Profit and public health

Amid the abandonment of tariff protection and the continued assaults on trade unionism, one union/lobby group has been consistently victorious. The Pharmacy Guild has managed to restrict competition so successfully that it’s impossible to open a pharmacy if it might hurt the profitability of an existing business, even if that business is failing to serve a significant group of customers. I ran into an example when I was at James Cook University in Townsville. A request for an on-campus pharmacy was rejected because it was within the market area claimed by a suburban pharmacy, more than a kilometre away and inaccessible by public transport.

Far more important to the Guild is the imperative of keeping supermarkets out of the pharmacy business. The key argument is that supermarkets are just businesses, happy to sell anything to make a buck, whether it’s cigarettes or cancer medications.

So, I was interested to read the Guild’s reaction to a proposal that medical professionals should stop prescribing homeopathic products. Whatever you might think about alternative/complementary medicines in general, homoepathy is plain quackery, combining a magical theory of medicine with the preposterous physics of water memory. Unsurprisingly, research has proved beyond any doubt that it’s no better than a placebo. So, the Royal Australian College of General Practitioners (RACGP) has formally recommended GPs stop prescribing homeopathic remedies and says pharmacists must also stop stocking such products.

The Guild’s reaction:

it is not a regulatory authority, and as such there will be no recommendation backing RACGP’s call for homeopathic products to be taken off the market.

In other words, selling medicine in the same shop as alcohol is unthinkable, but it’s entirely OK for a health professional to promote and sell water as a treatment for serious illness.

This episode demonstrates, to anyone who cares to look, that the Pharmacy Guild is (and in fact claims to be) nothing more than a rent-seeking lobby group, whose sole concern is the profitability of its members. As the Tobacco Institute of Australia would be quick to point out (if it were still around), there’s nothing illegal about that. But when profits and public health come into conflict, the Guild and the Institute are on the same side.

74 thoughts on “Profit and public health

  1. @Ikonoclast

    I actually believe all these medications now cause more damage than they prevent on a population wide basis though of course they do help some individuals when used “strictly in accordance” etc. etc.

    Given that life expectancy continues to increase, and morbidity and mortality rates from diseases like heart disease continue to decline, these belief doesn’t appear to be too well-founded. I agree with you point that we should try to use as few drugs as possible, though.

    In many cases, people would get better results with a no-drug regimen combined with weight-loss, exercise, proper food, proper sleep etc.

    This is probably true. I think the dilemma faced by many health professionals, though, is that it is very difficult to get people to change their eating, diet and exercise habits.

    A physician is more than likely to be aware that a given patient would get a good drug-free result by changing their diet and exercising regularly, but is equally likely to realise that the patient probably won’t do those things, and probably won’t persist with them long enough to get real results even if s/he tries. But if the physician prescribes a medication, it will deliver some genuine benefits and the patient is much more likely to keep up with a prescription than a diet-and-exercise regime.

  2. Blarg. “this belief” not “these belief”. “Your point” not “you point”. Damn Mondays.

  3. @Tim Macknay

    I assume you are talking about LEB (Life expectancy at birth). As Wikipedia notes;

    “The combination of high infant mortality and deaths in young adulthood from accidents, epidemics, plagues, wars, and childbirth, particularly before modern medicine was widely available, significantly lowers LEB.”

    Advances post-WW2 and continuing to this day have been particularly instrumental in increasing LEB by decreasing infant, childhood and young adult death rates. We can note better nutrition and health care, especially for infants and young children, along with immunisation and the defeat of major diseases like smallpox, diptheria, whooping cough, measles and polio.

    Thus, if you follow this argument, you can see that improved care at and beyond onset of old age is not necessarily all that significant in increasing the LEB of the whole population. Thus it is not necessarily inconsistent to suggest that (some) medications for old people essentially are doing more harm than good. Also, the harm might not result in aged deaths but simply decline in aged quality of life in some cases. I would even argue that today a proportion of prolonging life for old people is essentially just prolonging low quality of life. It can be pointless and even cruel.

  4. @Ikonoclast

    Maybe barracking for a football team is a tribal thing, and reflects our biological origins. Maybe it is actually good for us?

    What I find hard to understand is how barracking for the West Coast Eagles can be good for anyone. Their supporters have an insufferable sense of entitlement. The umpires love them. They are a blight on the competition, and should have their license taken away forthwith.

    Freo, on the other hand, are the source of all that is good in the world…

  5. My remark on placebos has sparked a lively discussion. But so far nobody has properly responded to my challenge for a reason why people should not be free to buy them in pharmacies.

  6. @J-D

    I agree, however the design of the RCT is crucial (although there are research methodologies which are said to more effectively measure the efficacy of homeopathy-see media release). To take the earlier example; whilst it is true that flucloxacillin can alleviate a chest infection, it would be naive to conduct a RCT which examined the effect of fluclox on everyone with a chest infection as there are only a very small number of chest infections for which it is indicated. The point I am trying to make is that any RCT into homeopathy needs to take into account the criteria by which homeopath’s prescribe. Western RCT are generally not inclined to do this very well. This will obviously skew the data.

    I am not interested in trying to convince anyone regarding homeopathy, rather I hope to encourage people to think beyond their biases (I obviously have biases also) rather than too readily accept conclusions based upon questionable research methodology because they match previously held beliefs. That is why I thought the original media release from AHA was worth a read.

  7. @James Wimberley

    Your question perhaps has two parts. Why shouldn’t people be free to buy placebos? Why shouldn’t people be free to buy placebos IN pharmacies?

    It’s a general principle that we expect truth in labeling. We expect a packet labelled 1 kg Sugar to contain 1 kg Sugar. We expect a bottle labelled 500 mls distilled water to contain that. It is how we make decisions as consumers. The problem here is that if you label a placebo honestly it cannot be a placebo. The selling or application of a placebo requires deception. There are cases where placebo deception might be warranted. However, the open market place is not the place to deliberately permit such deception. The precedent is poor in terms of making it more difficult to maintain laws concerning truth in marketing and honesty in market transactions. In everyday language, you invite snake-oil merchants into the market.

    Pharmacies should be able to issue placebos where a doctor prescribes them. But these ought to be pure and safe placebos understood scientifically by the doctor and pharmacist to be exactly that. Homeopathic medicines are often (but not always) pure placebos. However, they do not reliably come out of a safe manufacturing facility. They may be impure. They are also priced with a premium which accompanies the claim that they are in reality active and efficacious. This claim and pricing is dishonest. By the same token, I don’t know how pharmacies price doctor-prescribed pure placebos.

    I can imagine for example the case of a belligerent elderly patient with early dementia who might frequently demand antibiotics for every sniffle. A doctor might find it expedient to prescribe placebo pills. A UK survey found 97% of doctors admitted prescribing placebos although only 10% of prescriptions were pure placebos. The rest were impure placebos – treatments that contain active ingredients but are not recommended for the condition being treated, such as antibiotics for flu.

    I don’t defend the above actions by UK doctors. It seems excessive. But I think doctors, if they act ethically, are the best placed to prescribe placebos. The general market place is not the place to make allowance for deliberately dishonest and misleading products and product claims.

  8. @James Wimberley

    My remark on placebos has sparked a lively discussion. But so far nobody has properly responded to my challenge for a reason why people should not be free to buy them in pharmacies.

    This strikes me as disingenuous, James. You never gave any indication as to what you would regard as a “proper” response to your original comment.

    The question, or “challenge” as you now characterise it, that you raised was predicated on your belief that placebos are known to be effective for a range of ailments. I explained why I consider that belief to be dubious, and I also provided two other arguments against the sale of placebos on ethical grounds.

    You’re under no obligation to accept my opinion, but there was nothing “improper” about it.

    I wonder why you now want to pretend that no-one has really responded?

  9. @James Wimberley

    Actually, placebos are sold actively in pharmacies at the moment. Think of any condition for which there is no known treatment that works. Aging is one such condition. Now look for products in pharmacies that have “anti-aging” in their blurb. These are placebos.

    Of course, if you required them to say on the box, “doesn’t actually work – just a placebo”, that would actually ruin the placebo effect, at least partially. So for the good of all concerned, placebos are marketed as though they actually work. I’m not sure, but I think most pharmacies actually put all the placebo like products together, separate from the products that actually work. People buying placebos do have to suspend their disbelief a bit 🙂

  10. It’s correct that research shows a strong placebo effect for antidepressants. The proposed mechanism is that the regular assessments used to obtain data in the studies improve reported mental health. That is, talking to a clinician about depression makes people less depressed.

    That’s either a clinical finding or a “well, duh” moment, but the people who allocate funding look at the cost of a counseling session and the cost of a pill and make the economically rational choice.

  11. @Sancho

    It’s correct that research shows a strong placebo effect for antidepressants.

    It’s not clear what you mean by this.

    Do you mean that it’s correct to say that research shows that the performance of antidepressants is no better than placebo, or do you mean that, in controlled studies involving depressants, the placebo effect (i.e. the reported improvement in symptoms in the control group) is particularly strong in comparison with studies of other kinds of medication?

  12. Argh. Second paragraph, third line – should say “controlled studies involving antidepressants”. %#&@ Tuesdays!

  13. @Jed

    I don’t see how the fact that randomised controlled trials are a ‘Western’ development is supposed to be relevant; homeopathy is just as much ‘Western’ as randomised controlled trials.

    The proper design of randomised controlled trials is an exacting task, but the findings of properly designed trials of homeopathy are just as reliable as the findings of properly designed trials of anything else.

  14. Do you mean that it’s correct to say that research shows that the performance of antidepressants is no better than placebo,

    That one.

  15. @Sancho

    The proposed mechanism is that the regular assessments used to obtain data in the studies improve reported mental health. That is, talking to a clinician about depression makes people less depressed.

    So in this case the placebo is not actually a placebo, but an alternative treatment.

    But I remain troubled by my personal experience of an SSRI versus some study that shows they are no better than a placebo – or a chat with a psych. The two appear to be in conflict. That is, in my case I’m sure that the SSRI had a positive effect on my ability to cope with life. As I pointed out above, it also had side effects that are definitely not a placebo effect.

    And I need to reconcile the personal with the scientific. How?

    There are many possible explanations. One is that for every positive experience like mine, there is a negative experience. So overall there appears to be no effect. Another is that positive experiences are rare, so that there is insufficient statistical difference between the treated and untreated groups to draw any inference. Another is that people don’t like feeling like failures, so on each testing they try to present as slightly better than on the previous assessment. And of course, it could be that when I started on sertraline, I was just about to get better anyway, so I have misinterpreted my improvement as being due to the drug when it wasn’t.

    Me, I always have doubts about how well studies are conducted, and whether they measured the appropriate things. I think it extremely unlikely that a study contradicting a wealth of anecdotal evidence is correct. And let me say that this is an entirely scientific approach. Bayesian statistics takes ones prior estimate and modifies it based on new data. In this case the prior estimate is based on the huge commercial success of anti-depressants. Basically, doctors think they work, or they wouldn’t prescribe them. Hence my prior is pretty strongly in the “they work” camp.

    Now of course I’m going to head off to confirmation bias, and conclude that the study showing no effect was in some way wrong. But I don’t know that unless I read the study and learn more about how you do these things.

  16. @John Brookes

    To me it looks as if the research reports linked to by other commenters suggest that the effectiveness of antidepressants has been seriously overestimated.

    If this is true, it is important that the overestimate be corrected. However, that’s not the same thing as saying that the actual effectiveness of antidepressants is nil in all cases. If it turned out to be true that antidepressants don’t work nearly as well as supposed, but do still work sometimes, then it would be important to stop giving them to the people they don’t help, but still reasonable to give them to the people they do help. The question would be how to figure out which people those are, but it’s still possible you might be one of them.

    Obviously if the research findings turn out stronger than they seem to me at this stage, indicating that antidepressants don’t work at all, that would be harder to reconcile with your personal evaluation of your own experience.

  17. @J-D

    From the linked study:

    Our findings have several limitations: they are restricted to antidepressants, to industry-sponsored trials registered with the FDA, and to issues of efficacy (as opposed to “real-world” effectiveness33).

    We wish to clarify that nonsignificance in a single trial does not necessarily indicate lack of efficacy. Each drug, when subjected to meta-analysis, was shown to be superior to placebo. On the other hand, the true magnitude of each drug’s superiority to placebo was less than a diligent literature review would indicate.

    So I am somewhat happier, as the study does not show that SSRIs are only as effective as placebos.

  18. So in this case the placebo is not actually a placebo, but an alternative treatment.
    IIRC, the research required weekly check-in with a GP. So not treatment, but regular acknowledgement of depression.

    In this case the prior estimate is based on the huge commercial success of anti-depressants. Basically, doctors think they work, or they wouldn’t prescribe them. Hence my prior is pretty strongly in the “they work” camp.
    Doctors think they often work, and prescribe them because of requirements to provide the most efficient means of treatment, even if it’s not the most effective.

    If a patient demonstrates clear signs of clinical depression to a GP, the GP has a duty to prescribe an antidepressant (in addition to any referral). If the patient suicides two weeks later, the coroner is going to ask why they didn’t receive the cheapest, most widely-available treatment, and the doctor will probably be struck off. Hence, everyone sad gets an SSRI.

    Also, it’s difficult not to sound conspiratorial talking about “big pharma”, but it’s even more difficult to overstate the influence drug companies have on medical and psychiatric treatment in Australia. Policy needs to be based on research, and the drug reps have research coming out the wazoo. They’ve got billions to spend on carefully tailoring studies that endorse their product – and carefully cultivating relationships with policymakers – while every other treatment relies on PhD theses trickling out of universities to shore up findings that are often only reliable longitudinally.

    It simply doesn’t hold up legally if a health service chooses treatment that’s ten times more expensive than pills, with a tenth of the research to back it up. It would turn the health system into a backlogged festival of litigation. Cheap, fast and defensible is key.

    Oh, and the next big thing is using antipsychotics for everything. Over the next couple of years, watch how many people are prescribed quetiapine for anxiety or insomnia or depression. It’ll be the new normal, and it’s driven entirely by the quest for drug sales.

    I wouldn’t claim that antidepressants are useless (interesting essay to the contrary here), but they’re certainly over-prescribed, over-recommended, and contribute to over-medicalisation of the human experience.

  19. Bah! Wrestled with HTML and lost. VBulletin is popular for a reason.

    Easy to see where the quote is meant to end.

  20. Oh, and the next big thing is using antipsychotics for everything. Over the next couple of years, watch how many people are prescribed quetiapine for anxiety or insomnia or depression. It’ll be the new normal, and it’s driven entirely by the quest for drug sales.

    Hasn’t that already happened? This article is from 2013.

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