Prescribing by Numbers: Drugs and the Definition of Disease

Preface

Preface The way to live the longest is to acquire a chronic disease and take good care of it. — sir william osler This week, in clinics and hospitals across the country, thousands of perfectly healthy-feeling adults will receive a diagnosis for a disorder that they did not know they had. There are several such disorders: imperceptible to patients, they produce no fevers, no chills, no headaches, no stomachaches, no pains. Neither are they immediately perceptible to physicians or other health providers ; there is no lesion to be seen with an ophthalmoscope or suspicious sound to be heard with a stethoscope, no tell-tale skin finding or sense to be made from piecing together disparate observations into a cohesive diagnosis. These are diseases that bear no immediate relation to symptoms but rather are connected to a statistical likelihood of developing symptoms in the future, pathologies—such as high blood pressure, mild diabetes, or elevated cholesterol —that are measurable only with the aid of an intervening diagnostic technology. Although patients who receive these diagnoses are typically encouraged to change their diets, get more exercise, and pursue other therapeutic lifestyle changes, for most people these diagnoses lead directly to the prescription of a drug they will take every day for an indefinite period, if not for the rest of their lives. This book is concerned with the modern predicament of the subjectively healthy but highly medicated individual, a type that is becoming more and more common among the adult population of the United States.Americans on average filled ten prescriptions per person in 2003; those over age sixty-five filled an average of twenty-five prescriptions in that year.Dominant in this prescription practice are a set of drugs that modify conditions of risk and also happen to be the top-selling therapeutic agents in the pharmaceutical landscape. The widespread use of such agents supports an industry with worldwide sales rapidly approaching $500 billion and now represents the fastest-growing segment of health care expenditures.Because the preventive efficacy of these drugs has been determined only at the level of the population, individual patients who consume medications for asymptomatic conditions do so without knowing whether they will, in fact, ever receive any benefit from their pharmaceutical regimen. For the many thousands who experience side effects from these medications, the only certain result of their diagnostic and therapeutic experience is, ironically, a set of iatrogenic symptoms. And yet the promotion of this pharmacopoeia of risk reduction is not merely a marketing ploy on the part of drug manufacturers or a bid by physicians for more office visits. Among those lobbying for the broader use of these drugs have been public health advocates, well-respected scientists, eminent clinicians, and many patient-activists and disease communities themselves.Although their actions have contributed to the endorsement of widespread use of prescription drugs, these actors have not all simply been“bought off”by the drug industry. An enormous wealth of data—hundreds of long-term, randomized , placebo-controlled clinical trials representing millions of patientyears —have indicated that for many populations of asymptomatic patients, steady consumption of risk-reducing drugs has generated visible benefits in the prevention of heart disease,stroke,blindness,and renal failure.In the past three decades, as broad guidelines have supported increasing use of such drugs on a preventive basis, the number of actual strokes and heart attacks in the United States has significantly declined. The data behind the doctrine of pharmaceutical prevention are convincing, but the production and dissemination of that medical knowledge and its translation into medical practice is not insulated from the marketplace.In every step of the process we see an amalgamation of marketing and research: in the early stages of drug development, when a promising compound is conceived in terms of its potential market size; in the conduct of clinical trials, whose growviii Preface ing expense and largely private funding makes them increasingly accountable to shareholders as well as to scientists and regulators; and in the process of educating physicians and the public about the expanding use of these medications , which takes place largely through a promotional network of pharmaceutical representatives and direct-to-consumer advertising. In the course of several decades, disease has become simultaneously an epidemiological event and a marketing event. This book follows three overlapping narratives of drugs and diseases to explore the central confluence of...