Powerful Medicines : The Benefits, Risks, and Costs of Prescription Drugs

Rating:
Summary: A Magical Mystery Tour
Review: "Powerful Medicines" is a fascinating (and at turns horrifying) trip through the mysterious world of Rx meds, skillfully guided by a superb teacher. To a layman who has relied on prescribed powerful medicines, it was illuminating, compassionate, edgy and even laugh-out-loud funny.

The case studies Dr. Avorn uses are an excellent tool, and his transitions are especially helpful in navigating the reader
along through the stages of his argument. As a bonus along the way, the book is culturally literate...I even got my RDA of Dylan and Woody Allen.

If only the medical/pharmaceutical system would holistically adopt Dr. Avorn's prescription to discern its own interconnections, truthfully examine its underlying assumptions, learn together and commit to a shared vision of the future! Even in the current political/social climate, we might overcome our more venal and/or boneheaded tendencies and become a healthier society.

Rating:
Summary: Book for all to read
Review: Avorn's beautifully written book seems to become more important for "the rest of us" with every breaking news story about the pharmecutical industry. My suggestion in the light of the Vioxx disaster? If you are interested in your own health and the medicines we take so casually, then buy a copy of this beautifully written and oh so revealing book.

Let me give you a flavor of just how good a writer Avorn he and how revealing this book is by quoting the way he introduces a chapter from this book:

"In a former British colony, most healers believed the conventional wisdom that a distillation of fluids extracted from the urine of horses, if dried to a powder and fed to aging women, could act as a general tonic, preserve youth, and ward off a variety of diseases. The preparation became enormously popular throughout the culture, and was used widely by older women in all strata of society. Many years later modern scientific studies revealed that long-term ingestion of the horse-urine extract was useless for most of its intended purposes, and that it caused tumors, blood clots, heart disease, and perhaps brain damage."

This (sad) "fairy tale" introduces the whole sorry tale of hormone replacement therapy for women, and how badly the research was to defend it. The book just gets better from here.

Rating:
Summary: A must read for everybody who cares about health care
Review: Dr. Avorn's book is unique: it summarizes complex issues concerning modern medicines and related policies in a way that makes the field accessible to everyone and yet each chapter reflects the author's depth of knowledge and wisdom based on 25 years of patient care and active research at Harvard. He brings all relevant issues concerning modern drugs on the table, including effectiveness, safety, and costs, and draws connections that are not obvious to most of us but are essential to fully understand the interactions between patients, physicians, insurance companies, and drug manufacturers. Unless we understand this system and are willing to act accordingly, we will continue to pay too much for too little improvement in medicine and will further stretch our health care system to the limit. Dr. Avorn's book provides such an understanding accessible for everyone and is reason for hope.

Rating:
Summary: Listen To This Doctor - Engrossing And Definitive
Review: Dr. Jerry Avorn does a masterful job of evaluating the benefits, risks, and costs of prescription drugs. There have been almost ten books in recent time delving into the issues of good drugs, dangerous drugs, ineffective drugs and the corrosive effects of commercial influence over medical research. This book goes into more detail and is more sophisticated than any of the others on this topic that I have seen.

The list of problems that the consumer faces when taking many of these prescription drugs seems to be almost without limit. You will read about incomplete testing of drugs. You will also learn about testing in age groups that are different than the ultimate or target age groups. You will learn of drugs given to children without any non-adult testing. There are approved drugs such as Accutane that can have devastating results if the directions are not followed exactly.

This book addresses the out-of-control drug advertising on TV, online and in print media. The costs of drugs are often based on whatever the market can bear, even when the key discoveries are not made by the drug company. The author explains that the real scientific evidence shows that many of the things that you can do to protect and maintain your own health are far more effective than what the drug companies products can do for you. Many of these things that you can do to stay healthy are more difficult to do than just popping a few pills - things like exercise, weight lose, stop smoking and eating a low-fat and low-carb diet.

Rating:
Summary: A Doctor Speaks Out
Review: Drugs are one of our nations big problems, not those drugs that you buy on the street corner but those that you buy at the drug store.

Time after time during the recent election the problems of drugs were brought up with vague promises that the Government was going to help. In this book Dr. Jerry Avorn talks about the shortage of comparison data of similar drugs, lapses in the detection of lethal side effects, and drug company marketing plans that influence what doctors prescribe, and what patients demand.

The good news, he explains, is that the real scientific evidence shows that many of the things that you can do to protect and preserve your own health are far more effective than what the drug companies products can do for you. Unfortunately this means things like exercise, lose weight, stop smoking - things that are harder to do than simply taking a pill.

Another approach he is spear heading is to provide more information that is really useful to both doctors and patients. Perhaps this can be made to counter some of the one sided claims made for the newest and much more expensive wonderdrug over something older, cheaper but just as effective. See more at powerfulmedicines.com.

An unintended side effect: It made me wonder if it is time to buy drug company stock.

Rating:
Summary: Erudite, authoritative, courageous, honest, and flawed
Review: Easy to read and follow, wide-ranging in scope, dripping with insight from a real medical insider, and very humorous besides, this book is a tour-de-force in many aspects. Problems with HMOs, the FDA, Big Pharma, and out-of-control drug advertising are all addressed. The benefits of drugs are addressed by giving examples of the launching of some that were later risky enough to be banned. The most detailed illustration of the benefits and limitations of the randomized clinical trial (RCT) I have ever read are in this book. Dr. Avorn also gave the best illustration of the advantages of the observational study on large numbers of subjects as a better way to find the risks of drugs. The risks of drugs have many causes besides thier inherent toxicity. Dr. Avorn shows how the subjects in an RCT may be healthier or younger or too male compared with the likely drug target group, how dosages may be too high for children or the elderly, how adverse effects are hard to predict and under-reported and that RCTs are not run for enough time. He notes how too many drugs are approved by the FDA based on handy measurements such as blood pressure or cholesterol levels, not real clinical endpoints, like death. The costs of drugs are noted to be whatever the markets will bear, even when the key discoveries are made in government or academic labs, as is usually the case. He writes about the drug information overload for physicians from ads or "detail women" from Big Pharma, and of "education" courses put on by Big Pharma, all biased of course. Dr. Avorn has, for >25 years, been involved in studies on how to use computerized data on filled prescriptions and later medical histories of each patient to correlate drug use with well-being. Some of the results have been put into practice with improved patient well-being and lower costs for drugs. He also introduced "academic detailing" to teach physicians how to prescribe better and cheaper drugs. For these efforts alone he should have a Nobel Prize in Medicine, in my opinion. He makes a number of practical suggestions on improving health care in the USA, all with understanding that pluralism, competition and choice are key features of any success in the USA. Prescribing via computer could alert the MD to cheaper drug alternatives, dosage for each age group, and potential interactions. The pharmacy would have accurate input and alerts to prescriptions being filled at other pharmacies. Of larger scope is Dr. Avorn's idea of creating non-profit health-care provider organizations that are also the insurers. They would be audited annually and evaluated for effectiveness annually with all results being made public. Other suggestions are that drug approval by the FDA no longer be "yes and good luck" or "no", but that there be conditional approvals to be reviewed. Some other federal agency would evaluate risks, not the same people in the FDA who approved the drugs. There is great detail and subtlety overall. The index is adequate. Referencing by page number was sparse. ***** So how could I give only 3 stars to this tour-de-force? While Dr. Avorn was realistic about drug classes such as the NSAIDS (Vioxx, Celebrex), he is far too sanguine, in my opinion, about anticancer, blood pressure (BP) and cholesterol drugs. He is far too negative about vitamins and supplements. Anticancer drugs usually do not prolong life (Moss, 2000). There is no evidence that the wide use of BP drugs provides major benefits, even Dr. Avorn's preferred beta-blockers and diuretics. In RCTs combined in a meta-analysis, the use of beta-blockers reduced mortality by only 0.1% annually (Psaty, 1997). The ALLHAT RCT cited by Dr. Avorn had no placebo arm, and the results for the diuretic, which was not a thiazide type, were a bit worse than for the other drug types (Kauffman, 2004). Only when BP is very high, as in the Swedish Trial in Old Patients (STOP), (Dahlöf, 1991), is the result barely worthwhile. The 1627 subjects of both sexes were 70-84 years old and had mean BP = 195/102 at baseline and were followed for 4 years at 116 health centers in Sweden. The drugs were a diuretic, or the same combined with a beta-blocker. After 4 years 89% of the drug-treated group were alive vs. 85% on placebo, for a drop of just 1% per year in mortality. Stroke rate dropped just 1.5% per year. In the ASCOT trial of atorvastatin (Lipitor), the chance of not dying was improved by just 0.15% per year (Sever, 2003) at a cost of $1,000,000 to prevent 1 death for one year! And this was a trial that Pfizer chose to publish! In the few RCTs in which mortality for women on statin drugs was published, it was higher in all cases (Criqui, 2004), as it is also for aspirin use (Kauffman, 2002). The slight benefits of statin drugs on heart attack and mortality rates have nothing to do with lowering cholesterol or LDL levels, but are related to the presence of cytomegalovirus or inflammation in mostly male patients with severely blocked coronary arteries (Horne, 2003). Dr. Avorn does not admit that the low compliance rates with these two types of drugs is caused by their severe side-effects such that half drop them in a year and up to 3/4 after 2 years (Pahor, 2000; Jackevicius, 2002). Dr. Avorn was extremely negative on the use of supplements, and on the 1994 law that declared them foods, not drugs, unaware of the previous FDA bias in evaluating them. He wrote that none have had valid trial results. This is untrue for selenium (Bjelakovic et al., 2004), a few herbals (Vickers, 1999), ginkgo (Kleijnen, 1992), vitamin C (Hickey, 2004), magnesium (Paolissi, 1989) and some others. Stopping useless drugs altogether rather than substituting cheaper ones, and using certain supplements will save far more than prescribing generics! Willful perversions of RCTs is better covered in Overdo$ed America by John Abramson, MD. Complete references available.

Rating:
Summary: Any one interested in health must read this
Review: Few people besides Jerry Avorn would have the courage and authority to write a book like this. An associate professor of medicine at Harvard Medical School and pharmaceutical researcher, he knows drugs and drug side effects more than any author I've read. If you are considering another book about medicine or drug companies, think again. This book will be the most important you read for a long time. It's easy to read and Avorn's wit and conversational writing style make it a joy for anyone. Cliches be damned, I could not put this down, reading about drug company scandal after scandal and what to do about it.

Rating:
Summary: A delightful read. I bought four copies for my friends.
Review: The book is gilded with so many metaphors, anecdotes and literary allusions, and it is written in such an engaging style, that it is a delightful read. Avorn is a wonderful teacher.

This is also a mind-expanding book. I learned so much about a field that I thought I already understood pretty well. It felt like the biblical scales fell away from my eyes and I was able to see so much better: the history of the FDA's role in protecting the public (or is it the drug manufacturers?) from medications that are unsafe, ineffective or too expensive. The tradeoffs between risk, effectiveness and cost of drugs, and doctors' astonishing lack of information about these is a major theme of the book. But he taught me about many other areas as well. For example, the differences between prospective, controlled and observational studies and the ego-personalities behind each type--and why we need both types. These are just a couple examples. I might add that Dr. Avorn is really not out to bash Pharma or doctors or anybody. He's just describing reality as it is. He does have some terrific ideas for solutions. I wonder how many billions of dollars we would save annually, and how much better U.S. health care would be if Jerry Avorn was head of the FDA. Hmmm...

This book must have been a labor of love for Avorn-a gift to his readers. My friends have thanked me for giving them copies. I should caution that if you haven't been to college, this isn't for you. This book is for doctors, clinicians, legislators, health care policy professionals, and for people who care about the decisions that doctors make about their health.

Tom Doerr, M.D.


Rating:
Summary: A `must' for any interested in drug-related studies
Review: What are the benefits, risks and real costs of prescription drugs? Doctor Avorn is an associate professor of medicine at Harvard Medical School - and a chief of Pharmacoepidemiology IN Boston: as both a medical doctor and a drug researcher, he's the perfect author for an in-depth survey of the failings of drug prescriptions. From the lack of medical doctor knowledge about medicine effectiveness and comparisons between brands and types to dangerous, little-charted side effects, too-high costs and other health issues, Dr. Avorn provides a hard-hitting analysis of the drug industry and its lasting effects upon consumer health. A `must' for any interested in drug-related studies and safety.


Rating:
Summary: Behind the Medicine
Review: With a mix of investigative research, history of science, public policy, and humor, Dr. Avorn presents an engaging and informative look at modern medical practice. The impact of the drug industry on the development of the American health care system has been long overlooked as managed care and other similar issues have dominated the landscape, but this book helps tilt the balance with a near-comprehensive evaluation of drug development, marketing, and government policy. The style mixes folksy story-telling and satire with sharp-edged analysis. It should be a must-read for anyone in the health care industry--especially medical students and residents--but Dr. Avorn's expert perspective on some of the biggest headline issues of the past 20 years (Bendectin, fen-phen, etc) would be enjoyed by any news-savvy person.