Medical crystal ball gazing. Reasons to be cheerful in 2020

By Jerome Burne

Just as a major obstacle to tackling climate change is the power and wealth of the energy companies, so a medical system based on keeping people healthy must find ways of reducing the dominance of the drug companies. Sounds impossible but there have been some promising signs.

Drugs are not the best way of treating an ageing population with chronic diseases. They don’t keep people healthy; many are marginally effective, and few tackle the underlying cause. Doctors can only prescribe more and more of them

We obviously need drugs but, they will have to yield space other approaches, involving diet, lifestyle and other non-drug treatments that don’t come at such a financial and physical cost and can keep people healthy.

It’s an unequal struggle but as the 19th century ex-slave and social reformer Frederick Douglass observed ‘power concedes nothing without a demand’ so I’ve been searching for promising demands made the last year that might lead to concessions this year. 

Drugs don’t have to make huge profits

A remarkable proposal showed up in the prestigious New England Journal of Medicine (NEJM) in the summer. It was a brutally simple solution to the problem of antibiotic resistance. Stop relying on drug companies to come up with replacements. Instead, set up a not-for-profit organisation to research and develop them.

As the article explained: ‘We believe the current entrepreneurial development model for antibiotics is broken and needs to be fundamentally transformed.’

Quite. We are running out of antibiotics because companies, have largely stopped researching them. Not because they are not out there, but because they are not profitable enough. The death of millions is not a relevant consideration. A logic the fuel companies understand.  

They have become unprofitable partly because of campaigns to get doctors to dish them out less freely and partly because they are usually effective. Patients generally only need a short course. Both factors cut sales.

Benefitting patients not shareholder value

 As the article explains, non-profit organisations have benefits that go beyond getting us out of a nasty hole: ‘Non-profits don’t face pressure to generate continuous revenue growth to drive up shareholder value.’ The lack of shareholders means they also: ‘face less pressure to increase drug prices and are better positioned to control post-approval antibiotic use.’

 Not-for-profits are also far more flexible. ‘A drug with annual sales of tens of millions of dollars is a catastrophic failure for many (corporations) but would be a lifeline for non-profits which could reinvest revenue …to sustain research and development efforts.’ 

Sounds like the benefits of non-profits should be much more widely applied. Just think of all the other promising treatments that are largely ignored because they are unpatentable and so not profitable enough. The benefits claimed for the non-profit model highlights how little drug development has to do with patient needs.

But the wasteful and damaging need for ever greater profits, which may come to bankrupt the NHS, is not the only reason to be looking for a better model to produce and regulate drugs.

 The bad job drug regulators are doing

All drugs have side-effects but for decades the companies have done their best to play down their scale and severity. The way SSRI anti-depressant manufacturers, for instance, have misled patients and doctors about the risk over the years is shocking and the official regulators have done little to stop it.

 So one of the heartening developments last year were attempts by Citizen Scientist (an idea I set out in a previous blog Citizen researchers: fighting for truth about treatments ) to get regulators to uncover the truth about drug side effects. What they have been uncovering is a reason why we can’t rely on ever more drugs to keep us well.

Twenty years ago, it was BBC’s Panorama program that revealed the truth about SSRI antidepressants. At the time the companies were claiming they were virtually side-effect free and the regulators agreed. The revelations contained in the 2003 program drove the companies to put a new warning on the pill packets. 

These stated that SSRIs could cause pins and needles, burning sensations, apparent electric shocks, feeling nauseous, nervousness, agitation and restlessness. A lot of nasties they had hidden away

How NICE magicked away nasty side effects

Curiously though, at some point in the following years the drug advisory body NICE magicked away those alarming side-effects and officially informed patients that SSRI side-effects were: ‘usually mild and self-limiting over about a week’. 

I don’t know how long patients and their doctors had been badly mislead, but last October the BMJ reported that NICE been forced into a U-turn on SSRI side-effects and was acknowledging they could be: ‘severe and protracted’. This time it was in response to letters and lobbying by a group of radical psychologists and psychiatrists who knew about drugs’ true effects first-hand.

The same group of pro-active professionals, headed by Professor  John Read, a clinical psychologist at the University of East London,  had also been trying to reverse a decision by the drugs watchdog – the MHRA – to licence a new anti-depressant called esKetamine, a variant on a popular street drug, despite poor evidence of effectiveness or safety.

In letters to the Agency, the group had pointed out that most of the trials to test it for safety and efficacy had only lasted four weeks – not nearly long to get an accurate picture. ‘Any apparent benefit is not surprising in the short term,’ says Professor Read. ‘You could get much the same effect from any feel-good drug such as cocaine.’

New depression drug linked raised risk of dying

Even so. the results of the trials were remarkably poor. Despite being run by the manufacturer – Janssen Pharmaceuticals (company-run trials are more likely to be positive) - the majority found it was no more effective than a placebo and came with ‘multiple adverse effects’. This wasn’t that surprising since esketamine behaves like an opioid – becoming gradually less effective with a high risk of addiction. 

The side-effects included six deaths in the drug groups, three of which were suicides, compared with none among those getting a placebo.  Janssen, denies that the drug had anything to do with the deaths. The drug was licenced just before Christmas. 

So not a success but the fact that health professionals are coming together to challenge what seems like unsafe decisions by the regulators is a promising “demand”. It was collective action by doctors, persuaded by the evidence, that has encouraged use of the low carbohydrate diet as a treatment for diabetes. 

Alert readers may have recognised the name Janssen in connection with a far larger failure of regulation, primarily in the States – the massive crisis involving the painkilling drug oxycontin/oxycodone, which has claimed more than 200,000 lives since 1999. The companies had heavily promoted it with untrue claims it was side-effect free.

Oxycontin drug company active in all English hospitals

What’s not so familiar is that Jenssen is active in UK mental health units where it outspends all other companies promoting a long-lasting, heavyweight antipsychotic drug, according to a recent study by Professor Read.   

The details are set out in a report published last August in the journal ‘Ethical Human Psychology and Psychiatry’. This revealed that Janssen had the largest presence in the 52 mental health units in English foundation trusts. And that Janssen psychiatric drug sales accounted for an average of 40% of the total drug bill of those units. 

There’s been a long debate about whether drug companies should be allowed into hospitals to give “further education’ lectures to staff, and Read’s report was unambiguous. It concluded that official bodies ‘should prohibit NHS staff and representatives from receiving any pharma money and bar drug company salespeople from NHS premises.’ Many might think that a company with a record likes Janssen’s should set alarm bells ringing anyway.

How non-drug treatments are marginalised

Having companies constantly on site, giving upbeat accounts of drug benefits, reinforces that idea that non-drug treatments are the poor relatives of real medicine. This includes NICE-recommended treatments such as therapy, social prescribing, or stress reduction. ‘They get pushed to the fringes,’ says one of the authors, clinical psychologist Dr Chris Harrop of the West London NHS Trust. 

‘As a result, over 95% of patients with psychosis, the area I specialise in, are put immediately on drugs. That is absolutely not necessary and very often counterproductive.’

A favourite way of dismissing these non-drug treatments is to claim that their effect relies on the placebo response which, because it has no physical mechanism, can’t be scientific. But this casual lumping of “placebo” with ‘not real’ or quack medicine is going to be hard to maintain following on of the most surprising reports of last year. 

Placebo effect comes in from the cold

This was the finding that when a patient is responding to a placebo – such as being told by a doctor that an inactive pill or injection is going to help reduce your pain – something very obviously physical happens.  It triggers a response in a gene called COMT, which among many other things, is involved in controlling the brain chemical dopamine, and its associated enzyme.

What this means is that there is really no difference between the physical mechanism that explains how a drug works and the action of the placebo response. (Read more)

This new finding opens the possibility that patients could be encouraged to use DIY placebos. ‘Deciding to follow a healthy lifestyle can have much the same effect as a placebo given by a doctor,’ says the head of the team involved, Professor Ted Kaptchuk of the Harvard-affiliated Beth Israel Deaconess Medical Centre in Boston.

‘The rituals of eating right, exercising, practicing yoga, making time for social contacts and meditating can make you feel more comfortable in the world and that can go a long way when it comes to healing.’ These are just the sort of lifestyle practices that the myth of well tested and regulated, is keeping off the table.

So, pharma power could be facing an impressive range of demands this year. That a not-for-profit organisation be set up to get on with developing antibiotics along with properly investigating a variety of other unprofitable but promising treatments. 

Medicine linked with community and climate change

Once pharma’s lock on the profit motive stops being the only yardstick for admitting treatments for investigation, then all sorts of ways of meeting patient’s needs become possible. One is social prescribing, helping with practical or social problems, such as reducing loneliness to improve depression. 

Another is a very promising but ignored (unpatentable) way of slowing or maybe stopping progression to Alzheimer’s with mega doses of vitamin B. This is why Another I’ve written about is the use of old, off-patent drugs with anti-cancer properties. A year’s supply only costs 400 pounds. So, no interest from pharma companies.

But perhaps most radical would be acknowledging that placebos worked by using the same pathways as drugs do and setting up a large not-for-profit institute to test a variety of non-drug treatments. Not against placebos but in ways that maximised the placebo response and then tested maxed placebos against drugs with honest side-effect reporting. 

The College of Medicine is an umbrella organisation for such non-drug treatments and is developing a 360-degree view of the relationship between patients, clinicians and therapists and their environment. Seminars and workshop topics include creating healthy communities, sustainable agriculture and tackling climate change

The College is already pushing to get integrated medicine – combining the pharmaceutical and natural approaches – more widely accepted in the UK. The European Congress for Integrative Medicine (ECIM) is being held in London in September. (Read more)

So, cheer up, the medicine of tomorrow could be kinder, safer and cheaper.

Jerome Burne

Jerome Burne

Jerome Burne is the editor of HealthInsightUK. He is an award-winning journalist who has been specialising in medicine and health for the last 10 years and now works mainly for the Daily Mail. His most recent book “The Hybrid Diet” was written with nutritionist Patrick Holford, published 2018. Award: 2015: Finalist for 'Blogger of the Year' Medical Journalists' Association.

2 Comments

  • Good article Jerome. One can only hope we have now reached ‘peak pharmaceuticals.’

  • Pharmaceuticals a supplements treat symptoms; far better to prevent the cause. In most cased of mental and physical illness, the cause has to do with excessive intakes of polyunsaturated fatty acids; especially the omega-6 family of fat. Here is what some Norwegian animal science researchers tell suggest as a solution. “… an unnaturally high omega-6/omega-3 fatty acid concentration ratio in meat, offal and eggs (because the omega-6/omega-3 ratio of the animal diet is unnaturally high) directly leads to exacerbation of pain conditions, cardiovascular disease and probably most cancers. It should be technologically easy and fairly inexpensive to produce poultry and pork meat with much more long-chain omega-3 fatty acids and less arachidonic acid than now, at the same time as they could also have a similar selenium concentration as is common in marine fish. The health economic benefits of such products for society as a whole must be expected vastly to outweigh the direct costs for the farming sector.” https://lipidworld.biomedcentral.com/articles/10.1186/1476-511X-10-16

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