“Doctors are misinformed, patients are misled and millions of people are taking medication with no benefit for them.”
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, around 1/3 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.”
The problem with over-medicating
This leads us on to the next point to address which is – what is so wrong with over-medicating? Well, adverse side effects of prescription drugs are now having a serious impact on the healthcare system, with about a quarter of hospital admissions of the elderly being due to negative reactions to prescription drugs. FDA figures in 2014 indicated that in the US there were about 123,000 deaths due to adverse side effects of prescribed medication that year, a number that tripled in a decade, and there were around 800,000 serious disabilities caused. This is likely due to the fact that when drugs go through clinical trials they are usually tested on the young and fit, with only one drug at a time. Many elderly people are frail and taking multiple drugs at once, which can react against each other. The chemical compounds used in these drugs are all very complicated and may react with each other in unpredictable ways, but these are not comprehensively tested in trials, because it would be impossible to test every combination. This means that patients are essentially guinea pigs when taking multiple drugs at once.
What’s more, new drugs are being brought out all the time so we cannot know what the long term side effects of these will be or how they will interact with other drugs. And often the side effects of drugs are combated with… simply taking more drugs. For example, a patient may take a sturdy painkiller to help with joint pain, but this drug has a side effect of churning up their stomach, so they take another drug to settle their stomach. However, the most “unnecessary” medications according to Malhotra are the so-called “preventative medicines” like statins. Statins only slightly reduce the risk of heart attack and have been shown to cause Type 2 diabetes in 2% of patients.
The other issue with preventative medicine is that it is detracting from the importance of lifestyle choices. People think that they can take a pill such as one to lower cholesterol and that means that they can eat an unhealthy diet as they are ‘covered’ by the pill. The reality is that a cholesterol-only pill is probably not giving much benefit to them and eating burgers and chips every day will cause them serious harm, so they are getting a net harm from this attitude. In general, lifestyle is sorely overlooked, partly because GPs only have 10 minutes with each patient and it is easier to prescribe a pill than it is to explain the importance of healthy diet and exercise, and partly because people just don’t want to hear it. However, Malhotra says: “When you actually tell people the truth about how beneficial lifestyle is against medication they are amazed.”
Part of the solution to this crisis of overmedication is to actually actively take people off their medication, as seen in The Doctor Who Gave Up Drugs, as well as being careful when starting someone on a medication. Sometimes when people have been taking a drug for a long time they become accustomed to how it makes them feel; they don’t even realise that the reason they are feeling fatigued, depressed etc is because of the drug. When they stop taking it sometimes they suddenly feel a new lease of life without the side effects bringing them down. Malhotra claims that this is the case with statins. He said: “The original data suggested that only 1 in 10,000 people get any significant side effects, which is an absolute joke…in my view its at least 1 in 5 that will at some point experience a side effect that interferes with quality of life.”
Anti-depressants are also being prescribed more and more and whilst this is in part due to greater awareness around mental health, it is also because therapy is more expensive, so it is easier for GPs to simply prescribe a drug to help people suffering from mental illness. However, it is important to also consider and properly weigh up possible non-pharmacological interventions like cognitive behavioural therapy, or even something like a support group, as each person is different and anti-depressants may not work for them. This is most likely to be true for people whose illness stems from a trauma or something in their past that needs to be addressed by talking about it and cannot get better without resolving their issues.
Considering the importance of lifestyle is important both individually for patients’ health but also in terms of public health initiatives to improve the health of the population. In fact, most of the increase in life expectancy seen in modern times has been due to public health interventions. Around 25 of the 30 years improvement in life expectancy has been due to things like safe drinking water and sewage disposal, safer workplace environments, washing hands, smoke-free buildings, seatbelts in cars etc. Most of the further 5 years have been down to emergency treatments such as antibiotics for infections.
However, this is not where the companies make their money – preventative medicine like statins is where the profit lies. And whilst public health interventions have clear benefits they are not given the attention they deserve – but Aseem Malhotra is fighting against that. He is one of the original founding members of Action on Sugar which aims to reduce people’s sugar intake by educating people on the effects of sugar and he also endorsed the sugar tax.
So to answer the question ‘what is wrong with overmedicating?’ – on top of the issue of side effects we have the inconvenience of taking a pill every day, possible interactions with other drugs, cost for the NHS, the attitude that taking a drug means that a change in lifestyle is not necessary, possible dependence on the drug, possible bias in reporting of research meaning the side effects are more significant than you may be aware of (I could go on!). And either way, the issue is largely about transparency and giving the patient the right to make an informed choice on their health.
Transparency in health care
This brings me on to how information is being portrayed to patients when deciding what treatments they receive. If people are not receiving the correct information on treatments, they cannot make informed decisions about their own health. And this is not just limited to prescription drugs either – people are currently undergoing surgeries that may not even be necessary. For example, when a patient is having a heart attack they will undergo surgery to save their life and the odds for this being the beneficial course are very good. However, when it comes to heart surgery (stenting) for stable coronary heart disease it is a different story. Whilst 1/3 of people with heart disease in the UK will undergo stenting for stable angina, this procedure will not prevent a heart attack or prolong life. It does help to relieve symptoms, although usually these can also be relieved with the appropriate use of drugs without the need for an invasive operation in which there is a 1% chance you will have a heart attack, a stroke or die. However, the most troubling aspect of this is that 88% of patients, when asked, thought they were having the procedure to prolong their life and prevent a heart attack, which is does not do.
This means that the true nature of the procedure is not being accurately and comprehensively explained to the patients. Perhaps if they knew that the only benefit was symptom relief they would still want the operation, but perhaps not. What is important is that they get the informed choice. This is not just limited to cardiology either – the same can be said for orthopaedics and many other areas. Malhotra told us how multiple orthopaedic surgeons had told him that that is they had the same problem as some of their patients, they would not have chosen to undergo the treatment that they themselves had performed.
This is partly due to a culture of doctors wanting to be seen to be ‘doing something’, but also the way in which people and hospitals are paid. Whilst here in the UK there is a “payment by results” system, there is also an element of “payment by activity” as allocation of funding to certain hospitals are affected by what procedures are carried out at those hospitals. This gives an incentive for institutions to carry out many procedures, even if it is against their better judgement.
Despite this plethora of issues relating to drugs research and the communication of the facts, there is very little written in the media about such things and where it does it tends to simply perpetuate the perception and culture about more pills being necessary. One example which breaks away from this trend is a campaign by the Academy of Medical Royal Colleges, which Malhotra was lead author on in a research paper published in the BMJ, called ‘Choosing Wisely: Winding back the harm of too much medicine’, which was covered relatively successfully in the media. It encouraged patients to ask questions such as “How much benefit am I getting?”, “What are the alternatives?” and “What happens if I do nothing?”. It also encouraged doctors to try and revaluate their practice and only use interventions that are fully supported by the evidence.
There are many patients in the UK and abroad that are taking medication with little or no benefit that could be causing harmful side effects. In the US, about 1/3 of all healthcare activities bring absolutely no benefit to the patient. Whilst this is likely worse than over here because theirs is a commercialised system and based even more on activity over results than it is here, we still have a massive problem to address. If we take a step back and have a more sensible distribution of resources, where we divert attention away from drugs that cause side effects and just bring patients back to the doctor, we can focus on elements that would really benefit people like providing better social care.
A more idiosyncratic approach to medicine is also warranted; every individual is different and has different priorities. Some people may hear the truth about certain drugs and still want to take them and other may hear it and want to keep well away. It is about giving people the information and the choice to make their own decisions about their health.
Malhotra has recently made a new film documentary called The Big Fat Fix, which gives a positive message about the impact of lifestyle on health.
You can follow him on twitter @DrAseemMalhotra
Interview by Henry Fisher. Tweets @_Hydrofluoric
Words by Abbie Llewelyn. Tweets @Abbiemunch