Era of Blockbusters Is Over? I Hope So.

1BOM posted a link to a Forbes article on the issue of blockbuster drugs.  Journalists are typically slow to pick up on this because it takes the element of scandal out of any relationship between physicians and the pharmaceutical industry.  After all, aren't physicians clueless about pharmaceutical advertising and mindless cogs in Big Pharma's attempts at hegemony?  The tone of the article is that Big Pharma is now increasing the drug prices for therapies targeting fewer conditions.  No thanks to Big Pharma for all of the innovation currently used by the generic pharmaceutical companies.  As an example, I bought a bottle of montelukast (90 tablets) a month ago for $9.  It is the Singulair product list as Merck's 2010 blockbuster drug in the Forbes article.  As far as I can tell, it is the only effective treatment for an asthma attack that has caused me to take oral prednisone, inhaled glucocorticoids of various types, nebulizer treatments, inhaled ipratropium, and various inhaled beta agonists for the past four months.  I didn't see the US government or the academic community inventing montelukast.  In fact, I don't see the US government or the academic community doing much about the fact that the average asthmatic is still wheezing and there is no effective approach to preventing the spread of respiratory viruses that are a major cause of this problem.  I guess their solution is to partner with managed care and suggest that pay-for-performance is going to save us all.  Maximum treatment with everything except montelukast has done nothing for me.  What would pay-for-performance do?

Maybe that is why doctors who I have seen always ask:  "Are you sure you NEVER have smoked?" That seems to happen after the usual: "I like to treat asthmatics because I can do so much for them!"  If that is true why are most asthmatics still wheezing?  I think it is fair to say that the only reason I am wheezing less at this point is due to Merck.  The necessary CME disclosure at this point is that I do not own any pharmaceutical company stock, but I am quite willing to admit it when I see a good product defined as one that works for me.  Since the focus of this blog is on psychiatry - I also get direct feedback from patients that the medication I prescribe has had some of the same effects.  That is even in the case of medications that I never prescribe - paroxetine and fluoxetine, in people I see for consultation.  And for all of the clinical trials obsessed out there - I suppose I could just say or think: "I guess this person is unfamiliar with the meta-analyses critical of antidepressant efficacy." or at least: "I guess this person has never been on the Internet and read about the horrendous side effects of these medications."  But being the foolish psychiatrist I am, I am likely to think that a person with severe depression requiring hospitalization, severe postpartum depressions with psychosis and suicide attempts, or severe disabling depression may have actually found an effective medication that works for them.  I am much less impressed by the work of statisticians than the experience of my patients, especially when their lives are back on track.

In terms of the cost of psychiatric medications, this is really an old issue.  It was years ago when I noticed that people could pick up citalopram for $4 a month at Wal-Mart.  I had to point the wide availability of generic antidepressants in a response to a Washington Post article.  I guess the DSM-5/Big Pharma conspiracy is not looking too good now.   Sure there are new antidepressants, but there is no reason why they should be first line drugs.  Anyone with an first time PHQ-9 elevation is going to get an inexpensive SSRI.

All of the critics of Big Pharma were naturally slow to pick up on it, especially the antipsychiatry crowd because it means that the moral high ground is lost.  They can no longer devalue everything that psychiatrists do based on the alleged Big Pharma connection with a handful of psychiatrists.  Of course they can keep the conspiracy theories going about some missing clinical trial results of a now generic drug that is over thirty years old.  They can conflate that as having something to do with psychiatry despite the fact that the major regulators like the FDA have done nothing about the drug based on post marketing surveillance.  They  can blame psychiatry for the overprescribing of primary care physicians and the institutionalized overprescribing of managed care systems.  The antipsychiatrists will certainly continue to hate psychiatry and the critics will still have an axe to grind with particular psychiatrists. But at least I won't have to tolerate a smug blogger proclaiming that they were "Keeping psychiatry honest since 2007."  I have actually done very well maintaining my honesty without the help of a self promoting blog and the psychiatrists I know have done the same.

And wait a minute - what about the real epidemic that has been actually killing more than 10,000 people per year for over a decade?  Plenty of generics there and plenty of ways to take way too much acetaminophen.

The other problem with the Big Pharma conspiracy theories has been a general naivete about capitalism and marketing.  Advertising is good for the New York Times, but not a medical journal or meeting.  Physicians need to be cloistered from market influences.  They could be corrupted in a way that is inimical to the interests of patients.  Direct advertising of toxic medication to consumers is a much preferred route.  As far as the "me too drug" argument goes, let me illustrate the problem with that argument by my trip to the convenience store today.  I ran out of grape juice today.  I only drink Welch's 100% grape juice, diluted at a ratio of about 5:1 with carbonated water.  I drink about 576 fluid ounces of the stuff per month.  Rather than go to a supermarket, I went to a convenience store because it was closer.  On the shelf were a vast array of chemical drinks and sodas of no nutritional value, small bottles priced at what I could buy 64 ounces of pure unsweetened grape juice for.  The comparisons were overwhelming.  Self proclaimed nutritional drinks that had no calories, no protein, and plenty of artificial sweeteners.  Natural juice "beverages" or "cocktails" that had vanishingly low amounts of actual juice.  All of these products basically knock offs of fruit juice, but, heavily marketed, neatly packaged, much more expensive, and having the occasional nutrient value of added vitamins.   Does a "me too" pharmaceutical have less value than a "me too" soft drink?  There is no comparison.

I also had the association to my Peace Corps experience.  In the country where I served in Africa, there was a place called the Northern Frontier Zone.  There was a police outpost there and you had to sign a register acknowledging that the local government was not responsible for your safety once you crossed into that territory.  One of the best ways to get there was to hitchhike on large trucks carrying Coca-Cola.  You just had to get comfortable laying on cases of Coke.  Over the years,  I have drank as much Coke as anybody - but for the purposes of this post and the focus on advertising and marketing consider what I am saying here.  In 1975, Coke was widely available in remote African villages and the Northern Frontier zone.  For most people it was more widely available than clean water.  Since then. they have sold increasing amounts of the product.  The world is dominated by American cola manufacturers.  Are "me too" pharmaceutical products less valuable than Coca-Cola?  I would suggest that they are probably not and they are marketed a lot less vigorously.  Unless I have missed it there has been no complaint about Coke's world domination, although I sincerely hope that a psychiatrist is never photographed drinking a can.

I might be biased by a good four months of decreased wheezing, but I hope the general message on the Forbes article gets out and clears some of the air.  In psychiatry, there are many more important things to focus on than conspiracy theories that really don't apply to the vast majority of psychiatrists.  You can't take physicians out of their historical mandarin role and instead blame them for colluding with Big Pharma.  It may have been a political strategy to get them out of that role and suggest that politicians (of all people) should assume that role.

The work psychiatrists do is tough and demanding.  No psychiatrist who I have ever talked with expects a pat on the back.

Getting out of our face is a pretty modest wish.

George Dawson, MD, DFAPA

Supplementary 1:  I also have no financial interest in any of the other products mentioned here including Welch's grape juice or Coca-Cola.  I used the real names because they are historically accurate.