Too Much Emphasis on Drugs in the Health Care System?

Dr. Gary Hart, PhD. Dr. Hart is the Director of the Arizona Rural Health Office and an Endowed Professor of Public Health at the Mel and Enid Zuckerman College of Public Health at the University of Arizona. Dr. Hart received his PhD in Medical Geography in 1985 from the University of Washington. He was formerly the director for two decades of the Rural Health Research Center at the University of Washington in Seattle.

Dr. Hart has published widely on rural health care, health workforce, clinical practice variation, geographic definition methodology, and perinatal care issues. In 1995, Dr. Hart received the National Rural Health Association’s Distinguished Researcher award. He is a co-editor of a 2001 McGraw-Hill book entitled Rural Medicine and is an author on over a 150 journal articles in such journals as the Journal of the American Medical Association, Health Services Research, and the American Journal of Public Health. Dr. Hart is involved in public health teaching and with providing services to Arizona's rural population.

In addition, Dr. Hart is involved in a broad range of workforce and rural research and policy analysis projects on topics such as international medical graduates; dental hygienists; RNs; and use of guideline behaviors in rural hospitals for acute myocardial infarction. Dr. Hart was prescribed Paxil for stressful life situation a decade ago and remains on it to this day. His major concern over Paxil withdrawal stems from watching the catastrophic influence the withdrawal had on his wife Shelly and on the stresses other caregivers must face in similar circumstances. His one attempt to quit Paxil met quickly with failure because of onset of withdrawal symptoms that were incompatible with Shelly’s already severe symptoms.

Mission Statement

Our experience with Paxil has given us the drive and passion to want to make a difference for all those who are prescribed Paxil but do not need it and those who are already on it and need help getting off of it with a well informed physician’s guidance. Most importantly we want to help those who are sitting in a physician’s office tomorrow who will be prescribed Paxil and do not need it and who will not understand the consequences of starting Paxil.

Questions and Answers

by Trung Nguyen

Can you tell us about your responsibilities as the Director of the Arizona Rural Health Office?

In my position as Director of the Arizona Rural Health Office, I coordinate several programs designed to help provide rural Arizona with better access to medical care. For instance, one program helps small Arizona rural hospitals with their needs and survival. As a professor in the College of Public Health, I also teach regarding the public health issues in the U.S. and Arizona health care systems. I am currently involved in several research projects. For instance, current projects include the following: comparison of provision of guideline care for acute myocardial infarction in rural versus urban hospitals, Arizona State health workforce analysis, evaluation of on-line registered nurse training, and the role of international medical school graduates in rural areas.

What trends you are seeing in some of your research projects?

I have over 30 years of research experience and have published widely on such topics as rural health care, health workforce, clinical practice variation, geographic definition methodology, access to care, and perinatal care issues. It is impossible to summarize all the trends I am seeing across all of my interest areas here. Clearly the U.S. has a mal-distribution of health care providers, with rural areas lacking needed care access. The U.S. production of generalist physicians is declining in the face of these needs. The growing number of uninsured and under insured is a national tragedy – nearly 50 million uninsured.

As a doctor (PhD), and a person who can influence the direction of healthcare, what is your overall opinion of the U.S. health care system as it stands now?

I am a professor in the Zuckerman College of Public Health at the University of Arizona, having recently moved here from a similar position at the School of Medicine at the University of Washington. It would take a time for me to express my opinions of the U.S. health care system (using the word system loosely) and its cornucopia of problems. Access to quality care has to be at the top of the list. Far too many in the U.S. do not have financial and geographic access to care. A recent article in Health Affairs again shows that the U.S. suffers in comparison to other comparable nations regarding its health status, despite the huge sums expended for health care. Wearing my public health hat, I see the issues around Paxil as a major public health issue in the U.S. during the next decade. For example, all the female children who are now on Paxil will age into their 20s and face issues of getting off of Paxil because they are pregnant. Of course, this is also a symptom of what I would describe as a very loose system of pharmaceutical oversight by the federal government.

You've noted "…this is also a symptom of what I would describe as a very loose system of pharmaceutical oversight by the federal government." Is this implying that there may be too much emphasis on prescription drugs in the healthcare system?

I believe that there is too much emphasis on prescription drugs in the U.S. The drug companies are big business with a capital B. They influence medical providers and consumers through a variety of means. For instance, they use television advertising, magazine ads, and medical journal ads to continually put their drug names out their and to associate their drug as “good medicine.” Physician offices and hospitals are inundated with drug reps who provide all kinds of free samples, memo pads, pens, and the like – all of which carry the name and logo of the drug and drug company.

Even in medical school and during residency the drug reps support seminars and the like by providing food etc., with clear advertising of their logos and brand names. All these activities subtly and not so subtly work on the consciousness of both health care consumers and providers in such a way that expectations are developed for medication “fixes” – often for emotional swings that are just part of living. While evidence-based medicine is one of the key precepts that are being advanced in medicine, we have done little to curb or at least educate providers regarding how to evaluate and arm themselves regarding the relentless pharmaceutical blitz of advertising and promotion.

In reality, we do not require full disclosure of all of what the drug companies know per their research about the drugs they put on the market. We do not federally support enough studies of the long-term consequences of drug usage. In a word, “yes” I think there is too much of an orientation in today’s medicine for the quick pill fix. Besides what I have said above, other newer developments are contributing to this emphasis (e.g., emphasis on care cost reductions).

The following is a quote from Bill Maher, the comedian and talk show host, "In Hillary Clinton's health care plan, the words 'nutrition' and 'exercise' appear just once. The word 'drugs' appear 14 times, just as the pharmaceutical companies wanted." Kidding aside, do you more or less agree with the statement?

I do agree with his meaning. Senator Clinton is falling into the trap that most of the U.S. consumers, legislators, and providers fall into. We do not emphasize prevention nearly enough. While we give prevention much lip service, the emphasis and vast majority of the spending is focused on medical care, including drugs.

You've noted that Paxil will be "a major public health issue during the next decade." You've given some examples in the previous question, but can you expand on this?

SSRIs are among the most prescribed prescription drugs in the U.S. The population of SSRI users has increased dramatically over the last decade, including the number of children. As these children become older, they will be faced with several Paxil and other SSRI dilemmas. If a young woman who has been on Paxil for a decade and who is 25 becomes pregnant or wants to become pregnant, she will have to decide whether or not to try to get off of Paxil because of concerns over the health of her newborn. This young woman who is single and living alone or with a roommate has a relatively high probability of having significant withdrawal symptoms without an adequate mechanism for care and caretaker support not to mention lack of job security.

Furthermore, young folks like her will have insurance issues when they are dropped off of their parent’s health insurance policies and will often not be able to afford expensive medications. I could go on but you get the drift here. The ramifications of our over reliance on SSRIs and our lack of knowledge about withdrawal and the long-term consequences of using them are only now beginning. The numbers of uninsured in the U.S. are steadily increasing and now approach 50 million. We are entering an SSRI era where we are sailing uncharted waters. We do not understand Paxil withdrawal well. The research remains to be performed. The accompanying provider training remains to be done. A change in emphasis to prevention and non-drug management needs to be facilitated. Over drug prescription needs to be understood and controlled. Providers, consumers and at the highest levels of government an understanding of the human face of Paxil withdrawal and other related SSRI health consequences needs to be made common knowledge.

Because of your position and influence-- you work with and know many government officials and healthcare professionals--what is the consensus among the health care community regarding the pharmaceutical industry?

This is difficult to say. Few would argue that there are adequate safeguards in place related to the pharmaceutical industry. However, what we see in practice is very different than the lip service we hear. I believe that the only way things will change is for consumers and providers to make enough noise that legislators and regulators have to take notice and protect the welfare of the population as their highest directive.

On Paxil

How long have you been on Paxil?

I started on Paxil approximately 12 years ago. Now that we know much more about Paxil it seems clear to me that I never should have gone on it. At the time I started on it, I was experiencing short-term depression caused by various life events.

What made you decide to quit?

My wife, Shelly, started to talk about getting off of Paxil and I decided to get off of it also. I had been on Paxil a long time and had not reexamined whether I should still be on the drug.

What withdrawal symptoms are you experiencing?

Shelly started decreasing her Paxil before I did so. About two weeks after I decreased my Paxil dose from 20 mgs daily to 15 mgs daily I became much more emotional than normal. I felt as though I was on the verge of tears many times each day and sometimes cried. Because Shelly began to experience severe withdrawal symptoms and I was her caregiver, I increased my Paxil dose back to 20 mgs daily so that I could be stable to help her. It is at this time that I began to read the Paxil-related literature and visit the various Paxil-related web pages.

When you started on Paxil, who suggested it to you?

Paxil was suggested and prescribed by my physician.

Were you told of or aware of the side effects?

I was not told about the side effects of Paxil. I did read the clinical drug insert at that time and was aware of the common side effects of the drug such as sleep interference and sexual related issues. I was not aware of issues related to withdrawal.

Just off the top of your head, what are other alternative methods that someone can use to deal with depression besides antidepressants?

There are many alternative methods but we do need to understand their efficacy and personal indications -- research. Certainly many folks who are prescribed SSRIs inappropriately could be helped through exercise, counseling, meditation, alternative short-term medications, yoga, and many other methods. What we have done is create a huge experiment on the U.S. population. We have allowed them to be exposed to a group of drugs whose long-term and even short-term consequences are not understood. Prudence should have dictated that, at least, we limited exposure to fewer and monitored the outcomes.

What is your view on the theory that a chemical imbalance is the primary cause of depression, illness, and disease?

I believe that we are prescribing way too many SSRIs, especially because the consequences of doing so are so poorly understood. I think there is inadequate research to determine who should be on SSRIs and who should not be on them. I think we do not yet understand the costs and benefits adequately and that caution should be exercised. In the end, I think we will find that SSRIs do help a subset of those who are prescribed them. I think we will also find that the cost-benefit analysis for many of those on Paxil will be negative. These folks would be better off learning to cope through alternative methods.

Any parting words for our readers?

I am a relative newcomer to the world of SSRIs and the related research. I am still on the sharp learning curve. While I have much research, policy analysis, and public health experience, I still have a lot to learn about SSRIs, in general, and Paxil, more specifically. As Shelly has explained, this is personal. My family has clearly been influenced by our use of SSRIs. Our initial ignorance of the issues is nothing to be proud of. I am now committed to play my part in rectifying the broken system. Shelly has indicated her problems with Paxil withdrawal. My sons have had a difficult time. I have a teenage daughter who will face issues as she thinks about starting a family and if she no longer has insurance coverage. When my three-year old was born she almost died of respiratory distress – the possible connection of this and my wife’s use of Paxil should be familiar to many of you. As the caregiver for Shelly as she has struggled through her withdrawal crisis, I truly appreciate what she, our family, and I have gone through. For many of those who have also gone through withdrawal, there are families that have also paid the price.

I want us all to come to an understanding of the facts and to make sure providers know them. I want our welfare to be more important than profits. For now, I am helping Shelly as she puts together a book that will help us put a human face to the suffering related to withdrawal symptoms that many folks are experiencing. The suffering is real and is often painful and debilitating.

Gary Hart, PhD
Professor and Director
Rural Health Office
Community, Environment and Policy
Mel and Enid Zuckerman College of Public Health
University of Arizona
Drachman Hall, A247
1295 North Martin Avenue
P.O. Box 245177
Tucson, AZ 85724
Phone: (520) 626-6258
Fax: (520) 626-3101
University of Arizona e-mail address: garyhart@email.arizona.edu

Insight

Big Pharma: Exposing the Global Healthcare Agenda. The drug business is the most profitable in all of capitalism, journalist Law notes in this scattershot indictment of the pharmaceutical industry, but what do consumers get for the money shoveled into it? A dwindling stream of exorbitantly expensive new drugs, she contends, most of them "me-too" competitors, patent-prolonging reformulations of existing products or marginally effective nostrums for diffuse complaints; vast marketing budgets to cajole consumers into demanding-and doctors into prescribing-unnecessary medications; biased scientific studies and corrupted or intimidated researchers; a regulatory system lobbied and suborned into allowing unsafe and ineffective drugs on the market; and a society that automatically pops a pill for every discontent, real or imagined. Law offers a comprehensive, if disorganized, rehash of a now familiar but still timely portrait of drug companies' perfidy and greed, studded with case studies of firestorms like the Vioxx scandal and the controversy over the possibly deadly side-effects of anti-depressants. She's on shakier ground when she dilates her case into a brief against conventional medicine and in favor of a murky "holistic" regimen of "complementary"-i.e. alternative-therapies that harmonize with "the body's natural intelligence" and exploit the "untapped healing power" of the placebo effect. Law's flirtations with fringe conceits weaken an otherwise serviceable science-based critique of the drug industry.

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