Why Almost Everything You Hear About Medicine Is Wrong

Why Almost Everything You Hear About Medicine Is Wrong

by Sharon Begley, Newsweek, January 24, 2011

"If you follow the news about health research, you risk whiplash. First garlic lowers bad cholesterol, then—after more study—it doesn’t. Hormone replacement reduces the risk of heart disease in postmenopausal women, until a huge study finds that it doesn’t (and that it raises the risk of breast cancer to boot). Eating a big breakfast cuts your total daily calories, or not—as a study released last week finds. Yet even if biomedical research can be a fickle guide, we rely on it.

But what if wrong answers aren’t the exception but the rule? More and more scholars who scrutinize health research are now making that claim. It isn’t just an individual study here and there that’s flawed, they charge. Instead, the very framework of medical investigation may be off-kilter, leading time and again to findings that are at best unproved and at worst dangerously wrong. The result is a system that leads patients and physicians astray—spurring often costly regimens that won’t help and may even harm you.

It’s a disturbing view, with huge implications for doctors, policymakers, and health-conscious consumers. And one of its foremost advocates, Dr. John P.A. Ioannidis, has just ascended to a new, prominent platform after years of crusading against the baseless health and medical claims. As the new chief of Stanford University’s Prevention Research Center, Ioannidis is cementing his role as one of medicine’s top mythbusters. “People are being hurt and even dying” because of false medical claims, he says: not quackery, but errors in medical research.

This is Ioannidis’s moment. As medical costs hamper the economy and impede deficit-reduction efforts, policymakers and businesses are desperate to cut them without sacrificing sick people. One no-brainer solution is to use and pay for only treatments that work. But if Ioannidis is right, most biomedical studies are wrong.

In just the last two months, two pillars of preventive medicine fell. A major study concluded there’s no good evidence that statins (drugs like Lipitor and Crestor) help people with no history of heart disease. The study, by the Cochrane Collaboration, a global consortium of biomedical experts, was based on an evaluation of 14 individual trials with 34,272 patients. Cost of statins: more than $20 billion per year, of which half may be unnecessary. (Pfizer, which makes Lipitor, responds in part that “managing cardiovascular disease risk factors is complicated”). In November a panel of the Institute of Medicine concluded that having a blood test for vitamin D is pointless: almost everyone has enough D for bone health (20 nanograms per milliliter) without taking supplements or calcium pills. Cost of vitamin D: $425 million per year.

Ioannidis, 45, didn’t set out to slay medical myths. A child prodigy (he was calculating decimals at age 3 and wrote a book of poetry at 8), he graduated first in his class from the University of Athens Medical School, did a residency at Harvard, oversaw AIDS clinical trials at the National Institutes of Health in the mid-1990s, and chaired the department of epidemiology at Greece’s University of Ioannina School of Medicine. But at NIH Ioannidis had an epiphany. “Positive” drug trials, which find that a treatment is effective, and “negative” trials, in which a drug fails, take the same amount of time to conduct. “But negative trials took an extra two to four years to be published,” he noticed. “Negative results sit in a file drawer, or the trial keeps going in hopes the results turn positive.” With billions of dollars on the line, companies are loath to declare a new drug ineffective. As a result of the lag in publishing negative studies, patients receive a treatment that is actually ineffective. That made Ioannidis wonder, how many biomedical studies are wrong?

His answer, in a 2005 paper: “the majority.” From clinical trials of new drugs to cutting-edge genetics, biomedical research is riddled with incorrect findings, he argued. Ioannidis deployed an abstruse mathematical argument to prove this, which some critics have questioned. “I do agree that many claims are far more tenuous than is generally appreciated, but to ‘prove’ that most are false, in all areas of medicine, one needs a different statistical model and more empirical evidence than Ioannidis uses,” says biostatistician Steven Goodman of Johns Hopkins, who worries that the most-research-is-wrong claim “could promote an unhealthy skepticism about medical research, which is being used to fuel anti-science fervor.”

Even a cursory glance at medical journals shows that once heralded studies keep falling by the wayside. Two 1993 studies concluded that vitamin E prevents cardiovascular disease; that claim was overturned by more rigorous experiments, in 1996 and 2000. A 1996 study concluding that estrogen therapy reduces older women’s risk of Alzheimer’s was overturned in 2004. Numerous studies concluding that popular antidepressants work by altering brain chemistry have now been contradicted (the drugs help with mild and moderate depression, when they work at all, through a placebo effect), as has research claiming that early cancer detection (through, say, PSA tests) invariably saves lives. The list goes on...."

The secret about drugs is that they only work in about half of the people who take them

Making Personalized Medicine Pay - BusinessWeek:

"The dirty little secret about drugs is that they only work in about half of the people who take them. So says an educational nonprofit called the Personalized Medicine Coalition, and many drug executives concede as much. Of the $292 billion spent in the U.S. on prescription drugs in 2008, as much as $145 billion went to medications that didn't help individual patients, said Jerel Davis, project manager at McKinsey, at a recent conference. And billions more are being spent to treat adverse drug reactions and other complications. "When you look at the data, it's shocking," says Dr. Robert S. Epstein, chief medical officer at Medco Health Solutions (MHS), a $51 billion company that manages drug prescriptions for 60 million Americans.

Researchers know how to solve this problem. First, figure out the differences between those patients who respond to a drug and those who don't, then treat only to those who will benefit. But this personalized medicine approach 'has been slower to develop than we thought 10 years ago,' says Richard K. Schatzberg, CEO of Generation Health, a startup that offers targeted medicine services. Lack of enthusiasm in the drug industry is a big reason; companies would lose billions of dollars if only those who actually benefit were to use such blockbuster drugs as antidepressants, arthritis medicines, and cholesterol pills...."

When Doing Nothing Is the Best Medicine

When Doing Nothing Is the Best Medicine - WSJ.com:

"What cures colds, flu, sore throats, sore muscles, headaches, stomach aches, diarrhea, menstrual cramps, hangovers, back pain, jaw pain, tennis elbow, blisters, acne and colic, costs nothing, has no weird side effects and doesn't require a prescription?

Plain old-fashioned time. But it's often the hardest medicine for patients to take.

"Most people's bodies and immune systems are wonderful in terms of handling things—if people can be patient," says Ted Epperly, a family physician in Boise, Idaho, and president of the American Academy of Family Physicians.

"I have a mantra: You can do more for yourself than I can do for you," says Raymond Scalettar, a Washington, D.C., rheumatologist and former chairman of the American Medical Association. But, he says, "some patients are very medicine-oriented, and when you tell them they aren't good candidates for a drug they've heard about on TV, they don't come back."

An estimated one-third to one-half of the $2.2 trillion Americans spend annually on health care in the U.S. is spent on unnecessary tests, treatments and doctor visits. Much of that merely buys time for the body to heal itself.

And while temporary relief from symptoms is nothing to sneeze at, it adds up to a considerable amount of spending: $5.4 billion annually on cough and cold remedies, $2.7 billion on headache remedies and $411 million on chest rubs and other analgesics, according to Nielsen Co. Americans also spend an estimated $1 billion on unnecessary antibiotics that don't even relieve the symptoms of viral infections, and contribute to antibiotic resistance. But some patients are so insistent on getting antibiotics that doctors give in.

"I have colleagues who say, 'You can take this pill and get better in two days, or do nothing and get over it in 48 hours,' " says Dr. Scalettar.

Even H1N1, or swine flu, for all the uproar, almost always resolves in a few days with no treatment. The Centers for Disease Control and Prevention is urging physicians to use Tamiflu, an antiviral medication, sparingly to prevent shortages and avoid antiviral resistance. Only people who are hospitalized or at high risk for complications should get Tamiflu, according to the CDC.

The list of "self limiting" maladies—those that require no outside treatment—range from minor annoyances to what might appear to be more serious musculoskeletal problems. "Muscle aches and pain, minor traumas, sprains and strains typically do not need to be seen by a doctor," says Dr. Epperly, who recommends his organization's Web site, www.FamilyDoctor.org, as a resource to look up symptoms and health concerns. "Nausea, vomiting and diarrhea are typically time-limited. People will start to see improvement in two or three days—just watch that you're not throwing up blood," he says. If so, call your doctor.

Almost all viral infections resolve on their own, unless you have a compromised immune system. As a rule of thumb, Dr. Epperly says, infections in the nose, throat, stomach and upper respiratory tract tend to be viral. Infections elsewhere in the body are likely to be caused by bacteria, and those can get worse without antibiotics. About 80% of urinary-tract infections resolve on their own, for example, but about 20% develop into more serious kidney or blood infections. And even if they don't, the symptoms can be very uncomfortable.

Parents are often extremely eager to "do something" for children who complain of sniffles, stomach aches, scrapes and fevers. Yet kids are generally very resilient, writes Lara Zibners, an emergency pediatrician, in her book, "If Your Kid Eats This Book, Everything Will Still Be Okay." (For a fever, she advises calling the doctor if the patient is a baby younger than three months and has a fever over 100.4 degrees. For kids older than that, other symptoms are more important than the thermometer—especially if a child is listless, irritable, unusually sleepy, refusing to eat or drink, or having trouble breathing.)

Some chronic maladies follow predictable courses, according to many medical experts ,whether or not they are treated.

Colic is almost always gone in four months. Some 70% of acne is gone three to four years after it first appears. "Frozen shoulder"—a painful restriction of the shoulder joint—is typically painful for three to six months and stiff for the next four to six months, and resolves completely after one to three more months. Temporomandibular joint (TMJ) pain tends to go away by itself in 18 months. Sciatica resolves on its own in three weeks in 75% of cases.

For all the misery it causes, 80% to 90% of back pain resolves with only "conservative measures" (which include anti-inflammatory drugs, rest, heat, physical therapy and chiropractic treatments). "Sometimes it take days to weeks, sometimes it takes weeks to months, but pain lasts more than three months in only about 10% of cases," says Michael J. Yaszemski, chief of orthopedic spine surgery at the Mayo Clinic in Rochester, Minn.

Whether to operate even in those remaining cases is controversial, he says. With acute lumbar disc herniation, studies have found that two and five years later, there's little difference between patients who had surgery and those who did not. But surgery can sometimes provide relief faster.

"There are those patients who feel they just can't wait—like Joe Montana," says Dr. Yaszemski of the former San Francisco 49ers quarterback, who made headlines when he returned to playing football just eight weeks after spinal surgery in 1986.

Many patients are relieved to hear that they don't need to take medicine, have a blood test or undergo surgery for what ails them. But some feel embarrassed to have taken the doctor's time or frustrated because they think the doctor isn't taking their situation seriously. ("Much depends on the way you tell them," says Dr. Scalettar. "There are some arrogant doctors.")

And some patients resent paying for a visit when all the doctor provides is reassurance that they'll get better with time. "If a patient says, 'You mean, I'm paying $100 for you to tell me there's nothing wrong?' I say, 'There is something wrong—a virus,' " says Dr. Epperly. " 'But more importantly, I can tell you what's not wrong: it's not meningitis or cancer or a brain tumor or some other life-threatening illness. And if the pain doesn't go away in a few days, please, please tell me, and we'll investigate further.' "

"The longer you've known someone, the easier that conversation is," Dr. Epperly adds.

Indeed, applying what some call "a tincture of time" requires time on the doctor's part as well. Explaining why a medication or CT scan or MRI isn't necessary, or what signs to look for if an ailment isn't getting better, often takes more time than writing a quick prescription.

Of course, there are symptoms that people should never ignore, since they could signal a serious illness or a condition that could get worse, not better, with time. Contact your doctor immediately if you experience any of the following:

• Crushing chest pains—the classic signs of a possible heart attack.
• Sudden numbness or weakness on one side of the body, confusion, trouble speaking or severe headache—which could indicate a stroke.
• Sudden, severe headaches.
• Any major injury, especially involving loss of consciousness.
• Coughing up, throwing up or excreting blood.
• Suicidal or homicidal urges.
• Flashing lights in your vision—which could be a detached retina.
• Inability to breath—which could be a severe allergic reaction.
• Recurrent tooth pain. "You can typically give a tooth ache 24 hours," says Dr. Epperly. "If it's an abscess that would require a root canal, it won't get better by itself."

The bottom line: Don't hesitate to call your doctor if you have persistent pain or a loss of function or anything unusual for you. It's worthwhile to rule out something serious that does need medical attention. But if the doctor says you will get better on your own, that's a powerful prescription itself."

Alcohol, tobacco among riskiest drugs

Alcohol, tobacco among riskiest drugs

The Associated Press
Updated: 6:43 a.m. ET March 24, 2007

British study rated the substances more dangerous than marijuana, Ecstasy

LONDON - New "landmark" research finds that alcohol and tobacco are more dangerous than some illegal drugs like marijuana or Ecstasy and should be classified as such in legal systems, according to a new British study.

In research published Friday in The Lancet magazine, Professor David Nutt of Britain's Bristol University and colleagues proposed a new framework for the classification of harmful substances, based on the actual risks posed to society. Their ranking listed alcohol and tobacco among the top 10 most dangerous substances.

Nutt and colleagues used three factors to determine the harm associated with any drug: the physical harm to the user, the drug's potential for addiction and the impact on society of drug use. The researchers asked two groups of experts — psychiatrists specializing in addiction and legal or police officials with scientific or medical expertise — to assign scores to 20 different drugs, including heroin, cocaine, Ecstasy, amphetamines and LSD.

Nutt and his colleagues then calculated the drugs' overall rankings. In the end, the experts agreed with each other — but not with the existing British classification of dangerous substances.

Heroin and cocaine were ranked most dangerous, followed by barbiturates and street methadone. Alcohol was the fifth-most harmful drug and tobacco the ninth most harmful. Cannabis came in 11th, and near the bottom of the list was Ecstasy.

‘Current drug system is ill thought-out’According to existing British and U.S. drug policy, alcohol and tobacco are legal, while cannabis and Ecstasy are both illegal. Previous reports, including a study from a parliamentary committee last year, have questioned the scientific rationale for Britain's drug classification system.

"The current drug system is ill thought-out and arbitrary," said Nutt, referring to the United Kingdom's practice of assigning drugs to three distinct divisions, ostensibly based on the drugs' potential for harm. "The exclusion of alcohol and tobacco from the Misuse of Drugs Act is, from a scientific perspective, arbitrary," write Nutt and his colleagues in The Lancet.

Tobacco causes 40 percent of all hospital illnesses, while alcohol is blamed for more than half of all visits to hospital emergency rooms. The substances also harm society in other ways, damaging families and occupying police services.

Nutt hopes that the research will provoke debate within the UK and beyond about how drugs — including socially acceptable drugs such as alcohol — should be regulated. While different countries use different markers to classify dangerous drugs, none use a system like the one proposed by Nutt's study, which he hopes could serve as a framework for international authorities.

"This is a landmark paper," said Dr. Leslie Iversen, professor of pharmacology at Oxford University. Iversen was not connected to the research. "It is the first real step towards an evidence-based classification of drugs." He added that based on the paper's results, alcohol and tobacco could not reasonably be excluded.

"The rankings also suggest the need for better regulation of the more harmful drugs that are currently legal, i.e. tobacco and alcohol," wrote Wayne Hall, of the University of Queensland in Brisbane, Australia, in an accompanying Lancet commentary. Hall was not involved with Nutt's paper.

While experts agreed that criminalizing alcohol and tobacco would be challenging, they said that governments should review the penalties imposed for drug abuse and try to make them more reflective of the actual risks and damages involved.

Nutt called for more education so that people were aware of the risks of various drugs. "All drugs are dangerous," he said. "Even the ones people know and love and use every day."

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Drugs companies 'inventing diseases to boost their profits' - World - Times Online

Drugs companies 'inventing diseases to boost their profits'

Drugs companies 'inventing diseases to boost their profits'

By Mark Henderson, Science Correspondent, The Times, April 11, 2006

Pharmaceutical companies are systematically creating diseases in order to sell more of their products, turning healthy people into patients and placing many at risk of harm, a special edition of a leading medical journal claims today.

The practice of “diseasemongering” by the drug industry is promoting non-existent illnesses or exaggerating minor ones for the sake of profits, according to a set of essays published by the open-access journal Public Library of Science Medicine.

The special issue, edited by David Henry, of Newcastle University in Australia, and Ray Moynihan, an Australian journalist, reports that conditions such as female sexual dysfunction, attention deficit hyperactivity disorder (ADHD) and “restless legs syndrome” have been promoted by companies hoping to sell more of their drugs.

Other minor problems that are a normal part of life, such as symptoms of the menopause, are also becoming increasingly “medicalised”, while risk factors such as high cholesterol levels or osteoporosis are being presented as diseases in their own right, according to the editors.

“Disease-mongering turns healthy people into patients, wastes precious resources and causes iatrogenic (medically induced) harm,” they say. “Like the marketing strategies that drive it, disease-mongering poses a global challenge to those interested in public health, demanding in turn a global response.”

Doctors, patients and support groups need to be more aware that pharmaceutical companies are taking this approach, and more research is needed into the changing ways in which conditions are presented, according to the writers.

Disease-awareness campaigns are often funded by drug companies, and “more often designed to sell drugs than to illuminate or inform or educate about the prevention of illness or the maintenance of health”, they say.

Particular conditions that are highlighted in the journal include sexual function in both men and women. The prevalence of female sexual dysfunction, one paper claims, has been highly exaggerated to provide a new market for drugs, while the makers of anti-impotence medicines, such as Viagra and Cialis, have been involved with their presentation as lifestyle drugs that can boost the sexual prowess of healthy men.

Ordinary shyness is routinely presented as a social anxiety disorder and treated with antidepressants, while newly identified conditions such as “restless legs syndrome” — a constant urge to move one’s legs — are presented as being much more common than they really are.

Richard Ley, of the Association of the British Pharmaceutical Industry, rejected the accusations, pointing out that Britain has firm safeguards against disease-mongering. Many of the authors’ criticisms, he said, were aimed squarely at countries such as the United States, where pharmaceuticals can be openly advertised directly to patients.

“Drug companies are not allowed to communicate directly with patients, and we do not invent diseases,” he said.

“We provide information that there are treatments out there that might help certain conditions, but at the end of the day it is down to health professionals to decide if they are appropriate.

“The best safeguard is that the doctor who knows the product and knows the patient’s history is the one who decides what to prescribe.”

TRICK OR TREAT?

MENOPAUSE
Symptoms include hot flushes, night sweats and loss of libido
Criticism too often “medicalised” as part of a “disorder” when it is a normal phase of life

IRRITABLE BOWEL SYNDROME
Symptoms include constipation, cramps and diarrhoea
Criticism promoted by drug companies as a serious illness needing therapy, when it is usually a mild problem

SEXUAL DYSFUNCTION
Symptoms impotence in men, lack of libido or difficulty becoming aroused in women
Criticism drugs such as Viagra marketed not only for treating genuine erectile dysfunction caused by medical problems but as lifestyle improvers

OSTEOPOROSIS
Symptoms thinning of the bones, particularly among postmenopausal women
Criticism portrayed as a disease in its own right, when it is really a risk factor for broken bones

RESTLESS LEGS
Symptoms urge to move legs because of unpleasant feelings, often at night
Criticism prevalence of a relatively rare condition exaggerated by the media, along with the need for treatment

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We use caffeine to make up for a sleep deficit that is largely the result of using caffeine

Caffeine - the world's most popular psychoactive drug

Caffeine
By T.R. Reid, National Geographic, January 2005

Slurped in black coffee or sipped in green tea, gulped down in a soda or knocked back in a headache pill, caffeine is the world's most popular psychoactive drug.

It's hardly a coincidence that coffee and tea caught on in Europe just as the first factories were ushering in the industrial revolution. The widespread use of caffeinated drinks—replacing the ubiquitous beer—facilitated the great transformation of human economic endeavor from the farm to the factory. Boiling water to make coffee or tea helped decrease the incidence of disease among workers in crowded cities. And the caffeine in their systems kept them from falling asleep over the machinery. In a sense, caffeine is the drug that made the modern world possible. And the more modern our world gets, the more we seem to need it. Without that useful jolt of coffee—or Diet Coke or Red Bull—to get us out of bed and back to work, the 24-hour society of the developed world couldn't exist.

"For most of human existence, your pattern of sleeping and wakefulness was basically a matter of the sun and the season," explains Charles Czeisler, a neuroscientist and sleep expert at Harvard Medical School. "When the nature of work changed from a schedule built around the sun to an indoor job timed by a clock, humans had to adapt. The widespread use of caffeinated food and drink—in combination with the invention of electric light—allowed people to cope with a work schedule set by the clock, not by daylight or the natural sleep cycle."

Czeisler, who rarely consumes any caffeine, is a bundle of wide-awake energy in his white lab coat, racing around his lab at Boston's Brigham and Women's Hospital, grabbing journal articles from the shelves and digging through charts to find the key data points. "Caffeine is what's called a wake-promoting therapeutic," he says.

"Caffeine helps people try to wrest control away from the human circadian rhythm that is hardwired in all of us," says Czeisler. But then a shadow crosses the doctor's sunny face, and his tone changes sharply. "On the other hand," he says solemnly, "there is a heavy, heavy price that has been paid for all this extra wakefulness." Without adequate sleep—the conventional eight hours out of each 24 is about right—the human body will not function at its best, physically, mentally, or emotionally, the doctor says. "As a society, we are tremendously sleep deprived."

In fact, the professor goes on, there is a sort of catch-22 at the heart of the modern craving for caffeine. "The principal reason that caffeine is used around the world is to promote wakefulness," Czeisler says. "But the principal reason that people need that crutch is inadequate sleep. Think about that: We use caffeine to make up for a sleep deficit that is largely the result of using caffeine."

Get the whole story in the pages of National Geographic