Healthier pill popping

 

DRUG BUST Alan Cassels

SURELY OUR economic calamity couldn’t have any positive health effects, could it?

As people lose their jobs and watch their assets, retirement savings and homes diminish in value, one might assume that it inevitably means a big negative on the balance sheets of our lives.

Not so fast, I say. Among the pharmaceutical-popping public, recessionary times may indeed have a silver lining. In fact, this recession may be good for both our health and our pocketbooks, especially if it forces us to reassess our frequently thoughtless, overzealous and often un-economical, legal drug habit.

You have to admit that we have been somewhat conditioned by the media to believe that spending less on healthcare means rationing, longer waits and less access to health services. But can throwing less money at the pharmaceutical industry translate into better access and shorter wait times for things that actually count? It could, but I admit such heretical thoughts are based on my perspective that pharmaceuticals really do reside in a special place inside the healthcare world.

For each drug on the market that is truly lifesaving, providing profound benefits and extending the quality and length of our lives, dozens more either don’t deliver the goods or worse, provide the opposite – more harm than benefit. And the money we’re spending on those treatments could be buying less health.

Suffice to say, one of the side effects of these belt-tightening times could be that we spend more energy figuring out what is really essential for people who are truly sick and then making sure the system doesn’t reward prescribing what is unnecessary or harmful. After all, what better time to eliminate fat than when we are collectively facing lean times?

One clue that there is perhaps too much excess in the world of prescription drugs might be found in the way society pays for pharmaceuticals. In Canada, drug coverage operates by the rule of thirds: about a third of our collective pharmaceutical tab is covered by the public purse (in our case, BC Pharmacare). A third is paid for by your private and typically employer-sponsored health benefit program. And finally, a third is paid for out of your own pocket.

Since you, the employee, are essentially paying for the private drug plan, let’s conclude that two-thirds of all prescription drug spending is essentially coming from your bank account. Yet unlike visits to a doctor or an occasional surgical visit or your trips to the hospital that are 100 percent paid for by the government, the way we pay for drugs makes them seem discretionary. After all, if they were really essential the government would pay for them, right?

This might seem simplistic, but addressing the question of whether or not we can afford things should start with us asking whether or not we need them in the first place. Deciding whether or not to fill your prescription shouldn’t depend on how much is in your wallet, but you should always ask the big questions: “Why am I taking this drug in the first place? Is this really necessary?”

There is considerable evidence that discretionary, prescription drug taking is widespread; far too many borderline hypertensive patients are prescribed the latest-greatest pill for their blood pressure. Far too many people worried about high cholesterol take statin drugs, even when those drugs make almost no difference to the quality and length of their lives. And far too many seniors are drugged silly by over energetic nurses preaching “compliance.” Name any major class of drugs today and you’ll find gross examples of those products being overused in otherwise healthy people – hence a lot of spending for drugs of no impact, at great financial cost to ourselves and our health system.

So with an economy going into the tank, what should we, as individuals, do? How about making ourselves more knowledgeable about what is actually happening when the doctor’s pen is poised over the prescription pad?

A sweet new book, Ten Questions You Must Ask Your Doctor (Greystone, 2009), written by crack Australian health journalists Ray Moynihan and Melissa Sweet, succinctly captures the types of questions you need to be armed with when you talk to your doctor. (Disclaimer time: I wrote a book called Selling Sickness with Moynihan four years ago and was asked to write the foreword to the Canadian edition of this book, but I have no financial ties to its success.) I said in my foreword that people should never challenge their physicians for sport, but they can become more involved in their own healthcare by asking their doctors some simple questions, such as, “Do I need this test, this screening program or this drug? What’s the evidence behind the treatment? Are there potential benefits and harms related to the treatment and what are my treatment options? Are there things I should do on my own to maintain and improve my health?” While this book goes beyond drugs, it could have easily gone by the slogan “Just say “know” to drugs.”

Books like this help consumers deconstruct what is being offered to them and compel them to seek out better answers to what’s on offer. Considering that a new prescription is often accompanied by new side effects, asking your doctor for the safest, most agreeable (for you) and most proven drug – likely cheaper, as well – won’t hurt either.

Hard questions about our health should not be placed solely on the shoulders of doctors, but should also be asked of health system officials. Do we need to be offering all healthcare options all the time to everyone? What is most essential and what is least essential? Are there rational ways to provide access in the grey areas? This needs to be part of a larger public debate that strives to maintain society’s overall level of health, albeit on less money.

It’s also time to involve the drug companies that are seeing their profits – except maybe profits for anti-anxiety or anti-depressant drugs – decline. Can we help them sustain reasonable markets by negotiating better prices? After all, if people and health systems can’t afford what the drug companies are asking for, there’s no market. Radical as it might seem, lowering a product’s cost to the consumer might actually improve a drug company’s bottom line because, at least for some drugs, excessive prices might be preventing people from filling their prescriptions. I call it “Pharmacy Sticker Shock” and who knows how often people say, “Nope, can’t afford it?”

But beyond cutting out unnecessary treatments or negotiating drug prices, people taking a prescription drug for perfectly rational reasons will need to ask a few other questions: “Are there generic drugs that can do the same thing? Do I need to be taking the dose I am taking? Can I take the drug on an as-needed basis?” This is especially true for people taking proton pump inhibitors – drugs like Losec, Pantaloc or Pariet for reflux and heartburn. Most patients may do well taking the drug every other day with no impact on their symptom control. Many could even control their symptoms with lower cost, generic or over the counter products too. Basically, you won’t know until you ask.

“Can I consider splitting pills?” is another question to ask. Pill splitting is a growing phenomenon based on the “flat pricing” of drugs like cholesterol-lowering statins, whereas the higher dosed drugs cost about the same as lower doses. For example, a month’s worth of 20 mg tablets of the statin Lipitor costs about $67 and the 40mg tablet costs about $72. Doctors who think the patient needs 20mg could prescribe the larger 40mg tablet and ask them to split it, taking half a pill each day. This one small action will save the patient almost $400 off their annual drug bill.

So go ahead and pick up a pill splitter for less than five dollars at a pharmacy and proceed to get twice the medication for the same price. Pill splitting is not appropriate for every person or every type of medication, but in the case of statins, splitting the pills is safe and economical.

A study published last summer showed that patients in BC are already cutting their own drug costs by splitting their statins. Even without widespread promotion of the practice, it is estimated that about five percent of BC’s statin users were splitting their pills, saving BC consumers (and private health plans and governments) about $2.3 million per year. Every year, British Columbians consume more than $140 million worth of cholesterol-lowering statins, an amount that has been growing steadily throughout the past decade. If everyone split their pills, we’d save an easy $50 million per year.

Not bad. One drug class. One intervention. Tons of money saved.

Will this recession call upon more such ingenuity? I hope so. If it helps us put on our thinking caps and remove the waste from our prescription drug bill, it may well pay off in ways that allow us to reinvest those savings into things that count.

Alan Cassels is a drug policy researcher at the University of Victoria and author of The ABCs of Disease Mongering: An epidemic in 26 Letters.

cassels@uivic.ca

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