Americans Have Healthy Appetite for Medicines
Every day begins the same way for Alice and Ken Heckman: They each crack open a rattling plastic tray holding scores of pills in a rainbow of pastel colors.
Between the two of them, they will gulp 29 pills -- today, tomorrow and the day after that. The couple downs a combined daily regimen of 14 drugs and a chaser of vitamins and other supplements also approved by their doctors.
They feel pretty hale for people in their early 70s. He works in the yard, juggles spots on several community boards and volunteers for the Rotary Club. She volunteers for Rotary, church and hospice. They go to the gym sometimes -- when they’re not too busy.
They had heart procedures years ago -- he a bypass, she a vessel-clearing stent -- and recovered. She has well controlled diabetes. He has worked his way through heartburn, arthritis, an enlarged prostate and occasional mild depression.
About 130 million Americans -- many far healthier than the Heckmans -- swallow, inject, inhale, infuse, spray and pat on prescribed drugs every month, the U.S. Centers for Disease Control and Prevention indicates. In fact, Americans buy much more medicine per person than residents of any other nation.
The national appetite for drugs has sharpened over the last decade, driving up the number of prescriptions by two-thirds to 3.5 billion yearly, according to IMS Health, a pharmaceutical consulting company. Americans devour even more nonprescription drugs, polling suggests.
In past months, safety questions have beset some depression and anti-inflammatory drugs, pushing pain relievers Vioxx and -- most recently -- Bextra off the market. Growing ranks of doctors, researchers and public health experts say Americans are overmedicating themselves.
For a sizable minority of Americans, the consequences are dire. More than 125,000 people die from drug reactions and mistakes each year, landmark medical studies of the 1990s suggest. That could make pharmaceuticals the fourth-leading national cause of death after heart disease, cancer and stroke.
Americans spent as much on drugs last year as they did on gasoline. The $250 billion in sales estimated by industry consultants means an $850 pharmaceutical fill-up for every American. The vast majority was for prescription drugs.
Lipitor, Nexium, Zoloft, Celebrex probably should sound like names of alien invaders. Yet they have somehow acquired a familiar, even friendly ring.
Do we need all these drugs? A relative handful yank many people away from almost certain death, like some antibiotics and AIDS medicines. Although carrying some risk, other drugs -- such as cholesterol-cutting statins -- help a considerable minority dodge potential calamities like heart attack or strokeThe right balance of risk and benefit is still harder to strike for a raft of heavily promoted drugs that treat common, persistent daily life conditions: anti-inflammatories, antacids, and pills for allergy, depression, shyness, menstrual crankiness, waning sexual powers and impulsiveness in children.
“We are taking way too many drugs for dubious or exaggerated ailments,” said Dr. Marcia Angell, former editor of the New England Journal of Medicine and author of “The Truth About the Drug Companies.”
“What the drug companies are doing now is promoting drugs for long-term use to essentially healthy people. Why? Because it’s the biggest market.”
In fact, relatively few pharmaceutical newcomers greatly improve the health of patients over older drugs or advance the march of medicine. Last year, the U.S. Food and Drug Administration classified about three-fourths of newly approved drugs as similar to existing ones in chemical makeup or therapeutic value.
Confronted with mounting costs, drug makers churn out uninspired sequels like Hollywood: drugs with similar ingredients, but taken in a different way or for a different disease. Then they are advertised as vast improvements, with images of invigorating romps through the heather -- and oh-by-the-way safety warnings. Millions with arthritis have opted for pricey, TV-star painkillers that unnecessarily expose them to higher heart risks, without relieving pain any better than older, cheaper brands, research shows.
Of course, pharmaceuticals bestow important benefits that do improve American health.
“We now have more medicines and better medicines for more diseases,” said Jeff Trewhitt, spokesman for the Pharmaceutical Research and Manufacturers of America.
The Heckmans may owe some of their active life to better medicines. “Meds have enabled us to do these things,” said Alice Heckman, a former nurse.
But many drugs hold modest value for most people who take them, research shows. Far too often, critics say, the nation violates the classic caution of the ancient Greek physician Hippocrates: “First, do no harm.”
Drug safety researcher Dr. James Kaye, of Boston University, remembers his medical school teacher kicking off pharmacology class this way:
“All drugs are poisonous. If you don’t remember anything else from this class, remember that!”
The Heckmans found out on their own. Ken Heckman lost his alertness for several months to a depression medication. His wife has come down with a rash from one heart medicine and muscle aches from a statin. But each time, they switched medicines and escaped any lingering harm.
Many side effects, though, look so much like symptoms of common diseases that even doctors can’t tell the difference.
Studies suggest that bad side effects and interactions between drugs are disturbingly commonplace. Hospital patients suffer seven hard-to-foresee adverse drug reactions and another three outright drug mistakes for every 100 admissions, estimates Dr. David Bates, a researcher at Boston’s Brigham and Women’s Hospital.
With about 36 million admissions per year, that translates into 3.6 million drug misadventures. Over the last decade, adverse events reported to the FDA’s largely voluntary collection system rose more than 2 1/2 times to 422,888 last year.
The dangers potentially escalate when doctors prescribe drugs, as they often do, for uses not formally approved by the FDA. That’s what happened with women’s hormones, which doctors prescribed for more than menopausal symptoms -- until the discovery that prolonged use raised the risk for heart disease, stroke and breast cancer.
In a recent report, the Centers for Disease Control voiced concern about the huge off-label growth of antidepressants. They are being used to treat loosely defined syndromes of compulsion, panic, anxiety and premenstrual discomfort.
Drug makers, doctors and patients have been quick to medicate some conditions once accepted simply as part of the human condition.
The United States buys 18% more pharmaceuticals annually per person -- even adjusting for higher prices -- than the second-ranking nation, France, according to the Organization for Economic Cooperation and Development. Strangely, the United States lags well behind other industrial nations in important measures of health, such as lifespan, and rates of heart disease and cancer.
Americans keep putting faith in the drug pipeline, often assuming that new drugs inevitably work better than old ones.
“Newer isn’t always better, and more isn’t always better,” said Dr. Donald Berwick, advisor to the U.S. Agency for Healthcare Research and Quality.
With so many medications at hand, mounting numbers of patients stray into abuse. About 4% of the nation’s adults and teenagers misuse prescription drugs annually, suggests a 2001 report by the National Institute on Drug Abuse.
Paradoxically, right beside lavish overmedication, many miss out on medicine they need. The ranks of the uninsured have swelled, and near-death patients sometimes go without the strongest pain medicines over misguided addiction worries.
“We deploy these medications in a willy-nilly manner, so that the people who need them don’t get them, and people that get them don’t need them,” said Dr. Jerry Avorn, a Harvard Medical School professor who wrote “Powerful Medicines.”
If you’re looking for the Heckmans, try the drive-through chain pharmacy off Route 44 on a busy retail strip outside Plymouth’s historic town center.
They buy almost all their drugs there -- nearly $9,000 worth of prescriptions a year, plus hundreds of dollars in cheaper over-the-counter medicine both for their chronic conditions and passing ailments. Even with supplemental insurance, their monthly out-of-pocket share of prescriptions alone roughly equals their food bills.
Around the country, prescription drug sales have pushed relentlessly upward by an annual average of 11% over the last five years. Some health economists predict a similar trend in coming years. A Medicare drug benefit looms in 2006, promising to stoke drug use even more.
The demographics of heavier medication may be inescapable. The population is growing and living longer, shuttling attendant ailments of aging like cancer, heart attacks, stroke and Alzheimer’s disease.
Other conditions have proliferated, including asthma, diabetes and obesity.
Exercise and better diet ward off heart disease and diabetes just as effectively as drugs do, studies show. But many patients resist changing habits, and many doctors barely encourage it.
“There tends to be a reliance on drugs as the first option,” said Fred Eckel, who teaches pharmacy practice at the University of North Carolina and edits Pharmacy Times.
The drug industry works hard to fan sales. It dispatches sales representatives to medical offices, underwrites continuing education for doctors and sponsors drug research to help win government approval.
Drug advertising to consumers has boomed since the late 1990s, thanks largely to relaxed government restrictions. Spending for consumer ads has grown from about $55 million in 1991 to about $4 billion last year, government and industry figures show.
The FDA generally demands only that new drugs work -- not that they work better than existing ones. Dr. Janet Woodcock, an FDA deputy commissioner, says the result is more options -- and “choice is important.”
Many safety experts say more new drugs should be tested against marketed ones, with more safety data required, and stronger control of consumer ads and off-label promotion.
For now, though, most Americans seem to feel like Ken Heckman: “grateful that there’s a pill to take for something.”