Big Pharma’s marketing machine
DRUG BUST by Alan Cassels
• Since we’re now welcoming new readers in Ontario, I thought I’d tap into a topic that is sexy (not to mention timely and urgent), relates to drugs (the pharmaceutical kind) and has the unmistakable rockin’ beat of the pharmaceutical industry’s marketing machine. So, in this column, I’m trying to hit all the bases: sex, drugs and rock’n’roll.
Anyone who has had an encounter with the healthcare system lately, in any way that involves pain, will likely have heard of tramadol, sold under a variety of names including Tramacet, Ralivia, Tridural, and Zytram XL (Ultram or Ultracet in the US). It is a “centrally-acting, narcotic-like analgesic” prescribed for moderate to severe pain. There is one important difference between this narcotic and other weapons-grade opioid painkillers such as Dilaudid, Percocet or Oxycodone: it is how it is classified.
Strong opioids are considered “controlled substances” and closely monitored because of the potential for abuse and the toxicity of the drugs. Canadian prescribers of narcotics are required to fill out duplicate or triplicate prescription forms, counsel and monitor patients and only authorize a limited supply. Their prescribing behaviour is enforced by provincial Colleges of Physicians who are known to spank physicians they think are too exuberant in prescribing narcotics.
In Canada, Tramadol is a marketer’s dream – an “uncontrolled” drug that doctors anywhere can prescribe without paperwork hassles or Big Brother peering over their prescription pad. Only in New Brunswick and Ontario is it classified as a ‘monitored’ drug, yet because it’s still easy to prescribe, it’s the drug of choice for many physicians.
According to BC prescribing data there are about 127,000 patients who got a tramadol script last year (extrapolated that would mean about 375,000 people in Ontario) yet it’s use is growing more at a rate of more than 10% per year. In 2012, in the US tramadol was the 21st most dispensed drug that year.
Must be because it’s such an effective drug, right?
Wrong. While tramadol can be effective for pain, it is no more effective than other opioids. Plus, it comes with a hockey sock of other problems, including the risks of hypoglycemia (low blood sugar), serotonin syndrome and many potential dangerous interactions with other drugs. Independent experts have said it is actually a worse choice over other narcotics and many public drug plans in Canada refuse to cover it. This, however, hasn’t prevented tramadol from being widely prescribed, because, well, it’s just so convenient to use and has this illusion of safety because it’s “uncontrolled.”
This situation clearly infuriates Dr. David Juurlink, a physician, pharmacologist and toxicologist in Toronto. He doesn’t waste words: “Tramadol,” he says, “bothers me a lot.”
He knows this drug intimately so I tracked him down for an interview as he was navigating airports, enroute to Boston. Juurlink often gets asked to sit on committees evaluating the benefits and harms of prescription drugs, mostly because he’s one of those rare physicians with a geek-level insight into the action of a drug. He easily emits a dizzying academic monologue about receptors, enzymes and metabolic processes that explains where, exactly, the chemicals go and what they do once you swallow them.
He tells me the main issue is that when tramadol is ingested, for more than 90% of people, it is metabolized to an opioid, essentially becoming no different than the other opioids on the market. Juurlink reckons that other considerations, including the pharmaceutical industry lobby and funded patient groups, likely influenced Health Canada in classifying it the way it did back in 2007. Tramadol is a controlled substance in the UK and, since 2014 in the US, yet in Canada, Juurlink says, its lack of designation means that, for prescribers, the “normal antenna doesn’t go up and they don’t see tramadol for what it is.”
Doctors are taught to be wary of opioids. They know the lengthy list of dangers related to narcotics: abuse, addiction, toxicity and death. Tramadol is probably best compared to codeine, a powerful narcotic, and Juurlink reckons it should be treated like one. Some people may be more susceptible to the effects of tramadol and it can adversely interact with many other drugs, including SSRI antidepressants, which can lead to serotonin toxicity or serotonin syndrome.
Johanna Trimble in Vancouver has seen serotonin toxicity up close and personal. She became an autodidact on the subject of medicines in the elderly and over-prescribing (known as “polypharmacy”) when she was trying to figure out why her elderly mother-in-law, Fervid, went from a normal functioning 87-year-old to a near-zombie. (Read her story at www.isyourmomondrugs.org) The doctors wanted to prescribe drugs for dementia, but Johanna did some sleuthing and found she likely wasn’t demented at all – her symptoms started too suddenly after a change to her medications. Fervid was actually suffering from serotonin syndrome due to the interaction between tramadol and a new script for citalopram (an SSRI anti-depressant). Once taken off these drugs, she returned to normal.
Serotonin toxicity, which can result by mixing antidepressants with tramadol, can lead to hospitalization and sometimes death. This can happen accidentally as people in pain are often also depressed or anxious and end up taking a painkiller/antidepressant combination. One Australian study looking at nearly 300,000 elderly veterans found that about eight percent were prescribed two or more serotenergic drugs at the same time and about one percent were prescribed a potentially fatal combination with another drug like tramadol.
Another worrisome problem with tramadol is that many patients can suffer from hypoglycemia, which is unrecognized by physicians who would blame the low blood sugar on diabetes. Diabetics prescribed hypoglycemic drugs (to lower blood sugar) may also take tramadol and that can make things infinitely worse. Juurlink has written that, “If we replace conventional opioids with tramadol, as some guidelines have suggested, we may be left with more unintended consequences of the opioid epidemic to worry about.”
One wonders about the role of the drug companies, which clearly employ professional lobbyists and their own stable of pain experts to meet with Health Canada, provincial politicians and other drug plan decision-makers to explain their new miracle pills. Often, company-sponsored pain ‘experts’ are involved in delivering physician education, which can include a hefty load of the company’s pain pill propaganda.
This issue was brought into focus a few years ago in an article in the Journal of Medical Ethics by Dr. Nav Persaud. While in medical school at the University of Toronto, he discovered that a particular drug company that made pain medications was also slipping their own material into the medical school curriculum. Specifically, pharmacotherapy lectures contained questionable content about the use of opioids for pain management, leaving these medical students with a misleading view of the dangers associated with opioids. Since these conflicts of interest were not always disclosed, the medical students ended up dancing to the beat laid down by the drug industry’s spin machine. It’s clearly time to change that track.
Dr. Persaud concluded we desperately need better strategies to keep drug industry propaganda out of medical schools; he later told the Globe and Mail, “Doctors should not teach medical students and work for pharmaceutical companies at the same time… When you go to the doctor, you want to know that you’re getting the advice that’s best for you and not something that’s based on the marketing plan of a pharmaceutical company.”
Something to think about next time you’re in pain and your doctor wants to hand you a script for tramadol.
Alan Cassels is a pharmaceutical policy researcher and journalist. If you’re interested in ‘deprescribing,’ check out Medstopper.com and watch the video that features the Beatles singing about how to reduce medications. @AKECassels. You can read more of his writings at www.alancassels.com or follow him on twitter @akecassels