| I'm the first to admire the strengths and virtues of | | | | perphenazine, and the differences in outcome were |
| the free-enterprise model as it applies to drug | | | | minimal to none.3. When they draw attention away |
| development and sales. This model encourages drug | | | | from non-medication treatments.Drug companies sell |
| companies to employ talented people and to take | | | | drugs. Therefore, when it comes to marketing their |
| risks in developing new drugs for serious medical | | | | products, they have no interest in promoting -- or |
| problems. But let's face it, current practices also | | | | even mentioning -- non-drug treatments. There are |
| produce undesirable effects.1. When their drug that | | | | no salespeople making the rounds of doctors' offices |
| was wonderful last month is suddenly no good.It's | | | | to remind physicians of the rigorously proved |
| been entertaining to watch the drug companies | | | | benefits of stress management training for migraine |
| suddenly come up with new, patentable variations of | | | | and tension-type headaches, or of |
| their drugs just when their old patents are expiring. | | | | cognitive-behavioral counseling for depression.4. When |
| For example, since the 1970s, the Abbott company | | | | they hook us on samples.Doctors' offices receive |
| has been doing a dance with different formulations of | | | | samples of patented (high mark-up) drugs and not of |
| valproic acid (used for seizures, migraines and bipolar | | | | unpatented (low mark-up) drugs. Therefore, patients |
| disorder). At first, the brand name was Depakene, | | | | are steered toward the expensive drugs by means |
| but when that patent ran out, Depakene was | | | | of these "loss-leaders."5. When they shape medical |
| suddenly no good any more, and Depakote (just | | | | practice.Drug companies aggressively court the |
| barely different enough to be patentable) was the | | | | thought-leaders, like faculty members at medical |
| only drug one should think of. Then when Depakote's | | | | schools, with financial perks such as impressive fees |
| patent ran out, suddenly it wasn't any good, either. | | | | for speaking engagements. They also subsidize |
| Now Depakote ER (extended release) is the only | | | | medical publications. The effects of these marketing |
| way to fly.This approach of reworking the old drug | | | | activities on medical practice are not necessarily |
| into longer-acting formats has worked for other drug | | | | beneficial to patients.For example, tissue plasminogen |
| companies, too. For example, GlaxoSmithKline has | | | | activator (tPA) is an expensive clot-dissolving drug |
| gone through the same dance with their formulations | | | | approved for use in stroke patients. Its benefits are |
| of bupropion for depression, evolving from Wellbutrin | | | | modest and its risks are real (brain hemorrhage and |
| to Wellbutrin SR (sustained release) to Wellbutrin XL | | | | death). Thoughtful clinicians might reasonably conclude |
| (extended release). Wyeth, seeing a good thing, | | | | that the benefits of administering tPA do not |
| followed the same path with venlafaxine | | | | outweigh the risks. But this is not the message that |
| antidepressant, going from Effexor to Effexor XR | | | | comes from many thought-leaders and publications. |
| (extended release). It's just an amazing coincidence | | | | Instead, the implication is that administering this drug |
| how these new, suddenly-better drugs emerge just | | | | is a standard of care, and omitting it constitutes |
| when the old drugs expire and face generic | | | | malpractice.6. When the sales reps push unapproved |
| competition.2. When they make us forget that the | | | | uses.Recently, a Pfizer sales rep told me that his |
| older drugs work just fine.Since 1954 we've had | | | | company's drug, pregabalin, is effective in preventing |
| effective anti-psychotic drugs to treat schizophrenia, | | | | migraine. He shouldn't have said that. Pregabalin is |
| but beginning in the 1990s a series of new | | | | FDA-approved for treatment of epilepsy and |
| anti-psychotics emerged, now called the "atypical" or | | | | nerve-pain, but not migraine. Although physicians in |
| "novel" anti-psychotics. Suddenly, the older drugs -- all | | | | the U.S. are allowed to prescribe drugs for "off-label" |
| generic and therefore reasonably priced -- were no | | | | uses, drug companies are prohibited from advertising |
| good. Only the new, patented anti-psychotics were | | | | their drugs for non-approved uses. In fact, Pfizer got |
| any good and one might even be guilty of | | | | in trouble for pushing another drug, gabapentin, for |
| malpractice if one prescribed an older drug (or | | | | unapproved uses.7. When doctors don't think critically |
| continued prescribing one to a patient who seemed | | | | about what they're doing.This, strictly speaking, isn't a |
| to be doing fine). Indeed, a generation of new | | | | deficiency of the drug companies. But because the |
| psychiatrists cycled through training programs with | | | | only salespeople that doctors see are for expensive, |
| this concept in mind, rarely writing a prescription for | | | | branded drugs, the names of less expensive (or |
| an older drug.The alleged superiority of the newer | | | | more effective) alternatives may not come to mind |
| drugs was tested in the recently completed CATIE | | | | when prescriptions are written.(C) 2006 by Gary |
| (Clinical Antipsychotic Trials in Intervention | | | | CordingleyGary Cordingley, MD, PhD, is a clinical |
| Effectiveness) study and found to be absent. The | | | | neurologist, teacher and researcher who works in |
| study compared four newer drugs to an older drug, | | | | Athens, Ohio. |