More than molecules – how pill pushers and the media medicalise social problems [mp3 lecture]

January 2nd, 2008 by Ben Goldacre in bad science, big pharma, medicalisation, podcast, regulating research | 22 Comments »

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I’ve got a whole bunch of mp3’s to post from last year, which I’ll start doing in dribs and drabs. Here’s a talk I gave in Brighton, or rather, here is a recording of my invited “President’s Lecture” at the British Pharmacology Society’s annual conference, which I suspect is a bit of an honour.

The title was “More than molecules – how pill pushers and the media medicalise social problems”, and it’s a romp through tricks and traps which big pharma, quacks, and the media all share. More than that it’s about how attractive we all find it, as a society, to dodge important social, political and personal problems by reducing them to mechanical and sciencey-sounding explanations involving serotonin or fish oils.

One thing to notice – around halfway through – is that I have invented a word, which I’m rather pleased with. You’ve all heard of “me-too” drugs, where pharmaceutical companies (who aren’t coming up with novel drugs much these days) simply copy each other’s new molecules and then produce their own marginally different copyrighted versions (I’m thinking about omeprazole, lansoprazole, pantoprazole, and the rest).

There’s a new game in town, where the company releases one enantiomer of the racemic mixture, as a new pill, just when the old form of the drug is coming to the end of its copyright term. I’m talking about esomeprazole (the new omeprazole) and escitalopram (the new citalopram).

These rarely outperform their predecessors and are now officially called “me-again” drugs, because I have decided so. You heard it here first. Use it widely. The rest of the lecture, I should add, is infinitely more amusing and accessible than this geeky dig.

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At some stage I’ll sort out the mp3 podcast feed thing properly but until then you can play or download the files from here manually. One thing I’ve noticed is that people tend not to discuss podcasts as much as posts, although the mp3 files get downloaded and listened to loads. If anyone has any ideas on transcription that’d be great to hear, and if you like to tinker, here are the usual instructions for subscribing.

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If you want to do it manually, just use this link…

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Any problems let me know as the podcast is in testing phase at the mo.

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22 Responses

  1. Ulrich said,

    January 2, 2008 at 1:43 pm

    Wow! You invented a new word and it already found its place in the “Illustrated Companion to Pharmacology” of The Kanji Foundry Press
    and also in the 10th edition of P. Bennett’s “Clinical Pharmacology” (p. 36 in)

  2. muscleman said,

    January 2, 2008 at 3:20 pm

    Nice talk Ben, though you sounded a bit hesitant and under prepared to me. Pressure of work telling perhaps? BTW was that Alan Boobis introducing you?

  3. jackpt said,

    January 2, 2008 at 11:17 pm

    Good talk. Sounded like the audience digged it too.

  4. jonathansizz said,

    January 3, 2008 at 2:29 am

    I just read an interesting paper on pill pushers in PLoS Medicine:

    The conclusion states:

    From this new estimate, it appears that pharmaceutical companies spend almost twice as much on promotion as they do on R&D. These numbers clearly show how promotion predominates over R&D in the pharmaceutical industry, contrary to the industry’s claim. While the amount spent on promotion is not in itself a confirmation of Kefauver’s depiction of the pharmaceutical industry, it confirms the public image of a marketing-driven industry and provides an important argument to petition in favor of transforming the workings of the industry in the direction of more research and less promotion.

  5. yoav said,

    January 3, 2008 at 9:42 am

    Interesting talk.

    Last time I made a comment was in the days before this website existed and Bad Science was published on Thursdays. You dismissed some good science amongst the bad. Now you’ve done it again.

    Not all enantiomers are bad.

    Molecules made by biological systems (human cells, bacteria) are made in one enantiomeric form. When the same molecule is made in the lab by chemical means, the racemic form is made. It doesn’t take a great leap to realise that the intended effect of the molecule are the result of one enantiomer whilst the unwanted side-effects are caused by the other.

    A good example is bupivacaine, a widely used local anaesthetic which is effective but can be lethal in overdose. Recently, enantiomeric L-bupivacaine has been produced which whilst just as effective, has a much better safety profile.

    The same goes for the anaesthetic Ketamine, though no drug company has developed it into a marketable product. There are other examples.

    Otherwise keep up the good work.

    Yoav (brother of Rami)

  6. Ben Goldacre said,

    January 3, 2008 at 10:43 am

    i suspect you may be criticising me over something i haven’t said, although i’ve not listened back to what i said off the cuff.

    i gave esomeprazole (”nexium”) and escitalopram as examples of “me-again” drugs, where an enantiomer is wheeled out, we might suspect, to “evergreen” a product. in those two cases i am pretty clear, in my verdict on the literature (which is all one can ever have, but it’s a sensible one shared by many if not most) that there is little compelling evidence of superiority for either product over the racemic mixture, although i’m happy to be persuaded otherwise.

    in the case of the esomeprazole trials for example (from memory, bit busy) there are issues with inadequate comparator doses, minor differences, and if i remember correctly marcia angell (her out of NEJM) has accused the company of some form of research shiftiness. it’s one of the top five bestselling drugs in the world.

    but i agree, not all enantiomers are bad, as you say, and l-bupivacaine may well be as effective with fewer side effects. out of sheer curiosity i’d be interested to know which side effects of ketamine are reduced with the enantiomeric form, since i’d assume that the problematic ones which stop it being more widely used (eg raging scary hallucinations) might be related to its mode of action, glutamate blocking, but i’m no big expert on either drug.

  7. shpalman said,

    January 3, 2008 at 4:42 pm

    “Happy families are all alike; every unhappy family is unhappy in its own way.” – that’s the first sentence of Anna Karenina by Leo Tolstoy.

  8. Frunobulax said,

    January 3, 2008 at 5:34 pm

    Hi Ben
    Liked the talk
    Do you have links to the slides by any chance?

  9. dmfigaro said,

    January 3, 2008 at 5:41 pm

    What do you think of this item on web 3.0 and medicine?

  10. Dr Aust said,

    January 3, 2008 at 8:30 pm

    Of course, you might think that there was enough of the developing world out there for anaesthetics that were useful in non-fancy hardly-hospital conditions (i.e. a lot of the world) to be worthwhile… which in a way goes back to the economic-imperatives-for-R&D argument.

    As a sometime lecturer in pharmacological things and other half of an ex-anaesthetist was fascinated to recently read a med student blog describing the student giving iv ketamine infusions for anaesthesia during an elective stint in the South Seas.

  11. Dr Aust said,

    January 3, 2008 at 8:46 pm

    PS Re Nexium (active enantiomer of omeprazole), I thought the definitive “cultural” comment on its lack of added benefit vs the racemic form was that even the US Army had decided to go for the racemic stuff.

    US defence procurement has traditionlly been a money-burning snouts-in-trough gravy train of legendary proportions – hence the old jokes / urban legends about the three thousand dollar toilet seat for the B-52 bomber – the seat was supposed to be “nuclear blast resistant certified”.

    Anyway, if even the US Military isn’t taking “blue chip” Nexium over racemic omeprazole you can bet there’s no worthwhile evidence the single enantiomer is better.

  12. igb said,

    January 3, 2008 at 8:50 pm

    “ketamine […] raging scary hallucinations) ”

    50mg (0.5mg/kg) IV when you’ve been reading an Ian Banks `Culture’ SF novel is a good combination. The Colonel that administered it had the decency to escort my wife out of the room for half an hour: his advice was that hearing the babble can be quite upsetting. The hallucinations weren’t that scary, but having lived to 42 without taking any hallucinogens they were quite exciting.

  13. neilcam2001 said,

    January 4, 2008 at 2:17 pm

    I can’t listen to the podcast but I’d be interested to know whether the term ‘quacks’ includes some doctors or whether the medical profession as a whole is excluded from any allegation of participating in the ‘tricks and traps’.

  14. Andrew Clegg said,

    January 6, 2008 at 5:44 pm

    When I used to work for AstraZeneca a few years ago, the joke doing the rounds was that when Nexium (esomeprazole) went off patent they were going to release the other enantiomer… You never know.


  15. Andrew Clegg said,

    January 6, 2008 at 6:12 pm

    BTW did you record your talk from NICE 2007? I was asked if I wanted to go, and said no before finding out both you and Phil Hammond were speaking. Ah well.

  16. Dr Aust said,

    January 7, 2008 at 11:14 pm

    Like the AstraZeneca gag, Andrew.

    Nexium is, as I remember a recent survey I read (anyone got the link?) currently the MOST direct-to-consumer marketed pill in the repertoire, at least in the US. As I recall the spend to plug Nexium direct to the punters in the US runs to hundreds of millions of $$$ annually.

    The cynical interpretation: when there is zero evidence the pill is cost-effective vs. cheaper alternatives, and it is so flat-out obvious that you can’t flannel / bribe the doctors to go along, go to DefCon Two and blizzard the end-users with “ask your doctor for the LATEST state-of-the-art medication for your stomach grumbles!”… and then watch the patients do the work for you.

    Nothing new, of course. When I worked in the States a decade ago I remember being amazed by the incessant TV Ads for Losec, which were fairly obviously directed at anyone with “functional gastric disorder”, aka a “nervous stomach”. At the time I am pretty sure you had to have an endoscopically diagnosed ulcer to get Losec in the UK.

  17. Andrew Clegg said,

    January 8, 2008 at 11:14 am

    I thought there had to be SOME evidence of better or safer performance over previous treatments (in at least some patients) in order to get FDA approval… Can’t remember though, it’s been a while since I’ve been in that business.


  18. Andrew Clegg said,

    January 8, 2008 at 11:14 am

    Oh sorry, you said cost-effective — I should really read things properly before I reply…

  19. miffed said,

    January 8, 2008 at 8:18 pm

    hey ben

    Can you post the slides up as well, just so I can get the gags as well.



  20. Dr Aust said,

    January 9, 2008 at 8:42 pm

    There usually has to be something Andrew (i.e. some way the drug “improves” on the previous agents), but again, if you are being cynical, it can be pretty marginal. Not sure if it even has to be based on “real end points” (controlling / improving disease) as opposed to various kinds of “surrogate / proxy markers” (e.g. biochemical parameters). The cynical view might be that the more surrogate / proxy markers you measure, e.g. loads of things related to pharmacokinetics, the more chances you have of turning up something that will let you say “look, this new (under patent and therefore much pricier) stuff is an advance on the old (now generic and hence cheap) drug because…. and here are the figures…

    This is also why there is misgiving about the extent to which the US regulators (mostly the FDA) are influenced and in some cases even funded by the PharmaCos. It is argued that this will, at the least, make the regulators less likely to ask the PharmaCos hard questions about just why the latest “me too” / “me again” drug is sufficiently different/better to get approval.

    Of course, there is a wider debate about the drug discovery process. I have some sympathy for the view that it is getting progressively harder, and more expensive, to develop new entities to tackle currently untargetted diseases, and that that explains to some extent why there are so many “me too” drugs around these days. I reckon it has been a while since the last new small molecule / novel target blockbuster drug. But when you see the myriad ways the Pharmas go about pushing pretty marginally effective (or better) compounds it is hard not to get a bit cynical. Nonetheless, one shouldn’t forget that drugs like modern antihypertensives have saved many lives. To hear some of the Alt lobby idiots talk you would think the only reason doctors gave out pills at all was to make money for the PharmaCos. This seems to be the line Lionel “Quantum Homeopathy” Milgrom is favouring lately, though in the light of the rest of his delusional worldview I can’t say I’m surprised.

  21. Dr Aust said,

    January 9, 2008 at 8:44 pm

    Oops – screwed up the HTML italics. Reminds me why I started a blog so that I could correct my own mistakes. Aaargh!

  22. ScottishNaturalist said,

    January 17, 2008 at 11:30 pm

    Enjoyed your talk Ben. When I told my mate that no real trials had been done regarding the fish oils he couldn’t believe it.