Tuesday, December 21, 2004

Oh the PAIN! Celebrex, Naproxen, Accupuncture?

Naproxen is next on the block, with evidence that it may also contribute to cardiovascular problems. The consumer reaction that we hear from the media does not juve with our personal experience, however. That's because there's a media script here, and they only feature people who fit the part - the Confused Pain-Sufferer!

Bollocks, to use a great British term. Don't you think the average consumer can understand the difference between a 1 in 1000 chance of having a heart attack or stroke versus a 2.5 in 1000 chance? That's the difference between Vioxx users and non-users. Now, we know that in the aggregate data, there is no efficacy difference between COX-2s and NSAIDS. But this is the type of medicine that has unpredictable outcomes for individual patients. I'd like Syney Wolfe to go to our mother's house, and tell her that she doesn't really need her Vioxx for her crippling rheumatoid arthritis, despite the fact that NSAIDS clearly did nothing for her after many years of use. How do you explain someone taking their first few doses of Vioxx, and shortly thereafter feeling a freedom of movement that they haven't had in years? Placebo effect? Bollocks again!

We're picturing a new drug ring in this country, a gang of little old stooped-over ladies (shades of Monty Python here) who traffic in COX-2s, and get pissed off whenever a consumer activitist tries to tell them what's best for them. Wolfie's gonna be found face down in a pool of Ensure someday, knitting needles protruding ominously from his back with a clear message from Grandma - don't mess with my meds!

Seriously though, it is definitely a headache to restrict usage of a drug once it's on the market, despite its potential dangers, unless you want a patient registry like thalidomide has. The genie wants out of that bottle. So could we trust Merck and Pfizer to carefully restrict the sales of these drugs, to only be prescribed to those who have failed other older therapies, have no additional risk of CV illness, and have a miserable QOL (Quality of Life) without COX-2s? The overutilization is a joint effort between the Pharmas and physicians, who can't be bothered to do any drug research beyond what the reps give them, and who also probably didn't have pharmacology in med school. Still, we believe these drugs should have some place in the armamentarium.

The Washington Post gives us lots of pain today, as they have articles on the Naproxen findings, as well as using accupuncture for arthritis, and physicians getting upset at the DEA for giving them chills. While we certainly want physicians to more aggressively treat pain, with opioids if necessary, we still can't help but laugh at this passage:

"[T]he government can open investigations on the suspicion that a doctor is diverting controlled drugs or to make sure there is no improper activity. In reply, the three pain groups wrote: 'Reading that the government can investigate merely on suspicion that the law is being violated will send chills down the spine of practitioners who are treating patients with [narcotic painkillers] ....'"

"Merely on suspicion"? We don't watch much crime TV, but isn't suspician usually what causes investigations? Investigation does not equal indictment. Does the fact that an investigation may be underway cause problems for a practitioner who is not violating the law? What level of evidence should the DEA require for starting investigations...Rush Limbaugh parking in front of the doctor's house?


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