Misinformation X

I have a lot of blog posts in the works right now. That strategy works for me because my attention has always been a problem and it works better to work on many things at once rather than bogging down on one. I decided to post on this topic and the one that may be the most relevant. The content of my blog tends to go from scientific and medical topics, to social topics, to a lot of posts that address current misinformation. The Information Age has become the Misinformation Age and there is probably no better example than the platform formerly known as Twitter.

Twitter used to be an invigorating and informative place for physicians. I could count on reasonable discussions and literature references by daily participation and focusing on specific colleagues. In psychiatry – there is a chronic misinformation problem dating back to Szasz, Foucault, and others in the 1970s.  They created tropes and memes that are still repeatedly used by antipsychiatrists today to deny the reality of mental illness and the real function and value of psychiatry. In many ways this sort of criticism has generalized to the rest of medicine and that became very clear during and after the pandemic.  The takeover of Twitter by Elon Musk and his so-called “free speech” policies made that site a fountain of misinformation.  The amount of misinformation would be embarrassing to anyone concerned with the truth or reality but these days those constraints clearly do not apply.  The truth is of little value in much of what can be read on X.  I would go as far as saying the truth is actively devalued on X and you can read falsehoods about settled areas of science, medicine, and public policy.

There is a clear positive correlation between the transition in management and an increase in misinformation, hate speech, hate speech and antisemitism.  Problems also existed before that transition and some were highlighted during the pandemic. Misinformation about vaccinations, masks, and public health personnel were clear problems. Despite what happened during the pandemic that misinformation has clearly increased.  The day before I started writing this post there was a great deal of misinformation about how “jabs” (misinfospeak for COVID immunizations) cause blood clots and that there would be a tsunami of deaths from thromboembolic diseases.  Several physicians posted clearcut evidence to refute this misinformation.  Most physicians are also aware of the fact that immunization are the single most effective intervention to prevent death in large populations. That evidence, including the evidence for COVID-19 immunization effectiveness is indisputable.  Medical research on Long-COVID or chronic symptoms following infection with the virus is also clearer now. Trying to avoid that chronic state and the associated disability is another good reason to get immunized.    Practicing physicians have a healthy respect for respiratory viruses.  We have all seen healthy young people die from infections with what are considered common cold viruses.  

A great solution for physicians and scientist would be a medical or scientific Twitter.  It seems like a simple matter but I suppose maintenance and day-to-day fees would need to be covered in addition to the original programming. To prevent the vulgarians shouting in the city square behavior of X – a simple model of behavior consistent with what would be expected in a medical or scientific staff meeting should suffice. No personal attacks, gaslighting, ridiculing, etc. and active moderation.  People would certainly be able to debate the merits of climate change and other controversial topics – but the arguments would need to be based on facts and scientific merit rather than political rhetoric. People would not be allowed to post baseless claims about another person, a theory, or a piece of research. 

The defenders of name calling, gaslighting, and misinformation all tend to hide behind the First Amendment. There is plenty of evidence in the current news that there is no absolute right to say whatever you want to say about a person or a business.  Hundreds of millions of dollars have been assessed as legal penalties for those statements in several high-profile civil suits. Litigation is a crude and expensive instrument for keeping discourse focused and civil.  A specific environment is a much better approach. Instead of proclaiming a web site as having absolute free speech – it is far better to have the exchanges moderated according to specific rules. Hence the staff meeting approach.  I have certainly been in staff meetings where tempers flared, but there was no name calling or threatening behavior. There was disagreement about information but at no point was there any question about deliberately misrepresenting the information or repeatedly lying about it.  The largest professional staff I worked with was about 35 psychiatrists.  The entire time I worked there I had no doubt about the integrity or sincerity of my colleagues – even though some of the disagreements were intense. 

Who might run such a Twitter-like operation?   The American Psychiatric Association (APA) ran an email listserv that I participated in for decades.  They decided to stop this in the past year.  It had probably run its course.  The number of new participants and total participants was low.  Discussion by email tends to become too diffuse and they are difficult to reference later. There were also limitations on discussions based on the charitable status of the organization – no political discussions.  Twitter seemed like an ideal format for discussions, educational threads, and daily reviews. I doubt that the APA or AMA have the resources for a Twitter like platform but they might and it could be seen as a benefit to potential members. Doximity comes to mind.  Currently Doximity has threads that are posted as news updates presumably by their editors. They tend to be much less interesting than good Twitter threads and discussions.  A Twitter like platform would be a greater asset in attracting physicians to the site.  LinkedIn tends to have the same constraints as Doximity but it does allow member to start new threads. All of the commercial threads suffer from commercialization and overly intrusive members.  I don’t want to see an endless sequence of friend or connection requests when it is obvious that I have nothing in common with those requestors.  On Twitter – the commonalities were obvious and I knew who to follow.   

The competitors that were started based on Twitter’s obvious demise – Blue Sky, Threads, and Mastodon just don’t seem to have active physician communities at this point.  As more physicians leave Twitter – there is a clear socialization and discussion gap. It is probably obvious that I have no clear solutions for that gap – other than a hope that somebody with enough resources and insight to the value of Twitter for physicians can get a platform established.  Alternately – more networked and focused discussions on Blue Sky and Threads is still a possibility.  Either way – I think we need a functional blue bird back in one form or another….

 

Happy New Year!

 

George Dawson, MD, DFAPA 

Counterfeit Ozempic is NOT Off-Label Ozempic

 

Glucagon like peptide (GLP)

I was content to let the FDA release and the news media handle this problem until I watched a TV news person say the following:  “Counterfeit Ozempic or off label Ozempic is potentially dangerous…..”  Off label Ozempic is NOT counterfeit Ozempic.  Off label medications are FDA approved medications that are prescribed for indication other than what is listed in the package insert.  Based on a recent table that I made from package insert information practically all GLP-1 agonists like Ozempic are prescribed off label because the FDA indication is Type 2 diabetes mellitus rather than weight management. The FDA news release is all about Ozempic look alikes being sold as the real product.  In some cases they do not contain any active ingredient and in the majority of cases what they actually contain is currently unknown. 

The FDA warning (1) about counterfeit Ozempic surfaced on 12/21/2023.  Ozempic and many drugs in this class come in an injection device, since most of the dosing is by subcutaneous (SC) injection. The FDA also warned that the needles in these devices were counterfeit and their safety and sterility could not be guaranteed.  In the warning in reference 1 they describe 5 incidents of adverse effects – none life threatening.  The confiscated pens are being analyzed to determine what is being used rather than Ozempic.  Counterfeit pens were found in at least 9 countries and in some – insulin was found (2). The FDA provides lot and serial numbers of the counterfeit medication and advises pharmacies not to use it.

The same day as this release, the FDA also warned about compounded GLP-1 agonists (3).  Compounded products are prepared by compounding pharmacies.  If medications are in short supply – compounding pharmacies can produce them. Ozempic and Wegovey are both on that list.  Both are semaglutides and adverse events have occurred with the compounded versions.  Some of the counterfeit versions contain the salt form of semaglutide compared with the FDA approved medication that is the base form.  This warning also describes counterfeit semaglutide being marketed online, concerns about counterfeit Ozempic in the US, and it encourage patients to protect themselves by only purchasing semaglutides through state licensed pharmacies.

Although it is not emphasized in the warnings, I also have concern about the injection pen device that the semaglutide is contained in.  The injectors are calibrated to deliver 0.25. 0.5, and 1 mg doses according to the prescription for each patient.  The device is supposed to click when it is at the corrected dose.  This medication and unique injector is reminiscent of other medications where the patented delivery system was so critical to the medication that it essentially extended the patent.  Unless the counterfeiters are using a very similar device the recommended doses of medication might not be delivered correctly.  Exactly how problematic that will be depends on the medication or substance that has been substituted for the semaglutide.  Even if the counterfeiters can produce a semaglutide like name brand Ozempic or Wegovey – there is no guarantee that the pen device they are using can guarantee accurate delivery of the dose.

At this time, I have not heard that there has been an attempt to synthesize the actual medication. With today’s technology I would not be surprised if that attempt was made at some point. 

That led me to think about the issue of legal and illicit drugs. At some point – knowledge obtained in the past century seems to have been replaced by the rhetoric of drug legalization. These arguments are always about drugs that reinforce their own use or what are commonly referred to as addictive drugs. The legalization myth generally skips over the harms of these drugs directly to what is often referred to as harm reduction.  That generally means that it is more harmful to insist that people stop using these drugs than providing them with safe forms to continue using or in the more extreme case to leave drug dealing and all the illicit forms intact. In the latter case, methods to test the drugs and provide safer methods of delivery offer the users an opportunity to protect themselves from suppliers who may add adulterants to the drugs or substitute a more dangerous drugs without informing them. 

GLP-1 agonists are clearly not addictive drugs as far as anyone knows at this point. But the issue I attempted to cover in this post is drug safety – specifically the safety of the drug supply to patients with a prescription. Despite the provocative way the pharmaceutical industry is covered and often villainized in the press – there is no doubt that they can and have provided a safe supply of medication to the public. There are lapses and inadequate inspections and recalls.  The current system is far from perfect. But it is clearly superior to any system being run by a criminal enterprise supplying illicit drugs. It is hard to imagine a system where you would have to personally run a chemical test on your prescription medications to make sure they were safe.  It is equally hard to imagine producing counterfeit drugs and selling them to the public like the real thing.

That is what the FDA is trying to prevent with this warning. 

  

George Dawson, MD, DFAPA

 

Supplementary:  Aware of counterfeit Ozempic or Wegovey?  Can you get it without a prescription?

It has come to my attention that many people are aware of the availability of counterfeit Ozempic and Wegovey thorough their social networks. I am very interested in how widespread this problem is right now.  Please report your  experience here anonymously in the comments section or by emailing me.

References:

1:  FDA.  FDA warns consumers not to use counterfeit Ozempic (semaglutide) found in U.S. drug supply chain.  December 21, 2023 https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-consumers-not-use-counterfeit-ozempic-semaglutide-found-us-drug-supply-chain

2:  National Association of Boards of Pharmacy.  Counterfeit Ozempic Found in US Retail Pharmacy.  August 7, 2023 https://nabp.pharmacy/news/blog/regulatory_news/counterfeit-ozempic-found-in-us-retail-pharmacy/

3:  FDA.  Medications Containing Semaglutide Marketed for Type 2 Diabetes or Weight Loss.  December 21, 2023 https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/medications-containing-semaglutide-marketed-type-2-diabetes-or-weight-loss

 

Peptide Structure:

Drawn with PepDraw:  https://pepdraw.com/

 

 

 

The Ultimate Key Opinion Leader?

Key Opinion Leader or KOL is an interesting myth. In the long era of the pharmascolds, it was frequently stated that all you needed to successfully market a drug was a KOL paid by the company to sell it to the unknowing clinicians who were just waiting to prescribe in lock step with whatever was suggested.  KOLs were typically academics with research and lecturing credibility but also included clinicians who may have had some experience with the drug in clinical trials. The KOL/clinician interface frequently occurred over pharmaceutical company sponsored CME events or meals. KOLs in psychiatry were treated more harshly than those in any other field when a US Senator decided to investigate their individual employment arrangements. An explanation was never given about that selectivity, but I did notice some other specialists were added – probably for cover.

The myth of KOL as Pied Piper encouraging mass prescriptions always struck me as absurd for several reasons.  First, I know the psychiatrists.  It might be possible that the psychiatrists I know are more enlightened than most – but my contact with them in numerous clinic, hospital, academic and non-academic settings treating diverse groups of patients makes that unlikely. As a group they are looking for inexpensive continuing medical education (CME) credits, hearing about the latest developments, and getting better treatments to their patients. Better in this case means more efficacy, fewer side effects, or both.  With direct-to-consumer advertising in the US, patients coming to appointments requesting a new drug is a common occurrence and a fast way to learn about those drugs was listening to a KOL and picking up an FDA approved package insert at the same time. That confluence of factors can make it seem like this is all a great conspiracy that includes physicians – but it is not.  The clinicians involved are as skeptical about new drugs as they want something that works better. Second, pharmaceutical companies aggressively market drugs.  Most physicians are aware of this and the fact that people in the US pay much more for medications than is paid anywhere else in the world. Most physicians are also aware of the mechanisms that lead to those higher prices and must deal with the administrative costs and their patients going without needed medications.  Third, physicians have limited control over the prescription of newly released expensive drugs.  Rationing these drugs is a separate for-profit business.  Those businesses have gone as far as rationing low cost generic medications and they will make it painful for any physician to prescribe a new medication if there are cheaper alternatives.  Fourth, working as a KOL (or more probably a sponsored lecturer) can give a sense of satisfaction in terms of continuing use of basic science and discussions with experts.  All these factors lead to skepticism rather than uncritical acceptance of a sales pitch. I don’t know of any celebrity level psychiatrist who could endorse a pharmaceutical product that would lead it to be immediately and universally adopted. 

That leads me to the Ultimate KOL (UKOL).  For the past few weeks Oprah Winfrey has been in the news for a significant and visible weight loss. There was immediate suspicion in the gossip media that she was using weight loss drugs – specifically glucagon-like peptide (GLP-1) agonists.  She initially said that she lost the weight with the usual methods and that using a drug would be “cheating”.  She has had similar weight losses in the past and in one case ran the New York City marathon.   The photo of her at the top of this post was for her 50^th birthday when she lost all the weight through diet and exercise. More recently - she was at an opening and said she did use a medication and added that she was tired of being shamed for excessive weight and being treated differently at a higher body weight than a lower body weight.  She has not disclosed the name of the medication.

Oprah has unique status as a celebrity. According to Time magazine - she was one of three and four most influential people in the 20th and 21st century respectively (1).  She had a product endorsement segment on her daily show called Oprah’s Favorite Things that greatly increased sales for many products.  Her endorsement of Barack Obama produced an additional 1 million votes in the Democratic primaries (2). At first glance, Oprah’s statement about weight loss medication seems consistent with her past promotions of products, books, and her self-improvement brand. 

In this case things are a bit more complicated.  In October 2015, she purchased 6.4 million shares or $43.2 million ($6.79 a share) of Weight Watchers (WW) stock.  She sold about a million shares when the stock appreciated and was given an option to purchase an additional 3.3 million shares. (5).  According to the latest SEC document WW is in a Strategic Collaboration Agreement with Oprah that began in 2015 that has been extended to 2025.  In the annual report she is listed as one of 9 Directors.  Her last stock purchase was in January and April of 2023 (5,067 and 2,053 shares respectively). In April of 2023 Weight Watchers acquired the telehealth company Weekend Health/Sequence described in their press release as “a subscription telehealth platform offering access to healthcare providers specializing in chronic weight management.”  They now offer weight loss medications including GLP-1 agonists directly through their web site.  I did not go through the process because a name was required, but several sources suggest this is a monthly subscription service

Prior to Oprah’s self-disclosure demand for GLP-1 agonists was very high and there was concern that weight loss demand would reduce availability of these medications for people with diabetes mellitus.  Some medications are approved for weight management only and others for treating diabetes mellitus only. During the last 3 months of 2022 there were and estimated 9 million prescriptions for both branded version of semaglutide - Ozempic and Wegovey.  At the time, the average cost of Ozempic was about $800/month and Wegovey was $270/week.  Doing the arithmetic, at that rate of prescribing the costs of these prescriptions could easily exceed $100 billion per year. That would make them the highest selling drugs of all time.

GLP-1 agonists are unique medications.  They have a polypeptide structure and a much higher molecular weight than typical medications.   That protein structure makes them more likely to trigger antibody formation and an immune response.  The main side effects are gastrointestinal – nausea, vomiting, diarrhea, constipation and abdominal pain and a significant number of patients in the clinical trials withdrew due to these side effects.  Hypoglycemia can be a problem especially if there is concurrent oral hypoglycemic use. Dehydration is also a common problem accompanying acute weight loss and starvation. That combination of problems leads to a warning about needing to monitor for dehydration in patients being treated with these medications especially because there is a higher incidence of renal damage in that patient group.  There are warnings about pancreatitis, thyroid C-cell carcinoma, acute renal injury, diabetic retinopathy complications, and hypoglycemia. There was also a recent report of increasing calls to poison control centers about semaglutides and counterfeit products. The therapeutic effects of these drugs include glycemic control and weight loss although most of these drugs have an indication for Type 2 diabetes mellitus only.  

I plan a more detailed post on the standard and more interesting pharmacological properties of these medications in the new year.  So far, I have compiled a table and will be working from an enhanced version of that.  The goal of this post is to document the effect of who is probably the single most important influencer in American society and her impact on the sales of this class of medication in the United States. Just the events that have occurred so far will probably be far reaching – limited only by the supply and the availability of prescribers.  I expect that there will be many online prescribers available since the advent of telemedicine has led to specialty prescribing of a few drugs to many recipients.   

There are currently unanswered questions.  Will Oprah disclose the medication she used?  Will she endorse a specific drug?  We have recently seen Kareen Abdul Jabbar in NOAC commercials for apixaban.  Secondarily – how will this issue be studied?  The typical studies that purported to show that physicians were influenced by trinkets or KOLs were poorly done and any increase in prescribing was taken as evidence of influence.  How can the Oprah factor be studied to reduce confounders like the American fantasy of weight loss without effort or the debate that being overweight or obese is a disease rather than a personal responsibility. From an ethical standpoint, are there problems with conflict of interest given the share that Oprah has in a company that is promoting and profiting from weight loss drugs?  The scale of potential profit is enormous compared with what most physicians are reported to the CMS Open Payments database.  In 2022, the median payment to physicians who received payments from pharmaceutical manufacturers or device makers was $161.  

For the record, at this point I am completely neutral on the issue of GLP-1 agonists for weight loss. I am very familiar with the previous literature and pharmacology of weight loss drugs.  I was an early witness to the failed attempt to use stimulants to treat obesity and treated many of those patients for amphetamine dependence. It is clear to me that there is a lot of hype about these medications right now and how they are the best medications ever invented to treat obesity. Since the previous medications were mildly effective to not effective that is a low bar.  Just reading the available package inserts suggests to me that a significant number of people will not be able to tolerate them and many will probably tolerate significant side effects to maintain a lower body weight. And with all new medications, the real question is what happens to the population taking the drug with wider and longer exposure.  Will there be adverse effects not seen in shorter clinical trials?  So, stay tuned for more detailed pharmacology and theory about the GLP-1 agonists.  In the meantime, see if Oprah has a palpable impact on the market. My guess is that her effect will easily surpass any thousand or more physician lecturers and KOLs.  

George Dawson, MD, DFAPA

References:

1:  Garthwaite CL. You Get a Book! Demand Spillovers, Combative Advertising, and Celebrity Endorsements. National Bureau of Economic Research; 2012 Mar 15.

2:  Garthwaite C, Moore T. The role of celebrity endorsements in politics: Oprah, Obama, and the 2008 democratic primary. Department of Economics, University of Maryland. 2008 Sep:1-59.

3:  O'Connell B.  Oprah's Weight Loss Company Adds a Prescription Drug Feature.  May 7, 2023.  https://www.thestreet.com/personalities/oprahs-weight-loss-company-adds-a-prescription-drug-feature

4:  Summers J, Marquez Janse A, Ermyas T.  Oprah and Weight Watchers are now embracing weight loss drugs. Here's why.  Dec 18, 2023. https://www.npr.org/2023/12/18/1219710239/weightwatchers-oprah-ozempic-drugs-wegovy

5:  Fitzgerald M.  WW International extends Oprah Winfrey deal to 2025, shares rise.  CNBC  https://www.cnbc.com/2019/12/16/ww-international-extends-oprah-winfrey-deal-to-2025-shares-rise.html

 

Supplementary:

Current GLP-1 agonists - all data taken from FDA approved package inserts.

Photo Credit:

Photo by Alan Light, CC BY 2.0 <https://creativecommons.org/licenses/by/2.0>, via Wikimedia Commons

Merry Christmas From Your PBM

 

After some deliberation I went into my local Walgreens for an RSV immunization.  I have multiple unpredictable allergies and have had both anaphylaxis and significant local reactions to vaccinations in the past. Like 20% of the population, I have eczema and there is some research on flareups of this skin disease with vaccinations.  And like many people with eczema, I also have asthma and had a severe flare-up of asthma when I got a viral infection on a flight back from Alaska about 5 years ago. My primary care physician recommended it last week so I scheduled it.

As I was sitting there waiting for them to prepare the shot, I was able to observe patients coming and going to pick up their prescriptions. This is a busy Walgreens and there are people going past the drive-up window as fast as they are showing up in line.  Most people at there in the early afternoon are retirees.  There was an informal retirement poll of the old guys in line and it was unanimous – we were all quite happy to be retired. The people gathered were upbeat. I recalled being at a 24-hour pharmacy in 2002.  My late father-in-law was visiting and forgot all his cardiac medications.  I went over at midnight to pick them up and it was an ugly scene.  There were about 60 people there and the pharmacist was not filling the prescriptions fast enough. From where I was seated – I could see him working furiously.  The crowd was so agitated about this it seemed like they were ready to riot. If that wasn’t enough a rather cranky lady sitting next to me started to goad them and call them names.  Luckily, I got the medicine and got out of there as soon as possible.

 The atmosphere today was much better – but like most scenes in American health care it was far from perfect.  There were no simple transactions. In the transactions I witnessed, very few people walked away with the prescription medication ordered by their doctors. The most common problem as a lack of prior authorization. People were advised that their doctor had to get the prior authorization. Several were advised that they needed a new prior authorization. I remember all the messaging that people hear when they need a prescription refill.  Call your doctor’s office.  Don’t call your doctor’s office.  Call the pharmacy.  Don’t call the pharmacy.  Today 75% of that messaging was incorrect.  And it wasn’t like the medications were an option.  Antihypertensives, diabetes medications, prostatic hypertrophy medications – every medication name I heard had me hoping these impasses would be resolved as soon as possible for the patient’s sake. The related quality issue is that most of these medications were maintenance medications and yet they required reauthorization – in some cases just because of an insurance change.  I didn’t see anyone get hit with the Medicare Donut Hole. I have been twice in the past 3 months with a copay for apixaban ballooning up to $400 or roughly 7 times the usual amount just because of the way the rules are written to favor pharmaceutical companies and pharmacy benefit managers (PBMs). I am sure it would have happened if I had been there longer.

But 20 minutes was up and I did not have an anaphylactic reaction. Another immunization I can take.  I jumped in my car, turned the radio on, and thought about what I had just witnessed.  I am certainly no stranger to it. As a physician I have been harassed by PBMs.  They put me on hold for hours only to eventually connect me with a clerk with no medical training or credentials that would either approve or reject my recommended prescription.  PBMs are not some quality improvement project – they are patient and physician harassment to see who blinks first and loses the time and money.  They are multibillion dollar companies that add to the cost of medications rather than reducing the cost.

Overall prescription drug pricing in the United States is much higher than in comparable countries both on an overall basis and a brand name basis.  A study (1) that looked at 2018 data showed that all drug pricing ranged average 258% higher than comparable drugs purchased in Mexico, Canada, France, Germany, Italy, Japan and the UK.  Comparable brand name medications averaged 344% higher.  All of that translates to much larger copays for Americans and often an inability to purchase the medication. I saw that happening a lot today.

Advocacy from the physician side has been weak. After decades of no action on the prior authorization issue some professional organizations are now saying that it needs to be controlled. The problem with that position is that it is so ratchetted down on patients and physicians that any controls in the right direction will be trivial.  The only solution is to eliminate prior authorization completely. If pharmaceutical companies want to deny payment for prescription medications – they can do it directly without using the physician and pharmacist for cover. Beyond that the appeal can go through a state administrative authority independent of the pharmacy business.

I have written extensively in the past about the sheer amount of resources that are wasted on prior authorization and the associated pharmacy rationing strategies.  I have written about how pharmacists take a significant hit and their professionalism is adversely affected by poor PBM reimbursement and conflict of interest – especially when the PBM owns their own chain of pharmacies. Today as I was waiting for clearance after an immunization it was all about the human cost.

That never seems to get better, although the Obama and Biden administrations have provided some significant relief to Medicare recipients. Everyone involved would be happier if this system was just gone.

 

George Dawson, MD, DFAPA

Supplementary 1:  Additional inefficiencies - a couple of days after writing this post my wife got a text message that one of her prescriptions was ready and she could "pick it up after Sunday."  She asked me to pick it up on Monday because I was driving by the pharmacy.  I pulled up to the window and asked for the prescription and was told - "it is ready but you are one day early.  You can pick it up tomorrow." Not the first time that has happened.  The pick up rule seems to vary by PBM, insurance, and pharmacy but the automatic messaging obviously does not take it into account. Just another reason for going to the pharmacy and leaving without the prescription. 

 

References:

1:  Mulcahy AW, Whaley C, Tebeka MG, Schwam D, Edenfield N, Becerra-Ornelas AU.   International Prescription Drug Price Comparisons Current Empirical Estimates and Comparisons with Previous Studies.  Rand Corporation Research Report. 2021.

2:  Yetter DM.  Reprieve for Kentucky’s independent pharmacies is saving Medicaid millions.  Kentucky Lantern. October 5, 2023.  https://kentuckylantern.com/2023/10/05/reprieve-for-kentuckys-independent-pharmacies-is-saving-medicaid-millions/

This is the story of how Kentucky eliminated PBMs in their state and saved $283M in three years. 

Graphic credit:

Me - my wife reshot the photo.

We Need More Unapologetic Psychiatrists…..

 

I am not sure he would agree with the characterization but I came up with this title when I decided to comment on Daniel Morehead, MD.  I have never met him but I have read everything he has written in the Psychiatric Times.  He is director of residency training in general psychiatry at Tufts. In the most recent column, I notice the heading Affirming Psychiatry – that I wish I had thought of.  That was one of the primary goals of this blog when I started writing it 13 years ago.

This month’s column was titled Psychotherapy: Lies Cost Lives (1).  He starts writing about a New York Times column about psychotherapy that starts positive but rapidly shifts to ambivalent. He points out that this is characteristic of most headings that have to do with psychiatry and speculates about the origins.  Controversy, mouse clicks, and advertising dollars for sure.  He lists several titles and several themes of articles that with similarities and points out the only logical conclusion:

“The take-home message is that psychiatry rests on shaky foundations and does not quite know what it is doing, rather like someone feeling their way through a darkened room. Psychiatry, as usual, lags behind the breezy confidence of other medical fields, where no one wrings their hands about whether antihypertensives really work or whether surgery is just a lingering form of inhuman medieval butchery.”

That is certainly one way to describe journalistic gaslighting. I have offered several explanations for it on this blog.  First, folk psychology. Trying to figure out basic motivations and behavior of the people we encounter on a day-to-day basis is an adaptive human skill.  Many people think that psychiatry is therefore just common sense and that anyone can do it – at least until they encounter problems severe enough to where that level of common sense fails completely.  Second, there is the impression that anyone who prescribes psychiatric medications is basically equivalent to a psychiatrist. That is a trivialization of the psychiatric skill set and training.   Third, antipsychiatry is a cottage industry in the US and other countries and our detractors have had an inordinate amount of success in getting their rhetoric published in both the popular press and professional publications. The previous post on this blog was all about that. There are no other equivalent movements attacking other medical specialties even though their good outcomes are equivalent and their bad outcomes are generally much worse.  Fourth, , the reality is that about 40,000 psychiatrists go to work every day in the US.  The demand for psychiatrists is high. That demand is fueled by successful treatment and a niche that is unfilled by other medical staff.  Fifth, at least part of that demand is because psychiatrists have unique skills. We are the treatment providers of last resort, and other specialists know that and refer patients at all levels of acuity. The only way that happens is if you know what you are doing.

Psychotherapy is part of that skill set and that is the focus of Dr. Morehead’s column.  The science is there, even though there is a constant debate about clinical trial design and replicability.  Specific brands of psychotherapy have been investigated and shown to work.  There is also research into important non-specific factors in psychotherapy that branded therapies have in common. Even more basic than that are the interviewing techniques and courses taught to second year psychiatric residents focused on facilitating information exchange with patients for both diagnostic formulation and intervention. Communication is a critical skill in psychiatry.  In this era of checklists, screening, and electronic health records – it is easy to forget there is a much larger set of important information and like all things it requires a lot of training to do it right. It is that body of information that allows for the treatment of each patients as a unique person.  Personalized medicine has become a buzzword lately but from a communication perspective psychiatrists have been providing that for decades. 

These basic skills in talking with people and talking in therapeutic ways are hardly ever mentioned in discussions about psychiatrists. Criticism of psychiatry commonly seeks to portray psychiatrists unidimensionally - as excessive prescribers of medication rather than communicators.  Throughout my career the number one reason I was consulted was to establish communication with a person and figure things out where nobody else could.

Even in the case of prescribing medications, there is typically a lot more going on than a discussion of medications. One of my colleagues established the largest clozapine clinic and long-acting injectable medication clinics I have ever seen.  When he moved on, his patients asked me regularly where he was and how he was doing.  They valued the relationship with him even when he was providing a unique medical service. Ghaemi has written about existential psychotherapy and how it can occur during appointments that are medication focused (2,3).

The overall message that Dr. Morehead is trying to convey is that psychiatrists cannot let others characterize what we do.  When that happens there are multiple agendas operating that can lead to the clear distortion that psychiatry is not quite up to the level of other medical disciplines.  There is typically an overidealization of those other branches of medicine with a focus on innovations that often do not materialize.  The real message rarely gets out and that is – psychiatrists are uniquely trained, we are interested in problems that nobody else is and that other physicians often avoid, and we are good at what we do.  It is highly problematic that journalists seem reluctant to get that message out to the public. When I first read Dr. Morehead’s writing I found it refreshing because there are very few psychiatrists who want to get that message out. Most will cave in to the first suggestion of a level of uncertainty that every specialist in medicine has to deal with – the persistent risk no matter how small and the lack of a guaranteed outcome.

I look forward to a new generation of psychiatrists who can start to set the record straight.

 

George Dawson, MD, DFAPA

 

Supplementary:

Decided to add this explanation anticipating the typical criticism:  “Well he is arrogant isn’t he? We always knew he was arrogant.  All psychiatrists are arrogant!”  When I say unapologetic – I mean unapologetic for just existing and trying to help people.  That is the level that psychiatrists are forced to operate at that no other medical specialist is. There are the usual misunderstandings, errors, and adverse outcomes in psychiatry that there are in any other medical specialty.  There are psychiatrists who are burned out, forced to practice in a way that they would rather not, and even personality disordered - just like any other specialty.  But in those other specialties the assumption is that these problems are handled on a case-by-case basis by the responsible physician, clinic or hospital administrative structure, or medical board. There is no similar assumption in psychiatry.  Instead, there is an assumption that the entire profession can be condemned for some adverse outcome, unprofessional conduct, historical event, or any unreasonable criticism that someone can come up with. As I have pointed out in the previous post - many criticisms are fabricated or just absurd.

So when you read these unrealistic criticisms about psychiatry in the papers – keep in mind that there has been a doubling down on the rhetoric unlike what happens with any other specialty in medicine. Use that knowledge to moderate your reaction to it. 

References:

1:  Morehead D. Psychotherapy: Lies Cost Lives. Psychiatric Times 40(11).  Published online on November 10, 2023  https://www.psychiatrictimes.com/view/psychotherapy-lies-cost-lives

2:  Ghaemi SN. Rediscovering existential psychotherapy: The contribution of Ludwig Binswanger. American journal of psychotherapy. 2001 Jan;55(1):51-64.

3:  Ghaemi SN, Glick ID, Ellison JM. A Commentary on Existential Psychopharmacologic Clinical Practice: Advocating a Humanistic Approach to the" Med Check". The Journal of Clinical Psychiatry. 2018 Apr 24;79(4):6935.

Photo Credit:

Many thanks to Eduardo Colon, MD