More than one billion prescriptions are dished out in the UK each year, which is 2.7 million per day or 1,900 every minute, an increase of nearly 2/3 in just a decade. And the increasingly widespread use of prescription medication can have some serious consequences.
Most people are aware that the over-prescription of antibiotics has unfortunately led to the development of resistant strains of bacteria and many people are campaigning for more restrained prescription of antibiotics. However, an interview with Aseem Malhotra, a London-based cardiologist, reveals that the problem is by no means limited to antibiotics; in fact, there is a worrying trend in the over-prescription of drugs for all sorts of ailments, leading to ever increasing costs of side effects. He explains that this is due to misinformation at all levels in the system, from how research into drugs is funded, to how it is reported in academic journals, to how their pros and cons are presented to patients.
Aseem Malhotra, who trained as an interventional cardiologist, practices in London and is a former consultant clinical associate to the Academy of Medical Royal Colleges. Last year he became the youngest member to be appointed to the board of trustees of health think tank The King’s Fund. He has campaigned for years on a number of issues including transparency in health care, fighting excess sugar consumption and criticising the focus on total cholesterol and use of statins. He spoke to us about what he calls “an epidemic of misinformation” that has led to people undergoing unnecessary treatments.
The BBC programme The Doctor Who Gave Up Drugs has recently brought the issue of prescription drugs back into the limelight, highlighting how prescription of drugs has increased massively in the last five years especially, for example, prescription of painkillers (up by 25%) and antidepressants for teens (up by 50%). It also presents the alternative to this, one that Malhotra is also endorsing and led on, that other treatments such as lifestyle interventions like diet and exercise can be just as effective, if not more so, than drugs. It is important to take a holistic approach to health, but the culture of medicine at the moment means that people simply want a miracle pill to solve all their problems, or “a pill for every ill” as Malhotra called it.
Bias in funding for drugs research
So let’s look at the issues that Malhotra brings up with what he calls “a collective system problem”. Firstly, there is bias in the funding of drugs research. A great deal of funding comes from pharmaceutical companies who stand to gain a profit from the industry. The way they make the most profit is to create drugs that can be used by the largest number of people for the longest amount of time, which clearly means that they aren’t necessarily funding research that is the most beneficial to patients.
It also means that most of the new drugs produced in the last 20-30 years have been near copies of existing drugs, with just tiny alterations, meaning that the clinical advantages of these drugs over what was already available is minimal. A Barral report on all internationally marketed drugs between 1974 and 1994 found that only 11% were truly innovative and multiple independent reviews since then have also concluded that around 85-90% of all new drugs provide few or no clinical advantages to patients. On top of this, many of these drugs also have serious side effects, which have a negative impact on people’s health.
Biased reporting in medical journals
Another serious issue in the chain, that Malhotra points out, is bias in the reporting of drugs research. Firstly, there is a publishing bias whereby only the “success stories” even see the light of day, but even within these supposed “success stories” there can be misleading information. For example, the reporting of risk can mislead a reader, which is seen even in well-respected journals like The Lancet, the BMJ and JAMA. Between 2006 and 2009, around1/3 articles published in the three aforementioned journals had mismatched framing, which means that they report the benefits of a drug in relative risk (large numbers), whereas they report harms in absolute risk (small numbers). For example, take a drug that reduces your risk of getting heart disease from 10 in 1000 to five in a 1000 – it would be reported in relative risk as a 50 percent reduction. However, the drug also increases your chance of getting intense muscle pain from five in 1000 to 10 in 1000, but this side effect would be reported in absolute risk, as an increase of 5 in 1000, so 0.5 percent increase.
This is an obvious misrepresentation, yet it is permitted and used extensively in trusted journals. These are then used as marketing tools by the pharma companies, who pay for reprints of the journal. Doctors trust these journals and very rarely question what they say and their recommendations for patients will reflect this. For Malhotra: “The best way I can give quality care to my patients is to have complete transparency”, which means he has started telling patients the absolute risk involved with the drugs on offer and he reports that they are often underwhelmed by the benefits of these drugs when given this information.
These medical journals have also been found to print “bad data”. For example, a study investigated Riveroxaban as an alternative for Warfarin, a widely-used anticoagulant. It concluded that this drug had the benefit that, unlike with Warfarin, the blood does not have to be regularly checked. This is a major inconvenience avoided for patients, so the NHS spent around £50 million on this new drug. However, an investigation by the BMJ uncovered that a device used in the randomised controlled trial that justified the NICE guidelines recommending the drug, a key measuring instrument had been faulty, which casts doubt on the whole trial. Even though this has all come out, doctors up and down the country will still be prescribing this drug to patients because releasing an investigation in a journal does not guarantee that every doctor will both hear of this and change their behaviour accordingly, as ultimately doctors still follow NICE guidelines, which take a while to change.
The conflicts of interest in research can even result in serious scientific fraud and manipulation of statistics. GlaxoSmithKline paid the largest fine in US history for fraud, $3 billion, in 2012 specifically for illegally marketing drugs, misreporting and hiding data on harms. However, during the period covered by the settlement they made $25 billion in profit from the drugs. No one went to jail, no one went out of business and the cycle continues. And within academic institutions, even when fraud is revealed, often no one is punished. People are extremely unwilling to speak out against ‘Big Pharma’ because that is how their research is funded and they are scared that if they speak out they will lose this funding. Malhotra summarised: “Doctors are unwittingly becoming part of a system where side effects are underreported and institutions are funded by pharma so people don’t speak out when they should.”