Doctor: Medical Profession Needs Dose of Sanity in Drug Prescribing
by Fred Dickey Published July 16, 2012
Jay Cohen is a physician whose mantra seems to be, “Enough is enough.”
He’s a Del Mar psychiatrist who also is experienced in family practice. He believes that a major problem in medicine today is the overmedication of patients with doses of prescription drugs given in excess of what is required for their well-being.
He has lectured, written extensively and addressed a Food and Drug Administration conference to spread the message that too much of a good thing can result in serious health problems or even death.
The man doesn’t hesitate to scatter pigeons perched in the rafters of the medical edifice.
For stark, eyebrow-raising evidence, he says research he uncovered estimates that 100,000 deaths and 2 million hospitalizations occur annually from so-called standard doses of medication.
Cohen is 66 and has been in practice since 1972. He remembers that when Prozac was first released, it was available only in a 20 mg capsule, which could not easily be divided. However, he later found a study, done by the manufacturer before the drug was approved, that 54 percent of patients needed only 5 mg. That told him that over half the patients received four times the dosage they needed.
“No wonder some of them encountered severe adverse effects,” he concludes.
“Doctors are trained to follow the drug company guidelines, and they assume that drug companies have done thorough research into dosage. This is not always the case. In fact, drug companies sometimes choose higher doses in order to ensure approval by the FDA.
“When drug companies recommend the same dosages to Nancy Reagan and Shaquille O’Neil, you know something is wrong,” he says.
When asked for examples, Cohen can empty a heavy bag: When the “hot flash” menopausal drug Premarin was first offered, it was promoted as a “natural hormone,” but, Cohen says, it was natural only to horses. He opens an old Physicians’ Desk Reference (PDR) to show that in 1997 the recommended daily dosage for women was 1.25 mg for hot flashes, though smaller dosages down to 0.3 mg were available and proven effective. After a storm of controversy attacked the drug, charging that it could lead to heart disease or breast cancer, it was almost withdrawn from the market.
Fast-forwarding 15 years, Cohen opens a current copy of PDR and turns to the page showing that today the recommended dosage for Premarin is only 0.3 mg — the same dosage that was available as the lowest dose 15 years ago.
He mentions another female drug: “The Pill.” He says that when the birth-control drug first came on the market in the ’60s, it was 800 percent stronger than today and caused many deaths.
He believes that the anti-inflammatory drugs Vioxx and Bextra, which were removed from the market in 2004 and 2005, might have been saved if offered at a lower dosage at which they showed good results in trials.
Cohen shies away from directly blaming the FDA, the drug companies or physicians. However, the arguments he puts forth point an unwavering finger at all three, and to a limited degree, patients themselves. He himself acknowledges, “Every aspect of health care is at fault.”
Even as he treads lightly on assigning blame, I ask if he is controversial in medical circles. “I don’t know and I don’t care,” he says. “I’m not comfortable saying things unless I can substantiate them.”
Cohen explains that when a company submits a new drug for approval to the FDA, it must offer evidence based on clinical trials that it is effective in a sufficiently high number of patients. Obviously, the dose must be strong enough to achieve that, and — as the Prozac study showed — perhaps stronger than is needed by many patients. However, the dosage the FDA approves usually becomes the standard recommended to doctors for prescription to all patients.
That does not mean the pharmaceutical company cannot subsequently offer lower dosages, but faced with the need to prove the drug maximumly effective to both doctors and patients on an ongoing basis, it often is reluctant to do so, or if it does, to promote it.
The influence of the drug companies can become paramount to doctors because of the confluence of two realities that Cohen cites.
One: Typically, medical school education requires only one course in pharmacology, and that’s often in the first year. Cohen believes it should be augmented by a more practical course later on, especially when students begin working with patients. That early experience would guide them to be more patient-based on the prescribing of drugs.
Two: In modern medical practice, doctors, especially in large organizations, often are scheduled to see patients on an assembly-line basis, sometimes giving only a few minutes to “routine” patient appointments. They are hard-pressed to find time to read the independent literature on new drugs or to do deeper research on existing medications.
That time pressure leaves them reliant on information and recommendations from the drug companies, which, of course, are in the business of selling their wares and in a higher-priced dosage strong enough to immediately achieve noticeable results, though it might also lead to unnecessary side effects, Cohen believes.
Too often, he continues, doctors’ only guide to drugs is the PDR, a thick book published by “Big Pharma” and distributed free to physicians. That makes them a captive, of sorts. Common sense says that “free” to doctors is a good investment by the drug companies.
Asked what feedback he gets from the medical establishment, Cohen says, “I don’t get any. I don’t hang out with them. I’ve gotten notes from pharmacists who wish more doctors would think about these things. Sometimes, pharmacists have stronger training in pharmacology than the doctors do, and they’re the ones the patients [often] talk to when they have side effects, so they hear about it.
“One doctor told me, ‘How am I going to find the time to ask about all this?’ meaning asking patients [about their drug-reaction history]. But you only need to ask one question: ‘Have you had problems with medications before?’ ”
(I guess at some point I have to insult your intelligence by saying no one should make a dosage adjustment without talking to a physician. Or, as they say, don’t try this at home.)
Some patients have fears of going to the doctor because every time they’ve been given a medicine, they’ve had a reaction, Cohen says. “Most patients are pretty smart people: If they’ve had a reaction, they know it. If you ask, you’ll have trouble stopping them [from talking].”
Cohen stops short of criticizing the dosages of all drugs. He specifically excludes anti-viral drugs as well as antibiotics and cancer-fighting drugs. He also says the ultimate goal is to find meds that work while causing the least amount of side effects. And if that’s where a person is, there’s no need to change dosage.
He says that when he tells his own patients he will start them at the lowest dose of a drug and then track the reaction with them, they’re greatly pleased.
Cohen says patients have a responsibility to be aware of their own medication experiences and take the initiative in telling their doctor about them, even if he or she doesn’t ask first.
He concludes, “My basic principle is, the best dosage of any medication is the least amount that works.”
Fred Dickey of Cardiff is a novelist and award-winning magazine writer who believes every life is an adventure. He welcomes column ideas and other suggestions; contact him
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