Medical variation

All healthcare systems and doctors are not created equal

DRUG BUST
by Alan Cassels

Let’s compare doctor A and doctor B.

A 70-year-old man with high blood pressure and high cholesterol goes to see Dr. A. Even though the man is otherwise healthy, Dr. A thinks a few pills might bring down his blood pressure so he prescribes hydrochlorothiazide (a diuretic) and ramipril (an ACE-Inhibitor). He also writes a script for rosuvastatin for the high cholesterol. Because high blood pressure and elevated cholesterol are associated with an increased risk of heart attacks, the doctor is trying to reduce those risks. Later, the patient complains about his aching muscles – possibly caused by the statin – so Doc A also prescribes an anti-inflammatory drug. This man has two ‘conditions’ identified and four drugs recommended.

Imagine, instead, that the same man went to see Dr. B. This doctor doesn’t seem too worried by this patient’s high blood pressure. After all, ‘high-normal’ doesn’t constitute much risk so he tells the man to exercise more and watch how much salt he puts in his food. He jokes that, if his patient got off the couch more often and lost 10 pounds, his blood pressure would probably come back to normal. He also doesn’t think his high cholesterol is worth treating and he tells him not to stop eating the foods he loves just because of cholesterol worries. So with doctor B, the patient walks out of the clinic with the same condition, but no drugs whatsoever.

Of course, the big question we all have is “Does the 70-year-old man with high blood pressure and cholesterol live longer (or better) under doctors who practise like Dr. A or Dr. B?”

This is known as “medical variation,” a very important aspect of the practice of medicine. And it is worth studying if you want to make healthcare safer, of higher value and more effective. Studying the differences between healthcare systems can tell us a lot about whether high-spending areas versus low-spending areas get better or worse outcomes. The most famous of medical variation studies is probably the Dartmouth Atlas, which 20 years ago began looking at the differences in medical variations across the US. It found that although some states spent three times more per capita on certain medical procedures, those patients were no healthier and didn’t live any longer.

Last month, a report entitled “Unnecessary Care in Canada” came out, created by the people at the Canadian Institutes of Health Information and Choosing Wisely Canada. Choosing Wisely is a “national, clinician-led campaign committed to helping patients and clinicians engage in conversations about unnecessary care.” For the last few years, the group has compiled lists from almost every medical speciality on what is considered unnecessary or questionable care. For example, ordering a patient to have a CT scan for a mild head injury or an X-ray for lower back pain are unlikely to produce information of any value and shouldn’t be routinely done. With over 70 specialties producing lists of questionable care (see www.choosingwiselycanada.org), I’d encourage anyone who might be facing a medical procedure or test to see whether it might be considered unnecessary and potentially harmful. It might be too early to say if these lists are affecting the kind of care Canadians are getting, but I’m hoping they are giving ammunition to patients – and a good rationale for doctors – to start asking, “Is that test, drug or procedure really necessary?”

Knowing that unneeded tests or treatments can be harmful and lead to more wasted health care resources, the Choosing Wisely people have also examined the fact of medical variation in Canada.

One example is what is called preoperative testing, the kinds of tests and blood lab work you may be asked to undergo before you have an operation. If you’re asked to take tests, have X-rays or give blood samples before surgery, do they actually make a noticeable difference in the kind of healthcare that results? Choosing Wisely’s report said that one in three patients having eye surgery had a preoperative test in Ontario, yet that rate in Alberta for the same surgery is about one in five. Do patients in Ontario do that much better than patients in Alberta? Not at all.

There are some very good reasons why two different healthcare professionals (or clinics, hospitals or even health systems) treat the same patient in vastly different ways. For one, the doctors may have different training, they may be more or less influenced or aware of evidence-based recommendations or guidelines or they may just be expressing the culture of the clinic or group they work with. Health agencies’ policies, insurance and patient demand all go into determining the rate at which certain tests, treatments or drugs are ordered.

I called up Don Husereau in Ontario – he’s an expert on using and interpreting health research and also a former pharmacist – and asked what he thought about medical variation.

“It sometimes gets abused,” Don tells me. “They find variation and then say it’s just ‘uninformed clinicians’ who are deviating from a ‘gold standard.’ But sometimes there is something not accounted for in the variation. This notion that they are doing it poorly and are not evidence based and that they are ‘stupid’ is an overinterpretation of data.”

He says that, ultimately, “Data sometimes doesn’t tell the whole story.” There may be real differences between patients and he sees this in reference to vascular surgeons he works with. He says, “Some take high risk patients. Some won’t. Some might do more heroic things or seek out the highest risk patients.

“When we looked at the adoption of a new minimally-invasive approach to repairing damaged aortas, it is clear Canadian doctors were less enthusiastic than their US counterparts.” He went on to say, “Canadian doctors used the new approach half as much, were likely less susceptible to promotion and peer pressure and knew there was no clear evidence that either approach was better.”

I agree with Don Husereau that we have to be very careful when we compare doctors or health systems because there may be other factors affecting how much or what kind of medicine is being offered.

For me, a major difference comes down to the patient and their preferences. Even though doctors are trained to encourage “patient empowerment,” they may not have enough time to really probe what it is their patient actually wants. If the doctor feels the patient won’t be satisfied leaving without a script, guess what happens? They’re likely going to get one. Equally true is that if your physician doesn’t think you really want any drugs, she is also likely going to respect that, hopefully explaining the pros and cons of avoiding a new prescription.

So the next time you’re waiting at the doctor’s clinic, take some time to think about variation. Ask yourself if what you’re being offered is due to the doctor, the culture or the rules or regulations of a clinic? And maybe ask yourself what you can do to respectfully present your preferences. Take a look at what Choosing Wisely says about the conditions you’re interested in because those lists will remind you of a very important fact: some of the medical care being offered may not be necessary or perhaps is even harmful and worth asking questions about.

We should expect some degree of variation in the kind of care our doctors and health systems deliver. We can accept that every patient is different.

Whether you go to Doctor A or Doctor B, your job is to learn what you can. Take the effort to make your preferences known –in very clear ways – because at the end of the day, you are the one that has to swallow the medicine.

For you, asking questions and questioning answers are about the most important things you can do to stay healthy.

Alan Cassels is a former drug policy researcher, a writer and the author of several books on the pharmaceutical industry. www.alancassels.com

Which party has your back on health care?

DRUG BUST
by Alan Cassels

There are stark contrasts between the BC Liberals and the NDP

Let us say to the people not ‘How much have you got?’ but ‘How best can we serve you?’
– Dr. Norman Bethune

An election is looming and this may be one of the most crucial turning points in our province’s history. The market for prescription drugs is worth about $4 billion in annual spending in BC, and the way governments set policies around prescription drug approval, coverage and safety are vital to all of our futures. So the question is “Who do you trust?”

Below are six insights I’ve gathered over the last 23 years of watching provincial pharmaceutical policy, under both the NDP and Liberal governments. You may want to think of these when you step into the voting booth on May 9.

1. Evidence: When the NDP formed government in the early ‘90s, it was notable in how quickly they fostered a culture of evidence based policymaking at the Ministry of Health. They established an independent drug watchdog (UBC’s Therapeutics Initiative) and made sure science based decisions were going to undergird provincial drug coverage decisions. When the Liberals took power 16 years ago, they started to erode that base almost immediately, appointing drug industry lobbyists to oversee a panel on Pharmacare reform, sidelining the Therapeutics Initiative and ramping up the pharmaceutical industry’s involvement in drug coverage decisions. The quality of pharmaceutical governance under the BC Liberals, concerning approval, monitoring and safety of prescription drugs, has been an epic failure, and is the best way to explain why BC leads the country in opioid deaths.

2. Lobbying: Under the NDP, you almost never saw drug lobbyists wandering the halls of the Ministry of Health. Back in the ‘90s, the head of Pharmacare forbade his staff from meeting with them. The noticeable absence of pharmaceutical reps in the apparatus of government meant the ministry could get on with its job, unbefuddled by marketing messages and lobbying pressures. What a contrast to today where the BC Liberals have kicked open the door and invited industry officials, their experts and their funded patient reps right into the heart of government. The result? Even though the Liberals spout the aphorisms of evidence based policymaking, we can’t avoid watching a steady stream of often useless and expensive medicines being approved for coverage, and wasteful health spending decisions that may please Big Pharma’s lobbyist donors, but deliver little impact on public health.

3. Drug research: Under the NDP, BC established an internationally recognized cohort of independent drug policy researchers who studied changes in drug coverage policies, such as Reference-Based Pricing, which was responsible for eliminating much waste in the system. We studied the safety of drugs for acne (which cause birth defects), smoking cessation products (which cause psychiatric episodes) and drugs for ADHD (which are inappropriately prescribed), yet the message was loud and clear. The Liberals and their “partners” in the pharmaceutical industry didn’t want any independent research sullying their brands and most of that independent research was killed during the Health Ministry firing scandal in 2012. Meanwhile, millions in funding was ponied up for UBC’s Centre for Drug Research and Development designed to recycle our tax dollars into commercially viable products for private companies.

4. “Patient” groups: From the ‘90s onward, I remember seeing groups, such as the Osteoporosis Society, the BC Alzheimer’s Society and assorted astroturf patient groups, viciously attack the NDP. While patient groups can do good work for the diseases they represent, because so many of them are soaking in Big Pharma funding, they found allies in the Liberals. When the BC Liberals took office and warmly invited these patient groups into consultations and asked for their opinions about the latest pharmaceuticals, they were made to feel special. Sadly, the fine folks at BC Pharmacare who feel they are genuinely working in the public interest have been silently worn down by a steady stream of industry funded opinions and the drug-addled patient groups just make things worse.

5. Transparency: Under NDP premier Mike Harcourt, BC produced “model legislation for access to information,” according to the Vancouver Sun’s Vaughn Palmer. Palmer is certainly one who knows what a farce it is trying to access government documents through Freedom of Information (FOI). Hiding misdeeds from the public has become high art under the Liberals where politicians and bureaucrats routinely omit to write things down, use personal email or cell phones and “triple delete” to avoid anyone learning about government business. This corruption helps to partly explain why drug coverage decisions are often suspect and how the mysterious health firing scandal from 2012 remains the most expensive scandal in the BC Ministry of Health’s history.

BC’s Ombudsman may soon release his report on who called in the drone strike on the Health Ministry, resulting in the firing of eight drug safety researchers and millions of dollars of associated costs. Don’t tell me that the influence of pharmaceutical companies, many of which donate to the political BC Liberal Party, may not have wanted their products independently analyzed by those researchers. One of them, Rod MacIsaac, committed suicide before he could complete a study on Pfizer’s controversial smoking cessation drug. And yes, Pfizer, one of the world’s biggest pharmaceutical companies, has multiple ties to people within the BC Liberals. Quelle surprise!


Jack hirose 3 day mindfulness intensive in Banff


6. Wastebusting: One thing I noticed under the BC NDP’s culture of evidence based drug decision-making was a commitment to reduce waste. Not all new prescription products coming to market (happening all the time) are going to be worthy of coverage. Paying for the most expensive newer medicines, which aren’t any more effective or safer than those currently covered, only benefits the manufacturers. The BC Liberals have eroded this culture of wastebusting, allowing itself to be swindled on million-dollar drug coverage decisions. Is this because they’ve spent too much time cozying up to the drug companies and listening to the entreaties of officials, lobbyists and patient groups? Suffice to say every dollar spent on a useless, unnecessary drug is a dollar that isn’t going to be used where it is actually needed in the healthcare system. The Liberals don’t get this, while the NDP, in my opinion, always did.

Finally, when it comes to elections and political discussion, we all need to talk about what underpins health coverage decisions. Is it the needs of manufacturers and their armies of lobbyists? A conservative estimate would say we waste about $10 billion per year on what are sometimes unnecessary, useless or potentially harmful medicines, diagnostic tests and procedures. Every single person working in the health system has seen this shameful waste, yet the independent analysis and research needed to keep people from taking harmful drugs or useless tests no longer exists under the Liberals.

If a new government were to start by eliminating the pharmaceutical corruption of our health decision making, we’d be able to spend millions more on what is actually needed: more affordable drugs, better care for seniors, thorough homecare, manageable childcare and getting serious about affordable housing in BC. Let’s be clear, Alan Cassels is not about sticking it to the pharmaceutical industry. I’m about defeating waste because much of the money we send to the drug companies isn’t being used where it needs to be.

The BC Liberals have, for the last 16 years, shown their capacity to be tainted by drug industry messages, lobbyists and donations. At the end of the day, we need clean, clear health decisions as urgently as we need clean, clear water.

That’s what I think, but what do you think? Visit my website www.alancassels.com and answer my survey. Or tweet me at @AKECassels and put this in the tweet: #healthcarewastebusting Tell me what we need to do to make BC’s drug coverage affordable and appropriate. We need a dialogue on avoiding waste and I need your voices.

Eating our way to better mental health

Science shows we can

DRUG BUST
by Alan Cassels

Let food be thy medicine and medicine be thy food. – Hippocrates

There are very few golden bullets in medicine, very few. But some pharmaceuticals are extremely useful, especially if you’ve got type 1 diabetes, heart disease, severe pain or asthma. Then your drugs may be saving your life.

But, as I’ve said before, the problem with an overly drug-centric approach to healthcare is that it relentlessly eclipses other options. Much of our medical care is underpinned by research dominated by drug makers with the resources to conduct large, randomized, controlled trials. We need those studies, but we find the treatments that do not fit the profit paradigm are starved for respect and research funds, meaning the bias deepens and we end up with the kind of health care that society has decided to pay for.

Particularly problematic in our pharma-centric world are psychiatric treatments, often studied in questionable trials for short periods of time on people with indeterminate diagnoses. They are then used incredibly liberally even when evidence emerges, as it has with antidepressants and antipsychotics, that many people are being hurt by them.

Increasingly, even though society is swallowing growing amounts of drugs for such conditions as anxiety, depression, ADHD, mood and anxiety disorders, the prevalence of those disorders continues to climb. Where is the kid asking why the Emperor is naked? If we’re spending so much more every year on drugs for psychiatric illness, why aren’t the rates of mental illness dropping? Something is wrong here.

I think about this in the context of some friends of mine. They are having a terrible time with their daughter, who is so anxious she can’t go to school. I’m not sure what’s going on, but it appears she’s in a real rough space. She’s been taken to the hospital on numerous occasions and there have been several attempts to get her to see a child psychiatrist. She hasn’t been prescribed any drugs yet, but I’m pretty sure that when she finally gets in to see the psychiatrist, she’ll begin her entrée into the world of psychiatric drugs.

This is the standard road travelled by many people who are depressed, anxious, sleepless or hyperactive, yet there may be other options worth exploring. Certainly, cognitive behavioural therapy (‘talk’ therapy) and exercise come to mind. We’re also witnessing the growing area in the use of micronutrients – the essential minerals and vitamins we consume in our food and its importance to our mental health.

Bonnie Kaplan, an emeritus professor at the University of Calgary, has spent much of her professional life studying micronutrients, particularly in the context of mental health. The body and brain require a fairly large array of vitamins, minerals and essential fatty acids and when we have deficits it’s possible our brains suffer even more than our bodies. In our phone conversation, Bonnie tells me, “This is all about nutrition above the neck. The brain is the biggest consumer of nutrients.”

Because people have genetic differences, respond to stress differently and, hence, have different micronutrient needs, it is plausible that many of us could have nutrient deficiencies that affect our mood. We have to remember that nutrients are involved in every biologic, chemical and physiologic process.

“There are 50 known genetic mutations in the realm of physical health, where an alteration in the ability of enzymes to grab and hold the nutrients that they need for optimal metabolism is impaired. They need extra nutrients to make the pathways work,” Bonnie says.

She brims with enthusiasm noting there are somewhere in the neighbourhood of 45 clinical trials testing micronutrients in a variety of mental health conditions, including insomnia, ADHD, psychotic disorders, mood and anxiety. And she’s seen the greatest benefits using them to treat irritability, mood dysregulation, bipolar-type symptoms and explosive rage.

As an example of the kind of research out there, she describes an “amazing study from Spain,” best known for studying links between nutrition and cardiovascular disease, but which has also evaluated links to mental health. The researchers took about 9,000 people with no mental disorders and looked closely at what they ate, quantifying their intake of prepared pastries, processed foods and other forms of junk food. They divided the participants into three groups, depending on their consumption of processed foods, and waited about six years to find out who would be diagnosed with a mood or anxiety disorder.

“Those in the study who consumed the least processed food had a very low probability of developing mood and anxiety disorders. The group in the middle were generally ok, too,” Bonnie told me. “But those with the highest intake of processed foods were at high risk of becoming depressed or anxious.”

Bonnie is well aware of the difficulty this research has in making any inroads in the pharma-dominated world of psychiatry. Whether it is Omega-3s, vitamin D or calcium, so much research energy is put into studying single nutrients at a time. Many times she has seen researchers unable to get funding to study broad-spectrum micronutrients because of the central research tendency – and perhaps human nature – to want to find a single magic bullet. One reviewer asked, while looking down the list of 40 or so micronutrients in a nutritional formula proposed for a study, “Which is the important one?”

“They’re all important!” Bonnie exclaims. There is a strong rationale for studying a large batch of micronutrients together, which comes in a ‘broad spectrum formula,’ because the body requires all kinds of vitamins and minerals to work properly.

Another surprising finding came from a study in adults with psychotic disorders. Everyone was initially given a broad-spectrum micronutrient supplement. After a month, they were supposed to be randomized to receive either the supplement or a placebo in a blinded fashion. The wheels fell off the study when the patients refused to be randomized because they didn’t want to take a chance in giving up the formula. If the study participants themselves are that adamant about the effectiveness of the formula, there is probably something there!

There are a number of companies that produce broad-spectrum formulas containing vitamins, minerals and antioxidants and one might wonder how much bias seeps into this research, as we see in the pharmaceutical world, when the manufacturer pays for the research, gives out research grants and otherwise shapes the research in ways that support its product?

Having witnessed the intertwining of the pharmaceutical industry and the mental health world, and the resulting corruption of the mental health scientific literature, Kaplan and her colleagues have insisted on putting a firewall between the manufacturers and the research: they won’t accept research money from those making micronutrient formulas.

Researchers like Bonnie Kaplan are doing exactly the type of research the world needs more of. Most probably, there is a great link between nutrition and mental health. The way we currently treat mental illness needs a complete rethink and it must include better research and a better use of a range of treatments – even things we eat.

Kaplan sees the huge price governments and individuals are currently paying for the relatively ineffective pharmaceutical model of psychiatric care. They need to know that micronutrients, while no magic bullet, could be a very effective and safe way to help many people with mental health challenges. In two published studies, they have shown that micronutrient treatment was not only more effective, but it also cost less than10% of conventional care. It seems that governments could save a bundle if they helped contribute to the research and the treatments.

Kaplan has established two donor-advised charitable funds and has already raised over half a million dollars to support the clinical trials of junior colleagues around the world who are passionate about studying the use of nutrition for mental health. Contact her at kaplan@ucalgary.ca or donate directly to this kind of research through the Calgary Foundation.

Alan Cassels is a former drug policy researcher, a writer and the author of several books on the pharmaceutical industry.

Getting to the bottom of the opioid crisis

It starts by looking at prescribing practices

DRUG BUST
by Alan Cassels

More than a decade ago, UBC’s Therapeutics Initiative (TI) published a very alarming newsletter. It made virtually no waves at the time, but it struck me as a dire prediction of the state of prescribing in British Columbia.

The newsletter simply asked two questions about benzodiazepine use in BC. This class of drugs include products like Ativan and Valium ­– or generic drugs that end in ‘pam’ – and zopiclone and are typically prescribed for anxiety and insomnia. The TI asked how many people in BC were using benzos and of those, how many were using them contrary to recommendations?

As prescription drugs go, benzos are widely, widely used even though they are recommended only for “short-term” use, typically less than 14 days. The benzos are not supposed to be taken over the long term because they are considered highly “habit forming,” the euphemistic way of saying they can be addictive. Once you take them for too long, stopping can be hell and those who try to quit abruptly will face withdrawal symptoms so bad they’ll just go back on the drug.

Over time, benzodiazepines lose their effectiveness, yet there is good evidence that when a patient becomes tolerant, the doctor may just increase the dose. Long-term use of the drugs can cause learning, memory and attention problems and their use is linked to falls, injuries, hip fractures and other types of accidents. The other important thing is that the benzos are frequently found on the street and up to 80% of street drug users are also taking benzos.

The TI’s analysis found that nearly 10% of the BC population – about 400,000 people at the time – used benzos (based on 2002 data) and of those, 170,000 people received amounts “incompatible with short-term or intermittent use.” In other words, almost 5% of the BC population were essentially at risk of being physically dependent on a drug they got from a prescription pad.

The current opioid crisis seems a modern version of the same phenomenon replaying itself, but this time the stakes are much, much higher. Even though we have some of the best monitoring systems in the country – e.g. BC PharmaNet, a computerized, province-wide drug data system – it doesn’t stop dangerously poor prescribing and poor monitoring by those whose job it is to protect patients: the BC College of Physicians and Surgeons.

Searching for insight into BC’s current opioid crisis, I came across a 2015 report titled “Together We Can Do This,” written by a panel of 73 experts in addiction medicine and pharmaceutical policy in BC. It helpfully maps out why BC broke all records in overdose deaths last year (914) and why, unless there is drastic action to improve prescribing, people in this province will continue to die from overdoses in massive rates. These experts lay out a series of strategies to address BC’s opioid addiction, an urgent cause given we’ve got among the highest overdose-related death rates in the world.

The report noted BC “dispenses more than double the amount of opioids compared to Quebec, the lowest opioid dispensing province. Additionally, from 2005 to 2011, the rate of dispensing strong opioids in BC increased by almost 50% overall, including a 135% increase in oxycodone dispensation.”

Now, with thousands of addicts in BC and daily reports of new deaths, there is a lot of pre-election interest on the part of the reigning BC Liberals, as money is doled out for safe injection sites, naloxone kits – the drug to revive a person who is overdosing – and increasing the training of emergency personnel. BC’s provincial health officer is talking about “clean heroin” and giving addicts provincially subsidized opioids, yet all this energy trying to clean up the damage misses the point that it was mostly created in the first place by poor prescribing and poor drug policies.

That’s the view of this expert panel, which concluded, “Despite the scale of the present public health problem, strategies to meaningfully address unsafe prescribing have not been implemented.” They add that many people who are addicted to heroin or other intravenous drugs started out with pharmaceutical opioids and “ultimately, prescribers are largely responsible for the burgeoning illicit market in pharmaceutical opioids that has developed on the streets of BC.” And here’s the kicker: “The entry of organized crime groups into the manufacturing of counterfeit pharmaceutical opioids, which often contain fentanyl, to fuel the street market for illicit or diverted opioids is arguably a direct result of long-standing, unsafe physician prescribing practices.”

Added all together, the crisis is a political and medical boondoggle. Like the dangerous abundance of benzodiazepine use in BC the TI documented a decade ago, we are seeing the same sort of lax approach to prescribing around the opioids. The headlines may focus on the illicit fentanyl-spiked drugs killing citizens at astonishing rates, but the real story is in the high rate of opioid abuse and addiction happening in the wider BC population. In the wider pool of opioid addicts are our friends and neighbours who have thousands of prescription pills, including Dilaudid, Oxycontin, morphine, T-3s and many other opioid pills, sitting in their medicine cabinets, leaving them and other family members who might want to experiment open to abuse.

In my small circle of friends, I know of at least two men who had hip surgery last year and both were discharged with scripts of 100 pills of Oxycontin, enough to turn both of those men into addicts. I know teenagers who were given Oxycontin following wisdom teeth extraction. And another friend, a very successful professional, came within inches of being addicted to the painkillers he was prescribed for a lower back problem.

What can we do if those prescribing the opioids simply don’t know the potential harm they could be causing? It has been well documented that our physicians’ dependence on weapons-grade opioids has been shaped by the drug industry. In the mid-1990s, Purdue Pharma, the makers of Oxycontin, spent millions underwriting Canada’s pain guidelines, paying “key opinion leaders” in the physician community to downplay the dangers of opioids and infiltrating medical school textbooks and medical schools, teaching our young doctors about managing pain. Opioids are very effective for pain, but for many people, there are many cheaper, safer, simpler and far less addictive medicines that can effectively treat pain instead of the expensive patented opioids pushed by their makers.

To my mind, the biggest scandal is that physicians continue to allow themselves to listen to pharmaceutical industry messages and to be educated by the drug salesmen and tainted experts. Many doctors won’t be schmoozed by drug reps, but others don’t see a problem. Hence, this is not the last prescribing disaster we will have to deal with.

I wish I could say the BC Liberals are doing all the right things, carefully monitoring prescribing and using their considerable clout through PharmaCare to stop this carnage. But they’re not. Beholden to pharma’s donations, they act as if powerless to stop the flow of prescribed opioids. We used to have programs in place that monitored prescribing, but there has been no political will to restart them. BC PharmaCare no longer takes advice from the Therapeutics Initiative and we’ve seen the slow death of drug safety evaluations in BC since the 2012 Ministry of Health firing scandal.

The BC College of Physicians and Surgeons will pretend to be tough with new guidelines and try to crack the whip on flagrantly bad opioid prescribing, but it may just drive even more people to the street to find the pain relievers they’ve become addicted to.

We’ve got many reasons to vote in a new government in May. Our spectacular rate of overdose deaths continues to climb. It is a national shame that deserves local blame. Christy Clark’s government’s addiction to donor dollars continues to make us a laughingstock of the world and the only ones not laughing are the dead, the dying and the addicted.

Alan Cassels is an author and drug policy researcher in Victoria.

Billions wasted on cholesterol myth

DRUG BUST
by Alan Cassels

The alleged benefits of lowering our cholesterol have never materialized and we have wasted tens of billions of dollars over the last two decades, deluded by a myth. It’s time to drop that myth.

Though it may appear to my readers that I have cried wolf far too often on cholesterol-lowering drugs, I’m prepared to howl at the moon at least one more time. If you’ve read my columns over the last decade, you’ve seen me rant about the futility and absolute waste involved in our society’s collective obsession with cholesterol and our foolishness in swallowing a paradigm promoted by the pharmaceutical industry and the specialists in their employ. The alleged benefits of lowering our cholesterol have never materialized and we have wasted tens of billions of dollars over the last two decades, deluded by a myth. It’s time to drop that myth.

Ever since the early 1990s when the first cholesterol lowering drugs were being introduced to the market, no one had really ever heard of “high cholesterol” and certainly no one was going to their doctor just to get something checked that they never knew existed, that they couldn’t feel and which was responsible for zero symptoms. Then along came the blockbuster statins and physicians followed guidelines that told them a patient’s cholesterol level was an important risk factor for death by coronary heart disease (CHD). The hypothesis said that if you measured and lowered the cholesterol of patients deemed “high risk,” those patients would live longer and avoid dying from heart attacks. So how’s that working out?

Not so well, according to a study published in March of this year that probably delivered some of the boldest evidence yet and which should absolutely trash our enthusiasm for lowering our cholesterol. A European research team led by Dr. Federico Vancheri of Italy looked at statin consumption across 12 countries in western Europe between the years 2000 and 2012. During that time, the use of statins increased dramatically all across Europe – as well as in North America – yet his team wanted to know how this increase was reflected in the numbers of people who died of heart attacks. After all, with statins being used by tens of millions of patients, how many fewer heart attack deaths were there?

Here’s the good news: in all countries over that 12 year period, there was lower CHD mortality in 2012 compared to 2000; that is to say, fewer deaths by heart attack. The drop in those numbers is thought to be attributed to a range of things: healthier diets, more exercise, lower rates of smoking, better treatment once you had established heart disease, and so on.

However, things didn’t look so good when you looked at individual countries. The researchers found that “when the different countries were compared, there was no evidence that higher statin utilization was associated with lower CHD mortality, nor was there evidence that a high increase in statin utilization between 2000 and 2012 was related to a larger reduction in CHD mortality.” In other words, despite all the statin prescribing, it had no effect on the one thing we expected to see: lower rates of heart attacks. This kind of research is not exactly new. There was an earlier Swedish study that showed the differences in a large sample of municipalities where the amount of statin prescribing had zero effect on the rate of heart attacks or CHD death.

Despite this kind of bad news for the statin manufacturers, the world is not exactly mourning the loss of a very costly – and now proven wastefully ineffective – pill. Just last month, many of us watched in horror as we witnessed a high-quality source of health information – the US Preventive Services Task Force (USPSTF) – come out with the astonishing recommendation that statins should be used by even more of us.

In their analysis, the USPSTF amassed a massive amount of data from over 70,000 patients from 19 different trials. They wrote that low-to-moderate-dose statins should be given to “adults aged 40 to 75 years without a history of cardiovascular disease (CVD), who have one or more CVD risk factors and a calculated 10-year CVD event risk of 10% or greater.” Practically speaking, this means tens of millions more Americans were offered statins.

Sounds good, right? Not so fast. Remember, the people they are recommending take statins are basically healthy, middle-aged people, folks with no established heart disease, 90% of whom will live perfectly happily without a heart attack or stroke over the next 10 years. These are NOT sick people perched on death’s doorstep.

So, what’s up? It always surprises me when an otherwise reputable and trustworthy source gives absurd advice, especially given all the statin scandals and shenanigans we’ve seen over the last two decades.

In case you don’t believe me, here are some key reasons we should ignore the advice to give more statins to more people, as the task force recommended. I must acknowledge Drs. Rita Redberg and Mitchell Katz who wrote a scintillating editorial on this USPSTF recommendation and whose arguments I am partially summarizing here.

The first thing to know is that the body of studies examined by the USPSTF is tainted, as it included many people taking statins for ‘secondary’ prevention – for example, people with established heart disease and hence considered at much higher risk. You cannot extrapolate how they fared on statins to healthier people without established heart disease.

The second thing is that the evidence they looked at didn’t contain the kind of detail we need. The USPSTF didn’t examine what we call primary data, which are the actual reports from the subjects in the statin trials. Without actual patient reports, we’re only getting the results of what someone has chosen to summarize for us. Sorry, that isn’t good enough. Also, if you only examined the published reports of statins, you are being naive because we know that most of the trials on statins were done by the manufacturers and they have a tendency to bury negative data. The result? An overly rosy picture of the effects of statins.

Thirdly, there was a major bit of missing information in those data, specifically what we call “all-cause mortality.” Only half of the trials they looked at reported how many patients died from cardiovascular causes, heart attacks and strokes. The problem with missing data is you are only getting half the picture so you end up concluding the drugs are safer than they actually are. You wouldn’t conclude how rich you are by only looking at your assets, would you? No, of course not. You need to know your liabilities and debts as well. Same with statins. Without both sides of the equation, you are at risk of being misled.

We need to remind ourselves of one key thing: people of ‘low risk’ may have very little chance of benefiting from a statin, but will have an equal chance of harm. In this group of healthy, low-risk people recommended to take statins, the benefit/harm math shifts and they are more likely to be hurt than helped.

Overall, the danger of recommendations like these is that more people will be convinced they are at high risk when they aren’t and take a drug that is unlikely to help because it is only proven to help those with established heart disease. We have known for a long time that statins can cause muscle aches, weakness, fatigue, cognitive dysfunction and an increased risk of diabetes. Why would you want to take your chances?

Maybe all the statin denialism is just part of the post-truth world and people tend to believe what they want to believe despite the overwhelming evidence in the other direction. Are you a ‘low-risk’ person who still wants to take a statin? Then you should have to pay for your denialism.

Statins are currently the fourth most costly drug to BC’s Pharmacare budget, and with over 400,000 British Columbians consuming statins every day, costing taxpayers and patients about $100 million per year, couldn’t we just admit the experiment is over, it was a failure and it’s time to move on?

Alan Cassels is a drug policy researcher and writer. In each of his past four books, the latest which is called The Cochrane Collaboration: Medicine’s Best Kept Secret, he has written about statins. Follow him on twitter @AkeCassels www.alancassels.com

The looming epidemic of overdiagnosis

Where are the leaders in eliminating waste in health system spending?

DRUG BUST
by Alan Cassels

Lately, I’ve got overdiagnosis on my mind.

Currently, we’re living through a perceived doctor shortage in BC, a crisis affecting as many as 600,000 British Columbians. In 2010, the governing BC Liberals promised that, within five years, everyone in BC who needed a family doc would get one. They even made this promise part of electioneering in 2013. How’s that plan worked out?

Well, it hasn’t. A few people may have been helped by a dating service set up to connect doctors and patients, but it was universally considered a bust. Despite promised government fixes, we have about 100,000 more people today without a doc they can call their own than we did five years ago. In early 2015, the government basically acknowledged it was a failure.

Read more

Leave our prostates alone

Healthcare must engage in a wider discussion about preventive medicine

DRUG BUST
by Alan Cassels

• “Preventive medicine displays all three elements of arrogance…Aggressively assertive…Presumptuous…Overbearing.”

Dr. David Sackett wrote those words over a decade ago in a neat little column in the Canadian Medical Association Journal. He was, in this case, talking about hormone replacement therapy, after the publication of one of the world’s largest studies in preventive healthcare. The results of the Women’s Health Initiative showed that giving estrogen and progestin to healthy women going through menopause, on the assumption that this was vital preventive medicine, did not protect them from cardiovascular disease. In fact, it increased rates of some forms of cancer, heart attacks, blood clots and strokes. In trying to preserve and protect health, the recommended therapies were harming women. On a massive scale, I should add.

Read more

Hoodwinked by the diabetes industry

Drugs to lower blood sugars don’t do much for your health

DRUG BUST by Alan Cassels

 

Portrait of columnist Alan Cassels• In the last five years in British Columbia, taxpayers – that would be you and I – spent over $100 million on drugs and insulins for type-2 diabetes through our Pharmacare program. In addition, people in BC probably spent another $200 million out of their own pockets and the pockets of our employer-sponsored drug plans on diabetes treatments. Add to that the costs of all the doctor’s visits and the diabetes paraphernalia – including glucose test strips, lab tests and so on to keep blood sugars monitored – and two things are clear: this is one expensive disease and it creates a huge amount of medical busywork.

Maybe the hundreds of millions of dollars we’re spending on diabetes measurements and treatments is well spent. Surely, it would be if we could be sure people are getting the drugs they need so they don’t suffer heart attacks and strokes and the more serious complications of diabetes. But can we be sure of that? Hmm, probably not.

There is one particularly strong theme you’ll hear when doctors discuss diabetes: that if you have it, you are increasing your cardiovascular risk, for example, your risk of a heart attack and stroke, both which could be fatal. People with type-2 diabetes have difficulty processing sugar, a condition that is described in guidelines as a “complex chronic disease characterized by hyperglycemia due to defective insulin secretion, defective insulin action or both.” Insulin is produced by the pancreas and regulates both the breakdown and movement of glucose, which is critical to maintaining blood sugar levels within normal ranges. The good thing is if you’ve got too much sugar floating around in your bloodstream, there are many drugs to lower those sugars.

But if you read no further in this column, here’s the punch line: Most of the money we spend in this province on drugs to reduce blood sugars in type-2 diabetics achieves almost nothing. While the drugs can be extremely effective at lowering blood sugars – and so it appears they are doing something useful – they will do almost nothing at lowering serious health risks, such your chances of a cardiovascular event like a heart attack or stroke.

Don’t believe me? The latest newsletter put out by the Therapeutics Initiative at UBC, which assesses clinical studies of drugs, concluded, “Glucose lowering medications for people with type 2-diabetes are widely prescribed in Canada despite having been approved by Health Canada without credible evidence that they reduce mortality or major morbidity.”

The newsletter says a little bit more, but let’s consider the implications of this statement for the average person. A man named John is in his mid 70s and has lived all his life without any consideration that he may be ill. He has no symptoms, but after being sent for a routine blood test he is told he is now a diabetic and needs to take drugs and maybe insulins to control his disease. More specifically, he is told he has a “high” reading on his hemoglobin A1c test, (HbA1c), also known as a glycosylated hemoglobin test. This is a marker of how well one’s blood sugar has been controlled during the previous two to three months. If it is much higher than ‘normal’ the doctor will look for any signs of kidney or eye damage or damage to blood vessels in the legs, all of which are considered “microvascular complications” that are linked to diabetes. The next step is he’s put on a drug called metformin. This is how things usually roll.

In BC, the government sponsored diabetes care guidelines say that any hemoglobin A1c greater than 6.5% constitutes a diagnosis of type-2 diabetes. Most experts say that 7 percent is the magic threshold and keeping the HbA1c level below 7 percent will lead to fewer diabetes complications (eye or kidney disease). But again, this is controversial. Even Consumer Reports on Health in the US says there is no definitive proof that keeping HbA1c under 7 percent prevents heart disease or premature death and they remind us that most of the studies of HbA1c are short, a year or less. The upshot? Who knows what the long-term effects of driving blood sugars down below this level are?

But we push on. Why? Because John’s HbA1c is closer to 8.5 and the guidelines say it should be 6.5. The standard advice for anyone identified as having a “high” HbA1c level is to lose weight and control one’s blood sugars through diet and exercise. Controlling one’s diet – especially cutting back on carbohydrates – and getting more exercise can be the closest thing to a cure and the good news is you don’t have to be a marathon runner to get adequate exercise. In fact, daily walking is enough for many people to stave off diabetes, push their HbA1c down and avoid the worst complications of the disease.

Have you ever noticed how much activity there is around a disease if the drug industry can produce profitable products that appear to do something for it and can be sold for daily use over the long term? Well, type-2 diabetes is the poster-child for a drug-friendly disease, and you can imagine the absolute cornucopia of drug treatments for type-2 diabetics that are out there.

Diabetes is the marketer’s ideal condition as it allows a lot of profitable busywork around measuring blood sugar levels, altering those levels with drugs, and measuring again. Trying to get your blood sugars down to 7 or 6.5 percent makes for very good activity to distract people from the fact the drugs are doing almost nothing to alter the underlying course of the person’s diabetes.

Like most newly diagnosed type-2 diabetics, John first gets prescribed two of the oldest and cheapest drugs, metformin and glyburide. The real big money for the drug companies, however, comes from the newer treatments, including more than a dozen on-patent and much more expensive drugs that lower blood glucose. These include the Gliptins: sitagliptin (Januvia), saxagliptin (Onglyza), linagliptin (Trajenta), alogliptin (Nesina); the Tides: exenatide (Byetta), liraglutide (Victoza), albiglutide (Eperzan) and dulaglutide (Trulicity); and the Flozins: canagliflozin (Invokana), dapagliflozin (Forxiga) and empagliflozin (Jardiance).

Collectively, Canadians spend nearly $750 million per year on prescription drugs that lower glucose, an amount that works out to about 628 prescriptions per 1,000 people, about the same volume we consume in antibiotics. But how many drugs does one need to get those numbers down? In BC, about 100,000 people take a single drug (mostly metformin) every day to lower their blood glucose. But it doesn’t stop there. Nearly 65,000 BC residents take two or more diabetes drugs and nearly 30,000 take three or more.

A 2013 review from the Cochrane Collaboration found that ‘intensive glycemic control’ – trying to keep the HbA1c at or below the 7 percent mark – did not reduce rates of cardiovascular death, non-fatal stroke and end-stage kidney disease. What was cruelly ironic in that study – a meta-analysis of nearly 30 studies on the same question – is that patients who were subjected to intensive glycemic control had more serious adverse events, including severe hypoglycemia (which often ended in hospitalization). In other words, the taking of multiple drugs to drive one’s blood sugars lower and lower seems to be a fool’s game.

Who stands to benefit from the war on glucose? Just follow the money, I say. Driving for lower and lower blood sugars is big money in Canada. In BC alone we spend hundreds of millions of dollars chasing blood sugars into absurd territory. We allow the pharmaceutical companies to write the guidelines and our own doctors to be ‘educated’ about those pharma-funded guidelines.

Hoodwinked by the diabetes industry, we spend, as a society, tons of money treating this so-called risk factor called hemoglobin A1c, yet all that money does almost nothing to save lives or help people live longer. We should be spending healthcare dollars that purchase health. This diabetes scam just gives more profits to the drug companies while giving us nothing in return.

Alan Cassels lives in Victoria where he studies and writes about the pharmaceutical industry, disease mongering and overdiagnosis. His latest book is The Cochrane Collaboration: Medicine’s Best Kept Secret.

The growing backlash against medical guidelines

Doctors need to “show more spine”

DRUG BUST by Alan Cassels

 

PhotoHeadshotAlanCassels

• The disease-creation machine continues to creep forward, threatening to consume even more of us healthy people. Consider these recent news items:

– Americans, we are told, are facing an epidemic of heart disease. New cholesterol guidelines suggest that virtually the entire elderly population of Americans are “at risk” of having a heart attack and hence even more of them should consider taking cholesterol-lowering statins.

– Norwegians, among the healthiest people in the world, are also, apparently, facing an epidemic of cardiovascular disease. A recent European guideline suggested most Norwegians over 25 would be defined as ‘high risk’ of cardiovascular disease. If Norway were to take this guideline seriously, it would drain the country’s entire primary health care budget.

– Americans, the experts tell us, are suffering an epidemic of osteoporosis. A new US osteoporosis guideline says that 72% of women over 65 are considered ‘diseased’ – a number which rises to 93% for those over 75 years old – and hence in need of drug therapy.

What is going on here?

Clearly, the only real ‘epidemic’ is the growing phenomenon where risks for disease are being turned into diseases, in and of themselves. In this racket, ‘high’ blood pressure, elevated cholesterol, low bone density, fluctuating blood sugars, high eyeball pressure and low testosterone, among other things, become worrying signs of chronic, lifelong conditions that demand attention and medication. As I’ve said in the past, “If you want to know why pharma is increasingly targeting healthy people with ‘preventive medicine,’ it’s because that’s where the money is.”

One thing all these risks-as-disease models have in common is they are shaped and supported by clinical practice guidelines. In these guidelines, doctors are told to measure their patients’ parameters. If your measurements are outside some preset levels deemed ‘high risk’ by the expert guidelines, you know what that means: more frequent trips to the pharmacy. The main downside of guidelines is they slap labels on people who aren’t sick and instill in physicians the constant idea their healthy patients are really disease-ridden.

But this is a good news story and if you haven’t sensed it, there’s a rising backlash against medical guidelines, mostly led by doctors, researchers and even some patients outraged at what they see going on. These rebels have a right to be angry because the guideline-writing process is highly flawed and biased, created mostly by experts who see particular body parts in isolation – as if you were nothing but a hip, a liver or a pancreas. The guidelines are foisted on our doctors and treated as inviolable even though they are frequently corrupted by conflicts of interest so deep it’s no surprise they are at the heart of pharma’s marketing apparatus. Seems to me the only ones who like guidelines are the drug companies that fund them and the experts that participate in writing them.

Certainly, our family doctors have many types of illnesses to deal with and staying on top of changes in recommended treatments is difficult. Some guidance is clearly valuable if it helps inform doctors on new and better ways to treat people, but if we allow guidelines to widen disease definitions and dictate what patients must do to avoid potential future illnesses, we are in big trouble.

A colleague of mine at UBC, James McCormack, has a good eye for when disease definitions are being widened, and he tells me many guidelines are not a useful synopsis of the best available evidence. He says they rarely consider the most important thing: the preferences of the patient. I’ve often heard him ranting about guidelines in lectures, yet he has recently taken his rants to the next level – creating a music video (Google: James McCormack and The End of Guidelines) – which will leave you with little doubt as to what he and many of his colleagues around the world think of the present state of guidelines.

James likes to say guidelines are “thresholds for treatment” when what they need to be are “thresholds for discussion.” In other words, if a guideline is suggesting treating a person for a certain set of risk factors, this should be a signal for the doctor and the patient to start discussing those risks and the likelihood medications could help (what they call “shared decision-making”).

If you are told you have ‘risk factors’ for a future bad thing like a broken bone or a heart attack, you need to understand the magnitude of the risks. If I have a two percent chance of having a heart attack in the next ten years, that’s a very different picture than if the doctor tells me I have a 30 percent chance. And such information is vital because once understanding the risk, the next important thing is that the doctor and patient need to know how much a ‘guideline-recommended’ drug is likely to reduce those risks or potentially harm you. And you can then decide if it’s worth trying the drug, paying for it, and possibly facing annoying side effects.

A big part of the problem with guidelines is they exploit ambiguous definitions of disease. In the osteoporosis world, there are myriad different ways “vertebral fractures” are defined. These tiny cracks in the spine that tend to occur – mostly as people age and typically aren’t even felt – can be discovered on x-ray. But once discovered, does that mean you have to start taking a drug for the rest of your life?

Here’s how this maps out: If you take 100 asymptomatic older people (i.e. those who don’t have any pain or other symptoms related to their bones) and then x-ray all their spines, depending on what criteria you use, either three or 90 of them will be defined as having a “fracture.”

Osteoporosis guidelines – written mostly by experts with ties to osteoporosis drug makers – basically assert that if you discover one fracture, the goal becomes to avoid a second one (what they call ‘secondary prevention’). So if you x-ray Grandma’s spine – she had no idea she had these age-related vertebral fractures – you’re likely to make her worry and you start feeding her osteoporosis drugs. The guideline says, “A vertebral compression fracture signals a patient at high risk of subsequent fractures who should be managed appropriately. Vertebral fractures have debilitating consequences and even increase the risk of death.”

Since Grandma is old, she’s already at an ‘increased’ risk of death so labelling her as having a ‘high risk’ of a future fracture is just a label to get her to start swallowing more drugs. What makes this such a scam is that the bone-targeting drugs she’ll get prescribed won’t do anything to make her feel better or live any longer. This is so wasteful and so wrong on so many levels.

Among those riding a wave of rebellion against osteoporosis guidelines are a group of orthopedic surgeons in Helsinki who believe it’s time take a stand against crazy guidelines, and they want to start a conversation in the medical community. Since the definition of ‘vertebral fracture’ is being exploited, they say family doctors should stand tall and #show some spine on how vertebral fractures are defined. Not only do they want guideline writers to stop recommending stupid things based on shaky definitions, they want doctors to talk to their patients about so-called under-recognized, undiagnosed and untreated “vertebral fractures.”

Drug industry-sponsored guidelines and the doctors paid to write them should be exposed and challenged. And while waiting for the revolution, there is one thing you can do: as a potential ‘patient,’ you, dear reader, need to do your part and not so easily accept a new disease label. If you’re already healthy, a new disease label is unlikely to make you healthier.

These conversations seem long overdue. If our doctors are coming at us with new disease labels and the drugs that go with them, we should all hit the ‘pause’ button. We all need to have ‘the talk’ when it comes to how biased and unhelpful guidelines can be so we can avoid becoming a new patient.

Alan Cassels is a drug policy researcher in Victoria and the author of the new book called The Cochrane Collaboration: Medicine’s Best Kept Secret.

Concocted war on drug industry another Wag the Dog

BC Liberals can’t afford a real war against Pharma so they’ll fake one

 

DRUG BUST by Alan Cassels

Portrait of columnist Alan Cassels

• In the 1997 political satire film Wag the Dog, Anne Heche, playing an advisor to the US president, turns to Robert De Niro, another presidential aide and whispers, “We can’t afford a war.” De Niro waves his hand and replies confidently, “We’re going to have the ‘appearance’ of a war.”

The two are on a plane enroute to Los Angeles to recruit a famous Hollywood producer, played by Dustin Hoffman, whom they convince to work for them in constructing a fictional war. The sitting president of the US is caught up in a sex scandal 11 days before an election and, to distract the public’s attention, his advisers concoct a war with Albania. The De Niro character lays it out to Hoffman, waving his hands like a conductor: “It’s not a war, it’s a pageant. We need a theme, a song, some visuals. It’s a pageant.” The ensuing drama is ripe with scintillating satire, showing how craftily political operatives can manipulate the public’s attention and otherwise shape a narrative that can have a huge influence on world events – and elections.

How does this have anything to do with pharmaceuticals and drug policy?

Well, I found myself riffing on Wag the Dog when I saw a mini skirmish erupting between the BC Ministry of Health and the association of the Canadian brand-name drug industry known as Innovative Medicines Canada. This pageant included predictable talking points from astroturf activists and lobbyists berating the BC government and our Minister of Health while exhibiting unconvincing fearlessness.

If this was a war, I’d seen it before. But back then it was the real deal. In the mid 1990s, a newly elected NDP government in BC brought in one of the most radical and profit threatening changes the drug industry had ever seen in North America – at a time when ministries of health were embracing this new thing called Evidence-Based Medicine, where groups like the Oxford-based Centre for Evidence-Based Medicine, the Cochrane Collaboration and BC’s Therapeutics Initiative were being established. Basing policy on evidence instead of expert opinion allowed BC policymakers to consider Reference-Based Pricing to help reign in runaway drug costs.

Reference pricing was so simple a school child could understand it: if there was a bunch of products in a class of drugs that generally worked the same way – were ‘therapeutically equivalent’ – the government would pay for the cheapest one, the ‘reference’ drug. If you wanted a more expensive drug, you paid the difference. If the cheaper reference drug didn’t work for you, your doctor could ask PharmaCare for “Special Authority” and 95% of the time they were approved. The policy was a no-brainer and mirrored how many people shop: if there is no qualitative difference between competing products, why not buy the cheapest one?

By the end of the 1990s, Reference Pricing in BC covered five drug classes, including drugs for arthritis, ulcers, angina and blood pressure. Independent evaluations carried out by researchers found the policy saved the BC taxpayer about $44 million the first year in full operation, with no adverse impacts on health. With a provincial drug budget just over $400 million, this was a serious saving, yet the ensuing war between the BC government and the drug companies was a full-on, knock’em out fight.

For weeks, full-page ads ran in the Vancouver Sun and the Globe and Mail, paid for by the Pharmaceutical Manufacturers’ Association of Canada and the Canadian Association of Retired Persons. They featured a sorry looking senior helplessly staring into her medicine cabinet under the headline, “The Provincial Government wants to change your medication.” The Ministry responded in the press with its own ads and the media went crazy covering the story. One Vancouver Sun headline read, “Minister condemns drug manufacturers. Greedy multinational firms trying to terrorize British Columbians.”

Documenting this as a researcher was like getting a PhD in pharmaco-political propaganda. The BC Liberals listened to the lobbyists’ propaganda and promised to get rid of Reference Pricing if elected, which they were in 2001, helped by hundreds of thousands of Pharma money. After taking power, the Liberals commissioned several evaluations of the policy, which showed it was a great way to save money in the drug budget. Yet the policy was never expanded. We researchers knew of other drugs taxpayers were paying far more for than they needed to, yet the BC Liberals refused to expand Reference Pricing. The next class of drugs to be referenced – the cholesterol-lowering statins – was a big-ticket item when most of them were still under patent. Referencing them back in the 1990’s would have saved BC about $50 million per year. The Liberals refusing to implement this policy capable of saving $50 million a year for 16 years is an $800 million gift to the pharmaceutical industry. No wonder the drug companies were such avid donors to the BC Liberal party.

In the intervening years, other pro-Pharma policies under a BC Liberal government were shockingly generous to drug companies. In 2003, the Liberals created what they called “Fair PharmaCare,” which tied a citizen’s drug coverage to their income, proving to be a $100 million per year bonanza to the drug companies, right out of the pockets of BC citizens. Instead of ‘managing’ drug cost growth, the Liberals took the cowardly way out: shifting the cost growth onto consumers.

Perhaps the most blatant gift to Big Pharma was a 2007 commissioned review of PharmaCare designed to formulate recommendations on reform. The resulting Pharmaceutical Task Force was so stacked with drug industry executives and cronies, the recommendations were ridiculously generous to the drug companies. And then in 2012, we had the PharmaCare firing scandal, which destroyed the government’s own capacity to carry out proper drug safety research in this province, another massive gift to Big Pharma.

Fast forward to 2016 and an election looming; what do we see? The Liberals, to demonstrate how tough they are, dust off Reference Pricing, in the spirit of a wag-the- dog gimmick. This distraction is supposed to extend Reference Pricing to statins, angiotensin receptor blockers (for high blood pressure) and PPIs (proton pump inhibitors) for heartburn, but the savings, touted to be $9 million per year, are a drop in the bucket.

The drug industry has also played its dutiful part in this charade by launching a lobbying campaign asking BC citizens to write their MLA, the Premier and the Health Minister to complain they are being denied access to “world class” drugs. Astroturf activists in BC’s Pharma-funded Better PharmaCare Coalition are also pretending outrage and have weighed in on the debate too.

Terry Lake, our Minister of Health, told the Tyee he’s not a victim of lobbying by pharmaceutical companies. Really? Sorry, Terry, your whole government over the past 15 years has shown itself to be easily lobbied by the drug industry. We’ll know you’re serious about controlling drug costs when we see full-page attack ads in the Vancouver Sun. Until then, it’s a pageant.

A concocted war on the drug industry surely benefits the BC Liberal Party, which is desperate to prove it’s not in the pockets of the pharmaceutical industry. Historically, the drug companies that make up Innovative Medicines Canada are among the Liberals’ biggest donors. They are getting the government policies on pharmaceutical policy that they have bought.

I wonder what would happen if the Ministry brought in real, serious drug cost control policies such as halting the overprescribing of antipsychotic and diabetes drugs and oodles of other unsafe, and often useless, treatments? A government serious about playing hardball with the drug companies could probably save $300 million or more a year in BC and here’s the kicker: the health of the population would likely improve!

Just like in Wag the Dog, maybe the BC Liberals know they can’t afford a real war so they’ll just fake one.

Come election time, I’m hoping BC citizens can tell the difference between a government that has the cojones to take on the drug industry and one that is only faking it.

Alan Cassels is a drug policy researcher in Victoria and the author of the new book called The Cochrane Collaboration: Medicine’s Best Kept Secret.