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“Just Say No” to prescription drugs
DRUG BUST by Alan Cassels

Follow doctor’s orders. Make sure you fill your prescriptions. Don’t stop taking your drugs without consulting your doctor. Those sentiments form the heart of medical advice and we’re all expected to follow orders, right? After all, it’s your health that’s at stake.

Yet at the same time, the concept of obedience – just following orders – seems a bitter pill to swallow these days. There is a strong breeze of resistance in the air, whether it’s against bankers playing with our savings, corporations misleading us about their concern for the environment or governments forgetting the “other 99 percent” of the population. Should the urge to resist authority be expressed in how you receive medical care?

Sometimes, it is entirely rational to ‘Just Say No.’ When your doctor gives you a good grasp of the facts of the disease she thinks you have and what its natural course might look like and you learn about the drug she’s prescribing and its potential benefits and harms – from the common annoying side effects to the rare but potentially life threatening adverse effects – saying “No” is definitely within your power.

After all, you’re the one swallowing the pill. Actually, given the sheer volume and growth in prescriptions being written for the general population, refusing to take a drug seems a natural reaction.

To my surprise, a substantial number of physicians agree patients are getting too much medicine. A survey last year of US doctors found 42 percent believed patients in their own practice were receiving too much care and only six percent were getting too little. About three quarters of the doctors surveyed said the main thing causing them to practise more aggressively was concern over malpractice. Doctors are somewhat fearful if something goes wrong, the patient could sue, but that’s more an American phenomenon than a Canadian one.

What else is at play? About half the doctors surveyed said “clinical performance measures” were a strong reason for possibly overtreating their patients. In other words, doctors may order anti-cholesterol drugs or drugs for heartburn because the guidelines say they should. I could go into a rant why guidelines are so frequently bad, but suffice to say many guidelines are funded and composed by consultants acting on behalf of the pharmaceutical companies. If it looks like doctors are overprescribing, it’s because they’ve let the moneylenders into the temple.

Where’s the patient in all this who might reasonably ask, “Are you offering me a prescription because you are worried about getting sued or worried someone will accuse you of not following guidelines? Can you think of any lamer rationale for asking me to swallow a pill everyday?”

I wouldn’t counsel people to commit civil disobedience when it comes to their doctor’s advice because it could have a tumultuous effect on their relationship with someone who is genuinely interested in keeping them healthy. At the same time, with the rising level of people’s awareness about healthcare, particularly around the problems with prescription drugs, many people sense even their own trusted physician is too quick to prescribe. And they don’t know what to do about it.

So let me suggest an experiment in medical civil disobedience. Next time the prescription pad comes flying out, try saying “No” to that new drug.

There is some precedent for this. Remember 25-years-ago when then First Lady Nancy Reagan held a White House rally declaring society needed to “Just Say No to Drugs?” Of course, she was talking about illicit drugs that were seen as the utter scourge of American youth. As an aside, you don’t have to be a genius to conclude just telling a teenager to say no to something will make them want it even more, but let’s run with Nancy’s sentiment, if not her slogan, for a moment. Let’s dust it off and apply it to an older population.

It’s clear the overprescription of medications, especially to older people – our parents and grandparents – is fuelling lives of quiet desperation. If we want to start saying “No” to the rampant prescribing of drugs in the elderly, maybe we can start reducing the medical imprisonment they’re living in due to the staggering amounts of medication they are fed daily.

We need to come clean about the charade we all seem to be playing when it comes to pharmaceuticals. Even if we believe patients are “involved and engaged” partners in their healthcare, are the principles of fully “informed” consent actually at work? Does a new drug always arrive with full information about a person’s diagnoses and the natural history of the disease, the drug being offered, its potential for benefit and harm and so on? Does all that happen in a typical 15-minute interaction with your doctor? Hmm, maybe not. So just saying “No” could be a game changer.

This is radical because a lot of modern medicine depends not on ‘partnerships’ but on obedience. Hang around hospitals long enough and you’ll hear how a patient’s behaviour is described in such demeaning terms as “compliance” or “adherence.” The message is clear: follow your doctor’s orders, or else. Only the very brave would really want to fully resist.

But, in fact, saying “No” might help build on a more sensible “less is more” approach to medicine. It’s a subtle acknowledgement of what no one wants to come out and say: that much of what is offered in healthcare is unneeded, irrelevant or potentially harmful. This sentiment was captured in an article last year in the Archives of Internal Medicine (May 10, 2010). Physicians Deborah Grady and Rita Redberg wrote: “There are many areas of medicine where not testing, not imaging and not treating actually result in better health outcomes.”

One of the areas they highlight, in terms of overtreatment, is a class of drugs called proton pump inhibitors (PPI) – drugs like Nexium, Losec, Pantoloc and Pariet – which are widely prescribed to people with simple heartburn. No doubt these are effective drugs, but they are so widely and persistently used, many people are probably being unnecessarily hurt by them.

Recent research paints a troubling picture of PPIs showing they can increase your risk of developing a C. difficile infection (Clostridium difficile) or pneumonia and also increase your risk of fractures and cause recurrent diarrhoea. If you are getting weapons-grade medicine, such as a PPI for a simple case of heartburn, you are likely increasing your chances of being harmed. Maybe you shouldn’t have started on them or maybe it’s time for a drug holiday? Time to test-drive that “No”?

Many of us are not the type to go on marches and protests and we express our solidarity with the “Occupiers of Wall Street” from our couches, but that doesn’t mean we can’t participate in this social awakening in other ways. When many things are working against your interests, disobedience can be healthy. When it comes to swallowing medical treatments, being “compliant” can sometimes be bad for your health.

You won’t be alone in saying “No to Drugs.” A recent US study revealed one startling fact: many people don’t take their medications as ordered. In fact, about one in five patients fail to pick up their new prescriptions from the pharmacy. There are many ways to resist and maybe the first way is to have a frank discussion with your doctor. Ask her if you really need that new prescription or the ones you’re currently taking.

You might be surprised to find out she’s a resister too and doesn’t really want to prescribe it for you anyway.

Alan Cassels is a drug policy researcher at the University of Victoria. Read more of what he’s writing about at www.alancassels.com

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