More cholesterol craziness

DRUG BUST
by Alan Cassels

Ask if Repatha can get you on the path to way lower LDL. – Advertisement for the new LDL-lowering drug Repatha.

Some days I love this crazy drug world where there is a never-ending trove of stories that continue to amaze and entertain. This summer, it’s worth introducing my readers to a very new and ultra expensive class of cholesterol-lowering drugs known as proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors. They do an amazing job of lowering LDL, known as the “bad” cholesterol.

Certainly, on that parameter alone, they are much better than the oft maligned statins, but the main question is whether governments, and individuals, will be able to afford PCSK9 inhibitors. At $8,000 or so per year, this injectible drug will cost about 50 times more than statins.

While I’ve often maligned statins myself, it’s more due to the very real questions around the alleged dangers of ‘high’ cholesterol and what kind of meagre impact we see when medicating a normal and vital substance in our blood. To summarize in one sentence the arguments I’ve made over the last decade, lowering cholesterol with statins makes astonishingly small differences to the length and quality of most people’s lives.

Even for those who are at ‘very high’ risk of a heart attack or stroke, taking daily statins for five years might, at best, reduce their risks by two to three percent. Which is to say, 97 to 98% of people swallowing a daily statin are unlikely to see any benefit from them. Besides wasting their money and unnecessarily exposing themselves to statin dangers such as muscle weakening, cognitive effects and other bad effects, people can do many more things to improve their cardiovascular health.

So along come the PCSK-9s with another aggressive war on high LDL and some pundits predicting “blockbuster” status for these drugs. Some predictions say this class of drugs could cost as much as $100 billion per year in the US, making the PCSK9 inhibitors the costliest drug therapy class in the history of humankind. As we surpass new heights on the pinnacle of pharmaceutical absurdity, I am still jaw-droppingly awed by the length to which we humans will go to medicalize and medicate our cholesterol levels. And because of the mind-boggling amounts of money at stake, you can imagine there will be lots of high-priced rhetoric in the medical press working to get you to take these drugs.

The first two approved PCSK9 inhibitors in Canada are alirocumab (Praluent™) and evolocumab (Repatha™). They are approved for “the treatment of primary hyperlipidemia and mixed dyslipidemia (high levels of “bad” cholesterol).” Basically, looking at the ads, they seem to be pitched to anyone who requires “additional lowering of LDL-cholesterol.” In other words, “all of us.”

Let me summarize six reasons why you should probably not get too excited by this new class of drugs and why we need to be skeptical of many new drug claims.

1. Big trials: If you have to enroll a ton of people into your trial, that’s a sign the drug has a very small effect. The Praluent (ODYSSEY) trial enrolled 18,000 patients and the Repatha (FOURIER) trial enrolled 27,000 to see if the drugs reduced cardiovascular risk. Another trial (SPIRE-1 and 2) testing Pfizer’s PCSK9 inhibitor, bococizumab, enrolled 32,000 patients and was stopped early because even with that many people, the drug turned out to be a dud.

2. Exaggeration of the treatment effects: Many media reports on the PCSK9 inhibitors tended to exaggerate the effectiveness of the drugs, saying they reduced the risk of heart attack and other major cardiovascular problems by “more than half,” compared with standard treatment alone. One study in the New England Journal of Medicine showed patients taking evolocumab had about a 1% risk of cardiovascular events compared with 2.2% in the control group, for a 1.2% absolute risk reduction. But since one is “50% less” than two, you can imagine how the spin doctors repeat ad nauseam the impressive sounding “50% reduction.” Basically, it’s better to say the drug reduces risk by “50%” than to say the drug may have helped one in 100 people, which, um, is not so impressive.

3. Too many safety unknowns: Like any new drug, there are things we don’t yet know. The concerns here are around the neurocognitive effects of the drugs and whether they may also cause cataracts and type 2 diabetes. In the pre-approval studies, there were more strokes among the patients taking the PCSK9 inhibitors, compared to placebo. There is good reason that in the US insurance companies and pharmacy benefit companies are restricting the use of these drugs. Not only are they costly, but they could possibly be less safe than the alternatives. They typically require a patient to have tried at least two statins and ezetimibe – a statin ‘booster’ – before considering a PCSK9 inhibitor.

4. There are alternatives: For many, statins “work.” Some commentators have argued that PCSK9s will never be mass market drugs like statins. Statins are now generically available, tolerable to many people and easily available. Plus, you don’t have to get an injection with a statin. Unless there is some serious science discrediting the statins, they may remain the king of the cholesterol-lowering world for a long time yet.

5. Market forces and prescribing habits seem to be working against these new drugs: Since they were introduced in the US and the UK, uptake has been very slow, not even reaching a quarter of analysts’ projections. Added to this are skeptical clinicians who are not all (yet) convinced of the overall benefits and safety of these more difficult to administer treatments. You can imagine the PR world is working on that particular problem. Doctors have been fooled in the past due to the frequent exaggeration around the benefits of statins and the downplaying of the risks, so maybe they’re more cynical this time around.

6. Sticker shock: Governments, insurers and others have been dragging their heels due to the sticker shock. In Canada, the annual price tag for the PCSK9s will probably range from $8,000 to $11,000 compared to the annual statin bill which is somewhere between $90 and $1,400 in BC. In the UK, the National Institute for Health and Care Excellence (NICE), which appraises new medicines and health technologies initially rejected both PCSK9s. They have now approved evolocumab. In the US, the New England Comparative Effectiveness Public Advisory Council said the PCSK9s were “effective but overpriced.”

One wonders what is happening in BC and whether or not these drugs will be approved for coverage and prescribed by our doctors?

Those are both good questions and seeing as we’ve got a new government coming in, we have lots of opportunity to improve drug coverage decisions. The BC Ministry of Health recently sent out a notice requesting “Public Input into PharmaCare Drug Coverage reviews,” adding that “the Ministry of Health is considering evolocumab (brand name, Repatha) for coverage.

BC’s Drug Review Process, however, is not perfect. Right now, our Drug Benefit Council (DBC) gives advice to the Ministry. The DBC looks at research around the drugs, consulting the national Common Drug Review (CDR) as well as considering if the drug represents “good value for the people of BC.” They tend to collect input from doctors, patients, caregivers, patient groups and the manufacturers and use this information to make coverage decisions.

There are a million ways for the pharmaceutical manufacturers to insert themselves into the process. They will want the government to spend our money on these new drugs. Other more sober voices, including mine, would say we need to study them more and decide if they represent good value.

BC has a chance to be wise, to resist the lobbying and PR efforts designed to spend money on drugs like this. Our new government is going to be surrounded by lobbyists representing companies that make such drugs. We hope they will be wise and not fall prey to all the PR tricks used to spend our money on questionable forms of healthcare.

Alan Cassels is a writer and former drug policy researcher. His latest book is The Cochrane Collaboration: Medicine’s Best Kept Secret. @AKECassels

We’ve got good people and evidence

All we need now are good institutions

DRUG BUST
by Alan Cassels

Consider just a few classes of drugs that are pretty universally, but irrationally, used. For example statins, drugs that lower cholesterol, likely produce very little benefit for the vast numbers of the population who swallow them, and some are harmed in the process. Antihypertensives, drugs that lower blood pressure, are prescribed to seniors to such an extent that they are more likely to increase the risk of hip fractures than prevent a heart attack. And attention deficit disorder drugs are often prescribed to boys who can’t sit still in boring and unstimulating school classes.

These are just three examples emblematic of the problems of overuse and inappropriate use of pharmaceuticals, in which we see major waste in drug spending and possible harm to the population.

Even though physicians want to do the right thing, and we consumers are often reluctant to take drugs if we don’t absolutely need them, why do we see so much irrational pharmaceutical consumption? What if I told you part of the answer comes down to politics? For a provincial government that spends upwards of $1.5 billion per year on medications, decisions around drug coverage and prescribing policies are often political, not medical.

Ensuring that drugs are only prescribed when needed, to patients who would derive great benefit from taking them, needs to be reinforced by a system based on good scientific evidence, not politics. So how do we get there?

What we’ve seen in BC and around the world is that when a democratically elected government enacts policies that lead to rational and better prescribing (sometimes causing drug companies to see their profits suffer), the pharmaceutical industry will not hesitate to resort to all manner of political games. And when those fail, they use the courts.

We saw this in 1996 when BC PharmaCare was sued by Big Pharma under the banner of PMAC (Pharmaceutical Manufacturers Association of Canada) for implementing evidence-based drug coverage rules that saved the taxpayers millions. At stake was a policy of paying for a ‘reference’ price in a class of drugs, forcing the competing drug makers to lower their prices. It worked and was supported by both the public and the courts (Big Pharma lost the lawsuit), but it also sent a clear message to future governments: you will anger us at your peril.

About a decade ago, Big Pharma also sued the National Institutes of Clinical Excellence (NICE) in the UK. This group examines the evidence of benefit and harm of new pharmaceuticals and then makes recommendations on whether the drugs should be covered in UK’s National Health System. They have turned down drugs for colon cancer (Avastin) that show little benefit and drugs for Alzheimer’s (Aricept), which are widely prescribed but almost completely ineffective, if not harmful. Whenever a government has good scientific evidence to show that coverage of a drug or certain class of drugs is not in the public interest, one major tactic from Big Pharma is to destroy the group that produces the evidence.

That’s one tactic we’ve seen here in BC with our own group, the Therapeutics Initiative (TI) at UBC, whose commitment to the evidence make them a natural drug industry target. Over the years, the drug lobbyists, speaking into the ears of legislators, have said the TI has an anti-drug bias and isn’t transparent when it comes to assessing new drugs, but I would disagree. As a group that favours conservative, rational prescribing, in contrast to the hucksters out there, the TI’s advice to doctors is that they shouldn’t use a new drug until there is positive (and independent) evidence of benefit.

Now that we have a new government in BC, or at least the political structure where compromise and consensus will be necessary, it’s prime time to create a system shielded from the political power of the pharmaceutical industry. Because pharmaceuticals are such a vital, costly and central part of our health system, any reforms brought in on the provincial health front must be structured to reduce the waste and inefficiency in the drug budget. And those reforms must be resilient, above politics so to speak, to ensure they can’t be thrown aside the moment one drug company is upset because their blockbuster drug isn’t deemed worthy of public coverage, and they send their lobbyists to sort out the Minister of Health or the Premier.

There is a short list of examples of models from around the world to emulate. A group in Ontario called ICES (Institute for Clinical Evaluative Sciences) gets provincial money to evaluate drug evidence and medical procedures and they are independent from government. The scientists who work there are (generally) protected from the mud-wrestling of provincial or pharmaceutical politics so their reports can be trusted. And as previously mentioned, there is NICE, established in the late 1990s as part of the UK’s Department of Health, and now called NIHC, the National Institutes for Health and Care Excellence). While it has weathered political attacks, the structure of the organization as an independent agency allows it to sustain pharma’s frequent criticism, emboldened to serve the health care needs of UK’s citizens.

The new NDP-Green accord is getting set to run the province. One of their platforms is to get back to essentials and implement an “essential drug program.” This is a fabulous idea, but in order to determine what is essential from the drug cabinet, you need weapons-grade expertise and a resilient political structure to be able to withstand Pharma’s political slings and arrows. Making provincial-level decisions about what new drugs to cover, needs, most of all, scientific certainty, untainted by the manufacturer’s one-sided view of the value of their products.

Such a structure should be like the Therapeutics Initiative, funded for studying evidence and supplying government decision makers with distilled summaries of research to support the hard decisions on drug funding. The TI’s UBC affiliations have been helpful in fending off pharma attacks, but this new institution would need multi-year, stable funding. You could easily fund such an institution by halting the automatic coverage of classes of drugs that are deemed unnecessary, unhelpful and possibly harmful. Hmm, maybe statins for everyone, antihypertensives in the elderly or ADHD drugs in children?

Providing independent and science-based decisions around drug coverage decisions would make such an institution a big target of Pharma’s attacks. In fact, the more successful it is in asserting evidence around the value and cost effectiveness of new drugs, the more it will be hated by Big Pharma, and their minions, including specialists and patient groups who are often used as Pharma’s foot soldiers in battling for the control of the public narrative.

Why is now the time for such an initiative? For starters, the Green Party says they are committed to evidence-based policy and so it makes sense they’d be natural supporters of making evidence and evaluation centrepieces of healthcare services. They want to get the ‘big money’ out of politics and policymaking so what would be better than an agency free from political influence to produce evidence on policy and program effectiveness, protected from Big Pharma and other vested interests?

We’ve seen groups like NICE or ICES have a big influence on policy and practice, free from the whipsawing of politics and able to focus on local policies and programs. In BC, we have another great asset in our PharmaNet system so that rapid, low-cost evaluations of drug policies can happen. We’ve been world leaders and we have some of the best scientists able to use these administrative databases to study drug policy. What we need now is a politics-free institute to house them. A great opportunity for a new government in this province.


Alan Cassels is a writer and former drug policy researcher. His latest book is The Cochrane Collaboration: Medicine’s Best Kept Secret. Follow him on twitter @AKECassels

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!


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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.

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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.

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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.