the clearance of tuberculosis; on the prevention of death in HIV; on the progression of chronic myeloid leukemia; on the cure of Hodgkin’s lymphoma; on the prevention of hip fracture in osteoporosis; or on the extension of life in metastatic melanoma. Somehow these publications have not shown up in Pubmed.

          • John,

            You might be surprised to learn just how much research there is on the benefits of nutrients in both the prevention/treatment of disease. The Journal of Orthomolecular Medicine is a good place to start. As far as herbs, the American Botanical Council has a link to the Commission E Monographs (from Germany, which leads in the study of herbs).

            Duane

          • Niacin is good – Vitamin K helps shift the minerals from the blood vessels to the bone. If you want a more statin-like effect, there is Red Yeast Rice. And this doesn’t even begin to touch dietary measures, such as increased fiber, pectins, prostoglandins, digestive enzymes, and medium chain triglycerides.

            Statins cause mental deficiency, contribute to depression, cause vitamin deficiencies (CoQ10 and B vits, among others) and may even be harsh on the mitochondria. Statins DO contribute to diabetes, especially in women.

            As I am in a range of concern, I’ve had Doppler, and about to have a coronary calcium test done. For me, the risk of depression with statins (and the hypolipedemia of the brain in general) is too great. Additionally, with 2 close family members having Type II Diabetes – I think I’ll give the “published pharma studies” and their statins a miss.

            The point is – we need the FREEDOM to choose, and the knowledge to understand what we are choosing.

      • Hi John,

        Without doubt the treatment of high cholesterol can be inportant, includig the use of statins. However this class of drugs are now among the top profit earners for pharmaceutical companies, and while useful also have many side effects. I know of many family doctors who are backing away from prescribing these drugs without first doing other tests (like Dopplers) to see if the prescription is necessary. There are also ther things like exersize, diet, and some natural substances that can lower cholesterol and improve cardiovascular health. The issue that Jill raises is not whether certain drugs, prescription or otherwise, are helpful, but why certain drugs or practices become so popular at certain times. The fad aspect can be dangerous because it can stop people from following or recommending alternatives that may be better for many people.

        • I think in a coming blog I’ll talk about the return in some places in medicine to helping the body heal itself. As mentioned elsewhere, I work in an Immunology lab. The hot topic is getting the CD8+ cells to get rid of the tumor. This kind of approach would have far fewer side effects than the current slash and burn approach. Unfortunately as Ghaemi points out modern medicine is an assault on disease rather than an assistance to the body’s natural defenses. I welcome the paradigm shift.

          • Dr. Littrel, I don’t know if you’ve paid much attention to what is going on in industry, but the approach you advocate is not confined to academia.

            Bristol-Meyers-Squibb has developed the antibodies nivolumab and ipilumumab for the treatment of cancer. These antibodies unleash the tumor-specific immune response by antagonizing T-cell checkpoint pathways, and have demonstrated remarkable effects in patients with metastatic melanoma (including complete responses) and have outperformed chemotherapy in several other cancer types with reduced side effects.

            Juno Therapeutics and others are developing varous chimeric antigen receptor modified T-cells for hematological cancers, and have achieved what can only be called extraordinary results in acute leukemia, including a early stage trial in which complete remission was obtained in 91% of patients with relapsed or refractory ALL. Its an extraordinary result.

            Indeed, immunotherapy is front and center in industrial oncology research, and it appears likely that metatstatic cancer will be routinely curable within 20 years.

            So I don’t think your description of “modern medicine is a slash and burn approach” or “an assault on disease rather than aiding the body’s defenses” is entirely accurate. The best science is moving forward and not just in academia.

        • I was bullied into statins, which resulted in suicidal depression, and general ill health since, after 10 years of “maintenance use.”

          If I threatened to go off, I was told I would have a heart attack or worse.

          I went off 3 years ago now, and continue monitoring and testing. See my post to Duane above, I’m not well versed in this MIA thing and think I got them backwards.

          • Yes, depression is a rare side effect of statin treatment. But I’m curious as to why you believe that your current general ill health is attributable to the statin. Is it possible that it instead results from the fact that you are 10 years older? Statins have been taken by hundreds of millions of people, and I am not aware of any studies that have suggested a general negative effect on overall health. On the other hand, the effects of aging are extremely well-established.

          • thanks for your comments John. I have a friend with a recent diagnosis of metastatic esophageal cancer. I told him and my brother (CDC physician) about antibodies to PD-1 but no success in finding such treatment. We’re back to slash and burn. With regard to efficacy of the antibodies for solid tumors we aren’t there yet. No strategy for combating Myeloid Derived Suppressor Cells, MAT, and T regs in the tumor.

            By the way, a few years back I got curious about why statins are anti-inflammatory. I read a lot of Charles Serhan’s research. (He’s a biochemist who’s into lipids.) He provided the answer. Serhan also has contributed a lot on why omega-3s are anti-inflammatory. Given a choice between statins and fish, I’ll take the salmon.

      • JohnSmith

        Perhaps the statins are not a fad in your area of the country but they sure are where I live. I’ve stopped using the services of two doctors because they were abusive in their approaches in trying to make me take statins as their patient. Statins have lots of effects that are not helpful, for instance they can cause muscle problems in the hips, thighs, and upper calves to the point that the person effected cannot walk normally without the use of canes, crutches, or walkers. Once this happens it’s a permanent thing and cannot be changed. And yet, knowing all of this doctors still try to force these drugs on their patients. When I pointed this out to these two doctors one of them sarcastically stated that I’d have to decide whether I wanted to die of a heart attack or be able to walk. This quack has a policy that all of his patients forty years old or older will be on a statin as a maintenance measure! It would be good at least to check cholesterol first I would think before putting anyone on something like this. But not this arrogant quack! He states that statins are the safest drugs in the world with no side effects. I couldn’t believe what I heard coming from this very sought after GP.

        Needless to say I walked out of his office and never returned and refused to pay the astronomical bill that he tried to charge me for the simple consultation. I refuse to pay for abuse that I can normally get for free, if I want to be abused!

        • Jill, I don’t think its a matter of “back to slash and burn” as having not made the advance yet. Correct me if I’m wrong, but it doesn’t sound like your lab has yet developed inmmunotherapy for esophagael cancer either. Are you claiming to hold the moral high ground because you can’t offer chemotherapy either?

          As for fish oil, there are no RCTs that have shown an effect on CV outcomes. The anti-inflammatory effects of statins are just one hypothesized mechanism for their cardiovascular protective effect, and recent results with Mercks cholesterol uptake inhibit strongly suggest that their effect on LDL at least contributes.

          Steven, I certainly won’t argue that we should add statins to the water supply, but your assessment is dramatically out of synch with that of COI-free expert opinion, including that of the Cochrane Collaboration.

          • Well, even Cochrane Collaboration has to depend on the research which is largely funded by pharma so I’d not be surprised if their findings were influenced by publication bias, data manipulation etc. I know they’re doing tehir best to weed this out but the sad reality is that most of medical research is not objective.

            Btw, using statins on everyone above certain age is clearly medical malpractice.

      • Remember how it was prohibited for red rice a simple food stuff to be imported into the USA because it lowered blood pressure even better then the “medical drug ” Lipitor . To prohibit the importation of red rice was the reaction of Big Pharma Gov. to protect their Lipitor concession which had negative side effects . All for money. Like they really care about the people , right?

        • Was red rice prohibited at one time? I just recently bought some.

          Or did you mean red yeast rice which contains the same ingredient in lovastatin? If this, then I would wonder if the drug has nasty side effects, why anyone would want to take it as a non-controlled supplement.

      • Or you can just encourage people to exercise and eat healthy without risking the drug’s side effects. Btw, low cholesterol level is not the same as lower risk of cardiovascular disease and the number of people who have genetic predisposition to high cholesterol and cardiac problems is relatively low.

  11. Lucky they got rid of the Taliban in Afghanistan, that was causing all sorts of problems with the supply of street heroin. Still, production is back up to what it was before Mullah Omar had the crops destroyed, and food planted instead.

  12. Jill

    A good blog with some interesting facts and food for thought.

    I would add the following points:

    1) The proliferation of benzodiazepine prescriptions over the past 20 years parallels the epidemic rise in opiate overdose deaths. Over 30% of all opiate overdoses involve the use of ‘benzos.’ We cannot talk about the dangers of this epidemic without talking about ‘benzos.’ Many opiate addicts know how to use their opiates but they often forget about other sedative hypnotics they consumed earlier in the day.

    2) Drug addiction in society involves both a “supply” and a “demand” problem and they interpenetrate on different levels. On the one hand there is the profit motive along with medically induced dependency leading to full blown addiction, and on the other, there is the daily traumas arising out of poverty along with other forms of societal alienation that lead people to seek various forms of “self medication.”

    3) Prolonged use of pain drugs for most people will not lead to a positive result. There is increasing evidence that pain thresh holds are lowered through the chronic use of these drugs making people even MORE sensitive to pain. There is a noted phenomena of “opioid-induced hyperalgesia” which is a medical term describing one aspect of this tendency towards greater pain sensitivity.

    4) Methadone and suboxone are highly profitable to Big Pharma and to those doctors and clinics who have these programs. These programs are poorly designed and poorly run with an inherent tendency towards keeping people on “maintenance.” Even non-profits can subsidize other parts of their enterprise that are less financially viable.

    5) We need more than true “informed consent” when it comes to drug distribution in society. Harmful drugs need to NOT be approved for public distribution and possibly removed from the market place when proven dangerous. And harmful drug distribution practices need to be strictly regulated with clear punishments for violations.

    Richard

  13. Richard- Thanks for the info. on pain is the fifth vital sign on last blog. With regard to your comments here-there are so many issues. I’m kind of a libertarian so I don’t know if I want to remove options from people even when these options are stupid. However, I think where we would agree is that the medical profession should not be money driven. I’m for nationalizing the drug companies and all medical care generally. Last night Frontline was devoted to antibiotic resistant microbes. This is a crisis and I would move it up in the CDC agenda above everything else, except maybe Ebola. Of course, because there’s no market, no one is paying attention.

      • I think as long as we have “for profit” medicine and “for profit” development of drugs and devices, the truth will never be secure. Some company will always have an incentive to lie. As Marcia Angell points out most drugs are developed/discovered in universities anyway, so I don’t buy the argument that there would be no one willing to do research. Most of the researchers I know are in it for love of discovery and the approval of their peers. I don’t think anyone would lose if we created a system without financial incentives.

        • “Most drugs are developed in academia” – that would be funny if so many people didn’t believe it. In fact, the NIH’s annual budget for Alzheimer’s disease wouldn’t cover the cost of a single Phase 3 clinical trial. Marcia Angell shoots from the hip, but doesn’t understand where drugs come from any better than I understand nuclear physics.

          If you’d actually be interested in a detailed, extensively referenced, and unbiased history of where currently used drugs came from, I recommend “Drug Discovery – A History” by Walter Sneader. He’s an academic by the way. He details all his primary sources, and you can go look at the original publications for yourself and see what institution the key discoveries were made at. I’ll give you a hint – post 1960, the overwhelming majority were at corporations.

          • Yeah, let’s ignore 20yrs+ of basic research that goes into pretty much every drug discovery and is done largely by public institutions and praise the companies of putting a few months effort in the end with over 20yrs of huge profits.

        • I may be wrong, but my belief is “power corrupts, and absolute power corrupts absolutely.” And, therefore, I think breaking up the current FDA / governmental / pharmaceutical power structure (since Thomas Jefferson warned us of the “evil corporations” that would eventually overtake our society if we ever allowed the Federal Reserve bankers to control our currency, which we did) would be better.

          And an actual competitive market place, including hopes of the “American Dream,” is what made this country great initially. So I think breaking up the large oligopolies (albeit, this needs to be done on a worldwide scale now), and returning to an actual competitive market, which inspires and rewards create thinking an innovation, would be much better than continuing this move towards a corporate fascist dictatorship.

          And, Angel’s reseach does show that the large governmentally supported pharmacutical corporations are coming up with an extremely small number of actual new effective drugs. The bottom line is society is improperly set up right now. I agree medicine for profit doesn’t work. But I think breaking up things, and creating a more just competitive market, will benefit society more than further consolidating a system we already know doesn’t work.

        • Jill

          I agree with your above comment.

          The profit motive and the capitalist system stands as a major impediment to the advancement of both science and medicine in the modern world.

          To those who would suggest breaking up the big corporations and going back to a pre-monopoly stage of capitalism – this is simply not possible.

          It fails to understand the nature of the capitalist law of value and how the class political structure defending such a law will always protect those who seek the highest rate of profit by any means.

          Richard

          • Senator Grassley’s exposure of taxpayer-funded corruption at universities should be a red flag to all of us. Sure, there is corruption with drug makers, but it’s the cozy relationship between private companies and public officials that is the real problem. It’s called ‘crony capitalism’ Richard.

            Duane

          • Also, I would remind you that these drugs have the blessing on the FDA; psychotropics, the blessing of the NIMH… And the strategy would be to give the federal government more power? Really?

            Duane

    • Absolutely.

      We’ve created a very dangerous situation through the overuse and misuse of antibiotics. We’re creating resistant strains of “bugs” that nothing will stop. I was a hospital chaplain assigned to orthopedic units where I saw people without knees or hips because the prosthetic had to be removed because it kept getting infected by bacteria that were not touched by even the strongest antibiotics that could be used. One man, a medical doctor himself who’d had a double hip replacement had to be moved around by another person because he could not sit up on his own or get up or do anything because he had no hip joints. They couldn’t keep the prosthetic hip joints from becoming infected. and the bacteria was almost impossible to kill off. Another woman had to lie in the hospital bed for six weeks without moving off or out of the bed because the area where her knee should have been was packed with antibiotic beads of the strongest antibiotic available and they were still not sure that she’d ever have a knee again, or that they could kill out the infection that was taking over her body.

      And as you say, no one is talking about this or trying to do anything about it. Medicine has gone terribly off course.

        • It’s the overuse of antibiotics not only in medicine but first and foremost in agriculture where it’s being put into the feed to increase meat yield. These practices should be illegal but sadly they’re not in many places.

  14. Stephen-thanks for the comments. I do remember a Frontline where they talked about checking the bacterial status of patients coming into hospitals from nursing homes, where there are high rates of infections. This did not become hospital policy because it was too expensive. And yet our society has money for Abilify for treating foster children.

  15. John Smith

    Regarding your comment – “Indeed, immunotherapy is front and center in industrial oncology research, and it appears likely that metatstatic cancer will be routinely curable within 20 years” – I would suggest that, by simply substituting “pharmacology” for “immunotherapy,” you have a pretty simple cut and paste from the medical optimism and its promises in the 1950’s.

    We’ve all heard it before as have you, I would guess, from your list of your recent medical procedures. Maybe “chemical fixes” are not the way to health. And this a conclusion reached by many “survivors” of the medical system as well as honest doctors.

    I honestly don’t care what researchers are now touting. My experience leads me to suggest caution with the whole chemical approach.

    • Yes, of course, people have made optimistic predictions in the past and they were not fulfilled. Likewise, there were people who were skeptical of the polio vaccine and penicillin. It doesn’t take a PhD in Aristotlean logic to figure out that bringing up such examples doesn’t prove anything. I’ll happily trade an example of mistaken pessimism for every example of mistaken optimism you care to present. Let’s look at the data instead.

      If you look at the survival curves of the immunotherapeutics currently in clinical trials, patients just seem to stop dying about 2 years into the trial. Its too soon to say for sure, but it looks like even with the very early drugs based on this technology, we may be curing 20% or so of patients who present with metastatic cancer. This is unprecedented. With the exception of testicular cancer, metastatic cancer is generally a death sentence.

      http://jco.ascopubs.org/content/32/10/986
      http://www.nejm.org/doi/full/10.1056/NEJMoa1504030?query=featured_home
      http://www.nejm.org/doi/full/10.1056/NEJMoa1504627#t=article

      Of course if you develop cancer and decide that you would rather die than take the chance of discovering that the pharmaceutical industry had done something useful and valuable, that is absolutely your right.

      • My daughter had two of her young teachers die, one likely of a bad drug reaction and alcohol. The other likely due to a “cancer cure” drug which ended up breaking up the “cancer” and spreading it throughout the teachers’ entire body, rather than eliminating the cancer, in reality. I know this happened to lots of patients. I’m quite certain today’s medical community is completely deluded by today’s pharmacutical industries’ lies. I hope the medical industry wakes up.

        • To the fact the pharmacutical industry is about profit only, and has been misinforming you for decades. I still believe (despite the betrayal of many unethical doctors) that most doctors acually are decent and ethical people who went into the medical profession to help people. But you need to learn those informing you are corrupt.

          • Someone Else ,
            I believe all the pseudo science in psychiatry, big pharma and the medical profession and elsewhere is supported and strengthened by so much pseudo education in mainstream and ivy league universities funded by robber barons founding and funding them for their own purposes ( personal cash flow and power accumulation) and in this way subverting the curriculum . I’d sure like to see an honest study on that subject. Fred

  16. Hi John-I really hope you are right about antibodies to PD-1 and CTLA4 for cancer. I’m hoping for my friend, there will be a doctor around who is willing to use this approach when his cancer returns. (Right now the tumor has shrunk in response to chemo). Let’s be clear though, it was the research scientists at public funded universities that came up with this stuff. I remember listening to Raffe Ahmed over at Emory on PD-1.

    With regard to statins. I’m glad people have choices. With regard to no clinical trials on omega-3s, there is epidemiological diet on cardiovascular disease. For clinical trial on omega-3s to be positive, it would require attention to the whole diet. If a person took omega-3s while continuing to consume high fructose corn syrup, then it would not work. It’s all going through the inflammatory loop.

    • Jill,

      On a related note regarding fish oil, I assume you have seen the studies that show they generally don’t work for a variety of conditions. Being skeptical of conventional medicine studies on supplements, I will bet they totally ignored mitigating factors such as whether people continued to eat a bad diet.

      AA

  17. You wana a cancer cure for real go to Traditional Naturapath . If money is no object go to the Paracelsus Klinic in Switzerland or at least look up what they do there. You would be astounded. The head doctor is Dr. Rau This can be googled. 2 good Traditional Naturapaths are Richard Schultz Nd at http://www.herbdoc.com and Linda Page ND author of “Healthy Healing”. Also the Gerson clinic across the border in Mexico from San Diego which still follow Dr. Max Gerson’s protocols. His daughter Charlotte see’s to it. I’m not just talkin . This is for real. Study what the protocols at the Paracelsus Klinic are first like I said you will be astounded. Wouldn’t hurt to read Robert Youngs eye opening pseudo science free book “Sick And Tired”.

  18. I’m not sure that opiates are actually better. They are more addictive and easier to overdose on, but there’s also a public awareness. With anti depressants, everyone takes those. It’s assumed to be no big deal.
    However, since you mentioned heroin … Heroin is the drug you take when you are trying to outrun your own reality. Granted, as a painkiller it is certainly effective, but half of addiction is always mental. We’ve been told what feelings are okay to have and given drugs to numb any feelings we might have that step outside of those lines. We are a nation of people who don’t want to feel anything so we practice Mob mentality and gather to film gang rapes passively from the sidelines because we’ve limited ourselves from any emotions other than shock and horror. I can certainly see a connection between heroin use and psych drugs.

  19. Duane,

    You said,

    “”The drug reps, in their suits, or high heels and low-cut tops; the recent college grads with their marketing degrees visiting docs pose no immediate threat… The legislators who pass bills that force all of us to pay for these drugs – especially psychotropics children in Medicaid and foster care programs; they are the real threat.””

    Actually, the drug rep can pose an immediate threat if that causes your doctor to treat a condition with a med that this person was peddling which ends up possibly delaying the correct treatment since the physician was too lazy to do any detective work. Also, as one who ended up in an ER due to an adverse reaction to a med, how do I know that wasn’t prescribed as the result of a marketing rep since I was given a drug coupon to use?

    Agree about the legislators but you do realize this is a bipartisan effort right and not limited to those “evil” liberals?

    • AA,

      Good point. Drug reps are a problem, but at least a good doctor who cares about their patients can put a sign in the door: No drug reps. Actually, many are beginning to say no. Not so much with legislation … There’s a reason they’re called laws. We all have to pay for them. Which means vast amounts are prescribed, especially in Medicaid and in foster care.

      I’m all for bipartisan efforts, and I apologize for losing my cool on this site recently. It’s difficult to read the far- right comments, which I have to admit I take personally, as a conservative with a heart; libertarian with a conscience. It looks to me that many on the far- left would prefer to take in this fight alone, without a politically collaborative effort… Which continues to seem odd, coming from a group that calls for a “collective” effort, and “diversity.”

      Duane

  20. I think that is’ a mistake to think street drug users are always dysfunctional. A good percentage, no one knows how many, function adequately in society, are employed, are in relationships, and are not involved in the legal system.

    Its not uncommon that people use Heroin for 30 to 40 years, and every once and a while go into a program, to clean up when their tolerance gets too high, then chip slowly at the drug for a while, until their tolerance gets high again, then go into a program again to clean up. This cycle repeats itself throughout their life time.

    What treators, only see are the dysfunctional ones, people who cannot maintain, and who have problems that force them into treatment. Either through the legal system, or by family pressure etc.

    Opiate, users will use just about any opiate, from Heroin to Methadone, to Suboxone, etc. Society would prefer them to use legal drugs, and some do by manipulating prescribers, who don’t understand addiction, or how to work with addictive personalities.

    Treatment is an alternative, that society favors because it believes mistakenly that it works, when in fact it’s success rates are very low, compared to 12 step meeting, and quitting on your own. Quitting on your own actually has the highest success rate followed by 12 step meetings.

    Its not uncommon to see addicts, go through 15 to 20 rehabs with no sobriety, simply because treatment doesn’t have much to offer. There again, because treatment is a business of taking insurance, and providing the lowest possible pay to those that provide direct services, usually ex addicts, or people on maintenance, who have little sobriety of their own.

    This country has an insatiable desire for drugs, from morning coffee, cough medicine, antihistamines, alcohol, hundreds of different types of drugs, of all sorts, etc. We tend to favor those drugs that are associated with productivity. And disfavor those associated with indolence. Those that help us cope with the stress, of a society, that is crumbling economically.

    People probably become addicted to opiates because its used so much in labor and delivery, and exposing neonates to opiates when they are so vulnerable, changes the way the receptor sites are formed in the brain, creating more opiate receptor sites due to early imprinting.

    And also because Afghanistan, no longer controlled by the Taliban, has record Opiate production, with increased air traffic to and from that country, easing smuggling into this country.

    Its also true that certain types of drug preference reflect economic conditions, with stimulants used during boom times, like the 80’s Cocaine, and now depressants, during the current economic depression.

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