5 ms·

We're in a huge pickle in general because every simple, effective drug gets blacklisted pretty quickly, because people realize there's a simple, effective optio

We're in a huge pickle in general because every simple, effective drug gets blacklisted pretty quickly, because people realize there's a simple, effective option for treatment that doesn't make them dependent on our horrifically broken medical system and start buying it without funneling through the racket. This upsets the racketeers and they work to clamp down on it. In the rare case where a simple, effective drug gets into medical practice, it magically ends up becoming "not recommended" about 20 years after it hits the market when the pharmaceutical company's patent runs out. MAOIs work much better for depression than SSRIs, for example, yet the clock runs down, a few widely-publicized cases of serotonin syndrome caused by careless ER doctors hit the press, and suddenly anyone prescribing those drugs comes under scrutiny, and we all need to switch to the newly-patented option.

ghostbrainalpha 7y ago
Maybe this is pessimistic but I think a lot of the reason for the switch from MAOIs to SSRIs comes from people not wanting to gain weight. SSRIs tend not to have that side effect and less side effects in general, even though they are definitely less effective.
- InitialLastName 7y ago
  From my experience with loved ones' struggles with medicating mental illness, much of the difficulty is in finding a treatment regimen that's both effective enough to function normally and minimizes side effects. If SSRI's work well enough for some chunk of the depressed population and have fewer side effects than the alternatives, why would "lets try that first" be a pessimistic outcome?
  - cookiecaper 7y ago
    Because "fewer side effects" is such a massive overgeneralization that it's meaningless. Side effects are different for each drug and there's no reason to assume the patient would prefer the side effects of an ineffective SSRI to an effective MAOI right out of the gate. Additionally, each doctor wants you to try the less-effective drug for months at a time, each revision in the medication requires an expensive and time-consuming follow-up appointment at which point the doctor won't remember anything about you anyway, and SSRIs have their own non-trivial side effect profiles and withdrawal symptoms. It's just not as simple as -- or at least shouldn't be as simple as -- "oh, this one has fewer side effects!" It's especially bad in the case of SSRIs, because to switch from an SSRI to an MAOI or vice-versa, you have to "wash out" (that is, go unmedicated) for at least two weeks, during which time the person is unlikely to be functional regardless of their natural chemistry because they'll be withdrawing from the old medication.
nradov 7y ago
That's not how the process works. MAOIs may work better than SSRIs for some depressed patients, but certainly not everyone. Depression isn't a single disease; it has multiple causes and treatments. MAOIs have several serious side effects beyond just withdrawal syndrome so they shouldn't be prescribed lightly. But they absolutely are still prescribed when appropriate if safer treatments aren't effective.
- cookiecaper 7y ago
  Not to be overly antagonistic here, but "the process" doesn't work at all. Doctors make drive-by appointments, write an Rx after a few minutes, and they don't want to hear any guff about it. Many of them refuse to take action that would benefit their patients because they're worried about drawing attention from law enforcement or getting labeled as a pill mill. High-deductible health plans are becoming pervasive so each check-up is a hundred bucks. Patients are treated alternately like cattle or criminals, must adhere to the doctor's schedule ("sorry, I only work half-days 3 days of the week, and make sure you schedule 4 months in advance!"), and the doctor has forgotten everything about the patient by the next follow-up. These are the people to whom you're entrusting your brain chemistry. Meanwhile, the industry replaces pseudophedrine with phenylephrine (placebo whose only reliable effect is increased blood pressure) so that they don't have to admit every effective decongestant is now restricted and pushes the predominantly-ineffective atomoxetine as a replacement for amphetamines. There are definite benefits to competent medical supervision, if it ever actually happened, but it's so uncommon that we're better off dropping the pretense and just using drugs that work.
  - wayoutthere 7y ago
    This right here. I didn’t actually start getting better until I started seeing doctors in private practice who I paid to listen to me.
  - nradov 7y ago
    You seem to be confused and are all over the map with that comment. Sure some patients aren't able to get enough time with qualified doctors. However that has nothing to do with whether a particular depressed patient is best treated with an SSRI, MAOI, or something else. You cannot seriously claim that MAOIs are completely safe: like every powerful drug, doctors have to weigh benefits against potential side effects. Pseudoephedrine is still available without a prescription if you want it. I bought some at my local pharmacy last month. The government forced the industry to restrict sales quantities and require customers to show ID because drug dealers were buying it to cook methamphetamine.
GavinMcG 7y ago
> every simple, effective drug gets blacklisted pretty quickly, because... [they don't make people] dependent on our horrifically broken medical system This is a claim that demands substantial support - particularly when simple effective drugs are used routinely! - and you've offered none.
- cookiecaper 7y ago
  This is a discussion board, not a scientific journal. Every post doesn't have to be a thesis. If you'd like to discuss something specific rather than just pointing out that my comment doesn't come with a bibliography, feel free.
  - GavinMcG 7y ago
    No, but you're basically alleging a conspiracy. It's up to you to back up your claim, but I'm asking for some support rather than outright dismissing your view.
    - mirimir 7y ago
      Yes, they're alleging conspiracy. I think that Hanlon's razor applies here. > Never attribute to malice that which can be adequately explained by stupidity. It's just how the system works. People behave as if they're part of a conspiracy, but they're all just doing what seems best (here, most profitable) for them. That's somehow worse than conspiracy.
mirimir 7y ago
While that does happen, I don't think that it's as much of a conspiracy as you claim. But I do agree that it's "broken", in that it's more about economics than healthcare. One issue is that new drugs aren't approved based on testing against old drugs, or other treatments. They're just tested against no treatment. It's generally not until much later that comparison studies get done. The other issue, as you say, is patent protection. Patent protected drugs are heavily promoted. And a huge chunk of that is detailing to physicians. Generic drugs generally aren't promoted. That's because physicians aren't actually prescribing them. They're prescribing the brand, which pharmacies fill as generic equivalents, unless the prescription says "fill as directed". So when some new patent protected drug comes out, it tends to displace older drugs. Because the older brand drugs are no longer being promoted.
- munk-a 7y ago
  I really think you and the poster above are disagreeing a lot less than you think. The older post is being vague on the conspiracy and using an unnecessary amount of hyperbole - but what you've stated is the actual source of the conflict of interest... Drugs aren't being sunsetted because they're ineffective but because they're unprofitable. There are some pretty crazy effects from all the ridiculous players involved in this market with manufacturers plying clients with financial assistance, PBMs extorting manufacturers for rebates and providers over-billing everyone... the beautiful thing is this sunset effect is clear to see even through all that haze.
  - mirimir 7y ago
    I guess. But my point is that it's all about money.
    - mirimir 7y ago
      Belated edit. Medical care being about money is one issue, given the Hippocratic Oath. But it's possible to have medical care systems where economics drives good care. The US doesn't have that. As I said, there's a very similar situation in the US about child care and education. And really, it's about everyone who isn't effectively competing for resources.
derefr 7y ago
> In the rare case where a simple, effective drug gets into medical practice, it magically ends up becoming "not recommended" about 20 years after it hits the market when the pharmaceutical company's patent runs out. One might posit that the bias is in the drug being recommended in the first place (by a company that stands to gain from that recommendation and can afford lobbyists.) > MAOIs work much better for depression than SSRIs, for example, yet the clock runs down, a few widely-publicized cases of serotonin syndrome caused by careless ER doctors hit the press Or, y'know, caused by people eating cheese. Or drinking. MAOIs aren't not-a-first-line-therapy because they're easy to mis-prescribe; they're not-a-first-line-therapy because they're incompatible with many people's lifestyles. Treatment regimens are designed such that you prescribe first the thing that's least likely to interfere with the patient's life, however small a chance it has of helping them. Because, if it does help, then it helped with (likely) no negative consequences. In other words, most first-line treatments are placebos, and that's the whole point. First-line treatments should be placebos. People who can be cured by placebos shouldn't get drugs stronger than placebo; since drugs stronger than placebo necessarily have more side-effects than placebo. People who aren't cured, come back and get the second-line treatment. And on and on until they get one that works for them.

ghostbrainalpha 7y ago

Maybe this is pessimistic but I think a lot of the reason for the switch from MAOIs to SSRIs comes from people not wanting to gain weight. SSRIs tend not to have that side effect and less side effects in general, even though they are definitely less effective.

InitialLastName 7y ago
From my experience with loved ones' struggles with medicating mental illness, much of the difficulty is in finding a treatment regimen that's both effective enough to function normally and minimizes side effects. If SSRI's work well enough for some chunk of the depressed population and have fewer side effects than the alternatives, why would "lets try that first" be a pessimistic outcome?
- cookiecaper 7y ago
  Because "fewer side effects" is such a massive overgeneralization that it's meaningless. Side effects are different for each drug and there's no reason to assume the patient would prefer the side effects of an ineffective SSRI to an effective MAOI right out of the gate. Additionally, each doctor wants you to try the less-effective drug for months at a time, each revision in the medication requires an expensive and time-consuming follow-up appointment at which point the doctor won't remember anything about you anyway, and SSRIs have their own non-trivial side effect profiles and withdrawal symptoms. It's just not as simple as -- or at least shouldn't be as simple as -- "oh, this one has fewer side effects!" It's especially bad in the case of SSRIs, because to switch from an SSRI to an MAOI or vice-versa, you have to "wash out" (that is, go unmedicated) for at least two weeks, during which time the person is unlikely to be functional regardless of their natural chemistry because they'll be withdrawing from the old medication.

nradov 7y ago

That's not how the process works. MAOIs may work better than SSRIs for some depressed patients, but certainly not everyone. Depression isn't a single disease; it has multiple causes and treatments. MAOIs have several serious side effects beyond just withdrawal syndrome so they shouldn't be prescribed lightly. But they absolutely are still prescribed when appropriate if safer treatments aren't effective.

cookiecaper 7y ago
Not to be overly antagonistic here, but "the process" doesn't work at all. Doctors make drive-by appointments, write an Rx after a few minutes, and they don't want to hear any guff about it. Many of them refuse to take action that would benefit their patients because they're worried about drawing attention from law enforcement or getting labeled as a pill mill. High-deductible health plans are becoming pervasive so each check-up is a hundred bucks. Patients are treated alternately like cattle or criminals, must adhere to the doctor's schedule ("sorry, I only work half-days 3 days of the week, and make sure you schedule 4 months in advance!"), and the doctor has forgotten everything about the patient by the next follow-up. These are the people to whom you're entrusting your brain chemistry. Meanwhile, the industry replaces pseudophedrine with phenylephrine (placebo whose only reliable effect is increased blood pressure) so that they don't have to admit every effective decongestant is now restricted and pushes the predominantly-ineffective atomoxetine as a replacement for amphetamines. There are definite benefits to competent medical supervision, if it ever actually happened, but it's so uncommon that we're better off dropping the pretense and just using drugs that work.
- wayoutthere 7y ago
  This right here. I didn’t actually start getting better until I started seeing doctors in private practice who I paid to listen to me.
- nradov 7y ago
  You seem to be confused and are all over the map with that comment. Sure some patients aren't able to get enough time with qualified doctors. However that has nothing to do with whether a particular depressed patient is best treated with an SSRI, MAOI, or something else. You cannot seriously claim that MAOIs are completely safe: like every powerful drug, doctors have to weigh benefits against potential side effects. Pseudoephedrine is still available without a prescription if you want it. I bought some at my local pharmacy last month. The government forced the industry to restrict sales quantities and require customers to show ID because drug dealers were buying it to cook methamphetamine.

GavinMcG 7y ago

> every simple, effective drug gets blacklisted pretty quickly, because... [they don't make people] dependent on our horrifically broken medical system This is a claim that demands substantial support - particularly when simple effective drugs are used routinely! - and you've offered none.

cookiecaper 7y ago
This is a discussion board, not a scientific journal. Every post doesn't have to be a thesis. If you'd like to discuss something specific rather than just pointing out that my comment doesn't come with a bibliography, feel free.
- GavinMcG 7y ago
  No, but you're basically alleging a conspiracy. It's up to you to back up your claim, but I'm asking for some support rather than outright dismissing your view.
  - mirimir 7y ago
    Yes, they're alleging conspiracy. I think that Hanlon's razor applies here. > Never attribute to malice that which can be adequately explained by stupidity. It's just how the system works. People behave as if they're part of a conspiracy, but they're all just doing what seems best (here, most profitable) for them. That's somehow worse than conspiracy.

mirimir 7y ago

While that does happen, I don't think that it's as much of a conspiracy as you claim. But I do agree that it's "broken", in that it's more about economics than healthcare. One issue is that new drugs aren't approved based on testing against old drugs, or other treatments. They're just tested against no treatment. It's generally not until much later that comparison studies get done. The other issue, as you say, is patent protection. Patent protected drugs are heavily promoted. And a huge chunk of that is detailing to physicians. Generic drugs generally aren't promoted. That's because physicians aren't actually prescribing them. They're prescribing the brand, which pharmacies fill as generic equivalents, unless the prescription says "fill as directed". So when some new patent protected drug comes out, it tends to displace older drugs. Because the older brand drugs are no longer being promoted.

munk-a 7y ago
I really think you and the poster above are disagreeing a lot less than you think. The older post is being vague on the conspiracy and using an unnecessary amount of hyperbole - but what you've stated is the actual source of the conflict of interest... Drugs aren't being sunsetted because they're ineffective but because they're unprofitable. There are some pretty crazy effects from all the ridiculous players involved in this market with manufacturers plying clients with financial assistance, PBMs extorting manufacturers for rebates and providers over-billing everyone... the beautiful thing is this sunset effect is clear to see even through all that haze.
- mirimir 7y ago
  I guess. But my point is that it's all about money.
  - mirimir 7y ago
    Belated edit. Medical care being about money is one issue, given the Hippocratic Oath. But it's possible to have medical care systems where economics drives good care. The US doesn't have that. As I said, there's a very similar situation in the US about child care and education. And really, it's about everyone who isn't effectively competing for resources.

derefr 7y ago

> In the rare case where a simple, effective drug gets into medical practice, it magically ends up becoming "not recommended" about 20 years after it hits the market when the pharmaceutical company's patent runs out. One might posit that the bias is in the drug being recommended in the first place (by a company that stands to gain from that recommendation and can afford lobbyists.) > MAOIs work much better for depression than SSRIs, for example, yet the clock runs down, a few widely-publicized cases of serotonin syndrome caused by careless ER doctors hit the press Or, y'know, caused by people eating cheese. Or drinking. MAOIs aren't not-a-first-line-therapy because they're easy to mis-prescribe; they're not-a-first-line-therapy because they're incompatible with many people's lifestyles. Treatment regimens are designed such that you prescribe first the thing that's least likely to interfere with the patient's life, however small a chance it has of helping them. Because, if it does help, then it helped with (likely) no negative consequences. In other words, most first-line treatments are placebos, and that's the whole point. First-line treatments should be placebos. People who can be cured by placebos shouldn't get drugs stronger than placebo; since drugs stronger than placebo necessarily have more side-effects than placebo. People who aren't cured, come back and get the second-line treatment. And on and on until they get one that works for them.