A Tale of Two Medicines

Bias in Medical Practice

If you have read some of my other posts, you know I have an interest in the culture of medicine.  More specifically, how cultural biases in medical training and the culture of medical practice affect the care of patients.  I think one of the starkest examples of this is the reaction to deaths from rofecoxib (Vioxx) and those from opiate pain medications.

tale one: rofecoxib

Rofecoxib is a non-steroidal anti-inflammatory drug (NSAID) pain medication.  Ibuprofen and naproxen are common NSAIDs.  At high, sustained doses they have a range of negative side effects – GI bleed, kidney damage, hypertension, heart disease, etc.  Rofecoxib was biochemically more specific to inflammatory pain. Therefore, it was a new generation of NSAID with supposedly fewer side effects.

Rofecoxib was on the market from 1999-2004.  The FDA pulled it from the market after discovering evidence that it increases rates of heart attack.  Doctors prescribed it primarily to treat arthritis pain, which is more common in the elderly, who are also more likely to have heart disease.  It turns out, a deadly combination.

Hand Arthritis – By Internet Archive Book Images, via Wikimedia Commons

“Dr. Graham and colleagues estimate that during the five years Vioxx (rofecoxib) was sold in the United States, it caused between 88,000 and 140,000 excess cases of serious heart disease. Based on national statistics of heart disease and deaths, the researchers estimate that close to half of those cases, or 44 per cent, would have resulted in fatalities. This means anywhere from 39,000 to 61,000 deaths in the United States could be linked to Vioxx.” – Daily Globe and Mail

tale two: opiates

Opiates are a class of pain medications originally derived the opium poppy.  The category now also includes a number of synthetically created compounds designed to act on the same biochemically receptor.  These include oxycodone, hydrocodone, fentanyl, heroin, tramadol, etc. I am sure the current opiate epidemic is not news.   People are dying at an unprecedented rate from opiate overdose.

Like NSAIDs, opiates have a wide range of known side effects.  These range from constipation and urinary retention to addiction, respiratory depression, and death.  Let me clarify here: addiction and death from respiratory depression have been known complications from opiate use for over a 100 years.

In fact, roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them and between 8 and 12 percent develop an opioid use disorder (addiction). This is NOT new data coming out in research papers.

In 2017, 63,617 people died from drug overdoses. At least two thirds of those were linked to opiates.  Almost as many people who died from rofecoxib over FIVE years died in ONE year from opiates.   Many will say that most of those are from illegal use of the substances, which is true.

However, in 2008-2009, a study showed that 86% of injection drug users started with prescription opiates.  That means that conservatively, around 36,491 of those deaths can be traced back to prescriptions given by a physician or healthcare provider.  We don’t even have good data on how many people are currently struggling with addiction (the corollary to heart attack in this comparison).

To reiterate, addiction to opiates has been a KNOWN side effect of treatment for over 100 years.

Rofecoxib and Opiates Kill People

Merck eventually settled its Vioxx (rofecoxib) liability for billionsMany states are suing Pharma Companies for misleading consumers and doctors about the safety profile of their drugs.  Yet, doctors didn’t know about the heart disease risk when prescribing reofecoxib.  However, doctors did know addiction and death were side effects of opiates at the time opiate treatment was increasing.  Nonetheless, we kept on prescribing them.

Again: rofecoxib is a pain medicine killed up to 61,000 people over a 5 year period from heart attacks.  Opiate pain medicines have killed many times that over a 5 year period and almost as many in 2017 ALONE.  Rofecoxib was rapidly removed from the market to protect patients.  Yet, ALL of the opiate pain drugs remain on the market.  What explains this difference in reaction?

to americans, addiction is a vice, not a disease

The main difference in these two situations is our societal wide lack of compassion for people struggling with addiction.  Don’t get me wrong, people in the throws of addiction are often very unpleasant people to care for.

Then again, many schizophrenics in the throws of their disease are very unpleasant to care for.  However, we don’t blame their disease on their character.  We recognize that they are sick and need treatment.

I can’t count how many times patient’s have said to me, “Well, those people aren’t using the medicine correctly,”  when I am describing the risks of addiction and death.  The implication is that I could never be one of those people because I have a stronger character, am more educated, am God-fearing, etc.

Guess what, people?  Addiction can and does happen to anyone.  You are not immune.  Just like heart disease, some people are at higher risk (those with histories of sexual abuse, PTSD, depression, anxiety, etc).  No one is immune.

addiction is a terrible disease

Moreover,  I have cared for people with heart attacks and people with addiction.  Heart attacks are scary.  They can be personally devastating.  Whenever someone dies, it is very, very sad.

However, heart attacks do not leave entire families broken and scattered.  Babies, addicted to opiates from birth, are not struggling through withdrawals in NICUs around the country because of heart disease .  Whole communities are not in a constant state of grief because of heart disease.

Yet, people with heart disease are treated as sick people and people with addiction are treated as bad people.  This continues to happen everyday in this country.

when you find yourself at the bottom of a hole, the first thing to do is stop digging

It is time we stop digging.  I am not proposing we ban the use of all opiates. Yet, as long as we are unaware of our biases toward the risks of addiction and treatment with opiates, we will be doomed to repeat the cycle.

 

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