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A drug for all reasons

MagazineJune 1995 (Vol. 6 Issue 3)A drug for all reasons

Multiple prescriptions are often used as shortcuts or as devices to avoid responsibility for establishing an accurate diagnosis

Multiple prescriptions are often used as shortcuts or as devices to avoid responsibility for establishing an accurate diagnosis.

In 1967 Leighton Cluff found that the average patient in a teaching hospital received from 10 to 12 different medicines during his or her stay; some got as many as 50. These included penicillins, other antibiotics, sedatives, digitalis preparations, diuretics, tranquillizers, and such non-prescription drugs as laxatives, antacids, and pain-killers in brief, all the drugs a hospital patient can receive. The more medicines prescribed, the higher the incidence of adverse reactions.

Patients outside the hospital setting also mix antibiotics with other prescription and non-prescription drugs.

In the 1950s manufacturers took advantage of this polypharmaceutical yearning to market so-called "fixed combinations": penicillin and streptomycin, penicillin and sulfa drugs, tetracycline and aspirin, etc.

One of the simplest ways in which a new product may come about is through the observation of prescriptions. When a manufacturer's clinical research department sees that many physicians are prescribing several different drugs for the treatment of a given condition, it is common sense for the manufacturer to offer these various ingredients in a single tablet or capsule.

This simplified diagnosis and treatment even more drastically, and for a decade or so the fixed combinations became amazingly popular. In the late 1960s 50 per cent more fixed combinations were available to the market than single-drug entities (USDHEW, The Drug Prescribers, 1968). They accounted for half of all prescriptions in those years (The Christian Science Monitor, November 1971).

But the 1962 Kefauver-Harris amendments to the US Food, Drug and Cosmetic Law required manufacturers to show that fixed combinations were more effective than their ingredients taken individually. Out of 1200 combinations so evaluated, only 45 were adjudged by the FDA to pass this test, and after 1971 the fixed combinations were banned from use, even though physicians objected vociferously and continued to demand them (USDHEW, the Drug Prescribers, 1968).

In the "broad-spectrum" drug, suited to a variety of patients and a variety of entities, the interests of physicians coincide precisely with those of drug manufacturers who are always anxious to expand the market for any given new preparation and put pressure on regulatory bodies to include as many indications as possible on the package insert.

A medicine or therapeutic procedure which can be applied across the board (as opposed to the narrowly focused "specific") will always have the physician's preference. Hence, the popularity of bloodletting, quinine, arsenic and mercury in the 1850s, of the coal-tar drugs in the 1890s, and of the antibiotics in the 1950s. Chloromycetin (chloramphenicol), for instance, was initially supposed to be used in typhus, psittacosis, typhoid, brucellosis, meningococcal meningitis, and several other equally rare conditions. It was aggressively promoted, however and soon accepted as an all-purpose antibiotic for post-surgery prophylaxis, ear and upper respiratory tract infections, acne and even the common cold. It was used particularly by physicians in rural settings, presumably less sophisticated and more impressed by industry advertising, who considered it their favourite antibiotic. Half of the physicians questioned in a 1975 survey did not realize that Chloromycetin was the drug of choice in meningococcal meningitis one of the conditions for which it was originally introduced.

The anti-viral drug Ara-A (adenine arabinoside) was introduced in 1975 for herpes-virus encephalitis and herpes zoster, but its promoters

announced to the press that "the broader possibility is that Ara-A and similar agents could be used to cure a wide variety of viral diseases, ranging from smallpox to the common cold."

The estrogen preparation Premarin, approved for use in several rare

and specific conditions such as "vasomotor symptoms associated with menopause", atrophic vaginitis, and estrogen deficiencies during menopause, was promoted as a rejuvenator for middle-aged women and, in the 1970s, prescribed to as many as six million of them more than all the menopausal women in the United States.

In the antibiotic era, consumption of all drugs increased many-fold, with a consequent rise in the incidence of adverse reactions.

Careless prescribing is often exacerbated by incorrect diagnosis. A 1972 analysis of a thousand patient records in Ohio hospitals found that 340 received antibiotic treatment: the prescription was justified in only 13 per cent of the cases, questionable in 21 per cent, and entirely irrational in the remaining 66 per cent.

Antibiotic therapy is common in chronic bronchitis, and yet the death rate in England from this condition was the same in 1970 as in 1935.

The physician may prescribe an antibiotic rather than refine his diagnosis. Kunin observed in 1973: "The ready availability of the new agents . . . has changed the approach of physicians to the care of desperately ill patients. This change in practice also affects the care of patients with only minimal infection or in whom infection is only threatened."

Harris Coulter

Excerpted with permission from Divided Legacy: A History of The Schism in Medical Thought (US$54, inc p&p, The Center for Empirical Medicine, 4221 45th Street NW, Washington, DC 20016).

!AHarris Coulter


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