Too many Americans on prescription drugs

During a given year, seven out of every 10 people in my town go on some kind of a drug.

As a writer I am fond of hyperbole, but that's a verifiable statistic. It's culled from the Rochester Epidemiology Project and published this summer in the journal "Mayo Clinic Proceedings."

Epidemiology can be dull, but as a proxy for drug use in the United States, the tally of what gets taken around here is a helpful starting point for a more newsy question: What should we make of the celebratory fire-dancing in the news last month over the latest wonder drug for lowering LDL cholesterol?

First, some background: According to the Mayo database, 68 percent of Olmsted County residents were prescribed at least one drug in the course of the year studied; 51 percent were prescribed at least two, and 21 percent were directed to take five different drugs.

For comparison, only 46 percent of U.S. households own a dog.

In short, taking a pill may be more American than man's best friend. Which is unfortunate, given that owning a dog is one of the best things you can do for your health. (Dogs do come with powerful side effects: You fall in love with them and then they die.)

But here's some good news: the most-prescribed drugs in these parts, at 17 percent of the population, are antibiotics. I think we can agree that antibiotics have had a profound impact on reducing sickness and death.

As the authors noted, Americans spent $250 billion on drugs during 2009. That's comparable to the entire economic output of Finland, Greece, Israel or Ireland.

The researchers found the third-place showing of pain-­killing opioids "a bit concerning, considering their addicting nature," according to Jennifer St. Sauver, Ph.D., of the Mayo Clinic Health Population Program. The high use of antidepressants, however, "suggested that mental health is a huge issue and something we should focus on." Our use of cholesterol-lowering drugs escaped criticism as well.

But at least we're getting something for our quarter of a trillion dollars in annual drug spending. Depression is now easily cured, and death from heart disease is thing of the past.

In our dreams, right?

During the era of antidepressants — drugs refilled again and again thanks to withdrawal effects that mimic a return of the illness — the nature of depression has changed. It has gone from a mostly self-limiting condition ("Most depressions terminate in spontaneous remissions," wrote the father of psychopharmacology, Nathan Kline, in 1964), to a chronic illness requiring lifelong chemical management. This is costly, personally and for society.

We view these numbers and say "mental health is a huge issue and something we should focus on," when we could just as easily conclude "antidepressants are addictive drugs that do not work very well."

Statins, "risk-factor" drugs conferring compliance with the prevailing heart disease narrative, are taken by 41 percent of people over 65 in my county. The drugs lower blood cholesterol, supposedly reducing the risk of heart disease in the process, and supposedly with no cost to public health.

For people who have had a heart attack, the drugs do reduce the risk of a return of cardiovascular illness and early death, albeit by a small amount (from 3 percent to 2 percent in one large trial — or "36 percent" according to the TV ads).

But sick people were never the target of those confessional Lipitor spots featuring frightened and repentant midlifers. (The one with a 50-something jumping off a dock at sunset did at least promote ownership of a chocolate lab.) Two-thirds of the $17 billion market for statins is for primary prevention — people who have never had a heart attack.

Statins don't work in people who have never had a heart attack. Your risk of heart attacks goes down by a small amount, but you don't live any longer. (Woe be unto those who repeat this finding. In 2011 the Cochrane Review — sort of the supreme court for determining what works in medicine — agreed that statins don't help the healthy. But after coming under intense pressure for saying so, this year they reversed themselves.)

Statins do lower your LDL, or so-called "bad" cholesterol. So why don't they work? LDL comes in many forms, only the smallest of which predict heart disease. And as pioneering LDL researcher Ronald Krauss, M.D., will tell you, "they disproportionately reduce the large forms of LDL" (the kind that don't hurt you).

"It has been a convenient story that changing risk markers will change risk," says Harlan Krumholz, M.D., the Yale researcher Medtronic recently hired to tell them their spine plug known as Infuse had been oversold. "But it's just not that simple." Blaming LDL for heart disease may be like blaming fire trucks for fires.

Those details were lost in the excitement last month over the newest effort to reduce LDL ("New tool to cut cholesterol: Mutation set off a medical chase for a better weapon to fight heart disease," July 10). Written like a medical thriller for the biotech-curious, the piece by the New York Times' Gina Kolata described how three companies are engaged in a "fevered race" to test an antibody that mimics in patients a rare genetic mutation of a protein known as PCSK9, a mutation that lowers LDL.

In just two people identified with the mutation the world over — a mutation with heart benefits that separated according to race — LDL was so low it looked like a misprint (15, when numbers over 100 are normal). Kolata floated images of an injectable that might one day be taken in pill form by one out of every four adults.

The story ran on the Times' (and Star Tribune's) front page, and follow-up reporting in the biotech press speculated about revenue streams of a size that would only be of interest to hedge funders and others who make a living pouring gas into the engine of wealth concentration.

Good to know what someone paid to be excited about the project thinks.

Krauss, meanwhile, believes very low LDL could scoop up the worst forms of LDL, but what that means is still unknown. Krumholz says that until trials are concluded, "it is just an unknown."

Given that we already spend so much on drugs that do so little, perhaps we should think harder about how we greet the latest biotech adventure tale. We could start by not encouraging journalists who describe low LDL numbers as "dazzling," or who call a Pharma money chase "one of the greatest medical chases ever."

Following that splash, I managed to descend into a joyless if polite Twitter war with a nice enough biotech blogger who had chronicled much of the story, like the writer at the Times, in terms of what it might mean for the drugmakers' financial prospects. Maybe that was not fair. LDL-lowering drugs are perfect for stock pickers. Like the latest jobs numbers, LDL is a simple numeric taken as a shorthand for a complex system. Picking stocks has had as little to do with our economic health as moving LDL has had to do with our physical health.

In this way, the PCSK9 story is great fun for the gallery, but maybe just a fancier form of reality TV: captivating, dumb, probably harmful. Any time the health media start telling us to grab a bag of popcorn and pull up a chair because the guys at Sanofi, Pfizer and Amgen are close to landing a big one, we should know where this is heading.

-----------