Editorial: This post by Johanna Ryan is one of several that will pick up on the Fake News theme. But we also want anyone who has PPI stories to get in touch. And to pick up Dee Mangin’s legacy prescribing issue, do PPIs lead to SSRI use or is it the other way around? There is a complementary post – Fake What – on dh.org.
Increasingly, any information about adverse effects is smeared as “Fake News” – and patients who pay attention to it are condescended to or outright dismissed. The implication is that because we are so much less educated than our doctors, we can’t tell sensationalism from science. So we fall prey to “Internet fear-mongers,” who do us harm by scaring us away from taking medicines we really need.
The effect of the Fake News epithet on patients is to make us feel stupid, but the effect on our doctors is worse. Not only does it increase their confidence that the patient has nothing to tell them – it gives them a sense of virtue about shutting us down.
Twenty years ago they might have felt a bit arrogant when they did so, even if convinced they were right. But now they are encouraged to feel proud of their refusal to listen – even proud of “firing” a patient who, say, refuses a vaccine or drug the doc recommends. They’re not arrogant! They are brave warriors for Science. And the patient is not just a fool – he’s a dupe of the same forces trying to deny climate change and keep kids from learning about evolution in school.
Just ask leading UK psychiatrist David Nutt, who insists there is “overwhelming evidence” that mental health problems are caused by chemical imbalances in the brain.
“It’s like the climate change debate. Some people do not want it to be true, but there is a biological element. It’s not a myth. We know the chemistry of depression.”
Or as AstraZeneca (makers of Nexium, the blockbuster “Purple Pill” for GERD) tells us: Your doctor wouldn’t try to do your job, would he? So stop trying to do his job! You’ll only screw it up.
Esomeprazole (nexium) is along with omeprazole (losec), pantoprazole, lansoprazole, dexlansoprazole and rabeprazole are proton pump inhibitors (PPIs).
Well, since this blog has been dipping into Scripture of late, I will take my text from Luke, Chapter 6, verse 42 (English Standard Version):
How can you say to your brother, ‘Brother, let me take out the speck that is in your eye,’ when you yourself do not see the log that is in your own eye? You hypocrite, first take the log out of your own eye, and then you will see clearly to take out the speck that is in your brother’s eye.
Verily I say unto thee, Doctor, there are two lessons here:
The first point is probably the most important. Most doctors think the journal articles on which they rely were written by the Harvard or Stanford med school professors listed as official authors. More importantly, they also think those eminent experts actually did the research (or at least supervised those who did it) and have the actual data as to the results. But as regular readers of this blog realize, chances are neither one is true.
But the second lesson is important too. Fear-mongering shapes much of the “mainstream” consensus on drugs and diseases: deliberate, focused, relentless fear-mongering. It’s led by the drug companies and their marketers, with the full complicity of those Harvard and Stanford guys, who clearly know better.
The fear-mongering directed at U.S. patients is especially crude and all-pervasive. But increasingly it’s directed at doctors too. Things would be bad enough, of course, if the average doctor’s views were shaped by reading medical journals. But for the most part they are much too busy for that. Instead, they rely on medical “newsletters” and Continuing Medical Ed seminars that digest the latest studies for them and spit the correct conclusions into their open mouths, like baby birds.
I call it Prole-Feed, after the stage-managed “news” served up to the lower classes in George Orwell’s 1984. It comes in both Doctor and Patient Editions. It allows the medical establishment to aggressively push notions that have been thoroughly discredited and that the leading experts would insist no one seriously believes—like the “chemical imbalance” theory of depression offered us by Dr. Nutt. Worse yet, it allows the average doctor to absorb these notions, and transmit them to his or her patients.
One of the worst examples, in my book, was the campaign to make us all very, very afraid of Acid Reflux. Check out this scary 2002 ad for Nexium, AstraZeneca’s blockbuster PPI:
An earlier version of this ad raised an even bigger scare: Esophageal cancer. That’s right, the Big C. I can’t find that version online. I believe it was a “disease awareness” spot, produced before Direct-To-Consumer drug advertising was legalized in 1997, and thus did not mention a specific drug by name. But it featured the exact same forbidding “eroded” desert landscape, and the same anxious people repeating the same lines:
“I thought it was just—heartburn.” “I didn’t know.” “I didn’t know!”
The later, Purple Pill version replaced the cancer warnings with vague talk of “erosions” and “damage” – probably in order to satisfy the FDA. But the original spot remains embedded in the memory of every American TV watcher of a certain age. The Big C tends to have that effect.
You think I’m kidding? Check out this ad for Mylanta, a non-prescription acid-reflux remedy, which aired back in 1991:
The intensity of this ad may surprise you: Why is that nice, healthy-looking woman so terribly anxious about consulting her doctor for heartburn—and so blissfully relieved as she tells us that “My doctor said Mylanta”? Any US Baby Boomer would know: The poor soul lay awake for weeks worrying she had cancer, like they told us on TV. But thank God! It wasn’t GERD – it was “just heartburn.”
So what’s the difference, anyway? That’s one problem with this scare story: there isn’t much. “GERD” and “heartburn” are not really two separate diseases. They’re more like two sides of an arbitrary line in the sand: If your bouts of heartburn happen at least once or twice a week, and a product like Mylanta doesn’t totally fix them, we will agree to call them GERD. Since as many as 50% of Americans may have these symptoms at least once a month, estimates of the number of people with GERD run as high as one in every four of us, or about 80 million.
And while it’s true that people diagnosed with GERD have a higher relative risk of esophageal cancer, the absolute risk remains incredibly low, as a 2010 survey confirmed. For a 60-year-old woman who’s had weekly “GERD symptoms” for years, the risk is roughly equivalent to a man’s risk of breast cancer. For younger “GERD patients,” it’s even lower.
And yet, we still worry – because medicine has taught us to do so. Here are the top queries Google suggested to me just last week:
The persistence of Cancer Panic as a marketing tool for PPI’s was brought home to me in a recent article from Consumer Reports, titled “Should You Still Be Taking That Medicine?”
In general Consumer Reports is fairly good at giving Pharma claims a skeptical once-over. And this article was based in part on an interview with one of my favorite doctors: Dee Mangin, professor of family medicine and medical director of RxISK.org. Dee and her colleagues had just published a study examining why so many older people continue on prescription drugs for years longer than official guidelines recommend – legacy prescribing. The resulting “polypharmacy” (reliance on multiple meds) is not just useless, but can cause serious health problems in its own right.
But Consumer Reports also dug up an “independent expert” to comment on Dr. Mangin’s study (in the interests of balance, I guess): one Robert M. Breslow, a pharmacy professor from the University of Wisconsin. Breslow agreed polypharmacy has health risks, but sagely opined that in some cases doctors might have good reasons to continue the drugs for longer than usual:
But at certain times, experts say, this increased risk may be worth it. For example: If a person is suffering from gastroesophageal reflux disease (GERD), which can lead to esophageal cancer, the extra risk of a PPI may well be worth the extra protection it offers. “We have to deal with each patient as an individual and really assess them in a holistic way in terms of risk and benefit,” Breslow says.
“GERD, which can lead to esophageal cancer.” It just slid right in there, attributed to unnamed “experts.” In 2018, yet. The named expert, Dr. Breslow, would not likely want to be directly quoted saying this, because it’s so deeply misleading. Nonetheless, a casual reader would definitely see his expertise as giving it the stamp of truth. Taking PPI’s for mere heartburn might cause “rare but serious problems,” we’re told. But what if we actually Have The Disease Of GERD? Best to do what we gotta do, we’re apt to think, to avoid getting cancer.
It’s hard to imagine the developers of Proton Pump Inhibitors, or the “thought leaders” in gastroenterology, ever seriously believed that 80 million Americans should be on PPI’s for life to save them from death by cancer. That business of “absolute risk” versus “relative risk” can be understood by anyone with a high-school education. It’s hardly rocket science. Yet thanks to well-designed Prolefeed, plenty of medical-school graduates are powerless to sort this out. They can be counted on to advise their patients to stay on those PPI’s no matter what, for the sake of “prevention.”
Why does that matter? The potential harms go far beyond wasted time and needless worry, or even the billions spent on AstraZeneca’s patented “purple pill.”
For the record GERD/GORD is an entirely made up disorder invented in the 1980s by companies attempting to block the bitter taste of the disappearance of the most lucrative market in medicine – the duodenal ulcer market – after a brash Aussie discovered a short course of antibiotics could cure ulcers. The Acid blocking drug companies did everything they could to block anyone hearing about cures for ulcers. When they failed they created GERD/GORD.
The human body is not designed to take drugs chronically. When PPIs emerged first they were thought to be so powerful that they should only be taken for a week. They are now routinely prescribed for ever.
In clinical practice I see a large number of people who become anxious on them and who often end up prescribed anti-anxiety meds without anyone realising its the PPI that causes the problem. Stop the PPI and they become much less anxious. But others seem to end up on PPIs after their SSRI.