Product Description

If you believe that the latest blockbuster medication is worth a premium price over your generic brand, or that doctors have access to all the information they need about a drug’s safety and effectiveness each time they write a prescription, Dr. Jerry Avorn has some sobering news. Drawing on more than twenty-five years of patient care, teaching, and research at Harvard Medical School, he shares his firsthand experience of the wide gap in our knowledge of the effectiveness of one medication as compared to another. In Powerful Medicines, he reminds us that every pill we take represents a delicate compromise between the promise of healing, the risk of side effects, and an increasingly daunting price. The stakes on each front grow higher every year as new drugs with impressive power, worrisome side effects, and troubling costs are introduced.

This is a comprehensive behind-the-scenes look at issues that affect everyone: our shortage of data comparing the worth of similar drugs for the same condition; alarming lapses in the detection of lethal side effects; the underuse of life-saving medications; lavish marketing campaigns that influence what doctors prescribe; and the resulting upward spiral of costs that places vital drugs beyond the reach of many Americans.

In this engagingly written book, Dr. Avorn asks questions that will interest every consumer: How can a product judged safe by the Food and Drug Administration turn out to have unexpectedly lethal side effects? Why has the nation’s drug bill been growing at nearly 20 percent per year? How can physicians and patients pick the best medication in its class? How do doctors actually make their prescribing decisions, and why do those decisions sometimes go wrong? Why do so many Americans suffer preventable illnesses and deaths that proper drug use could have averted? How can the nation gain control over its escalating drug budget without resorting to rationing or draconian governmental controls?
Using clinical case histories taken from his own work as a practitioner, researcher, and advocate, Dr. Avorn demonstrates the impressive power of the well-conceived prescription as well as the debacles that can result when medications are misused. He describes an innovative program that employs the pharmaceutical industry’s own marketing techniques to reduce use of some of the most overprescribed and overpriced products. Powerful Medicines offers timely and practical advice on how the nation can improve its drug-approval process, and how patients can work with doctors to make sure their prescriptions are safe, effective, and as affordable as possible.
This is a passionate and provocative call for action as well as a compelling work of clear-headed science.


From the Hardcover edition.

Product Details

• Amazon Sales Rank: #161019 in Books
• Published on: 2005-08-09
• Released on: 2005-08-09
• Original language: English
• Number of items: 1
• Binding: Paperback
• 480 pages

Amazon.com Review
Profiteeering pharmaceutical companies and the FDA have met their match in Dr. Jerry Avorn, a Harvard Medical school researcher and clinician. In Powerful Medicines, he brilliantly combines patient vignettes, scientific critique, and statistics to create a risk/benefit balance for prescription drugs. His premise: "Every drug is a triangle with three faces--representing the healing it can bring, the hazards it can inflict and the economic impact of each." Avorn's gifts as a writer are apparent in the prologue, an edgy account of the mismanaged medications of several stroke patients. He then details the intellectual history of drug assessment and benefits, including the biblical food police in the Book of Daniel, the deer in the headlights Estrogen debacle and the current infatuation with Ginseng and other alternative medicines. Turning from benefits to risks, Avorn examines diet pills, Viagra, cold medicines and diabetes drugs with comparisons the decisions of Dr. Fautus--who makes life-changing bargains between safety and effectiveness. Other insightful chapters offer views of prescription drug economies, and comparative healthcare around the globe. The final chapters create an insightful template for emerging public policy. Throughout, Avorn pulls at common threads: the line between personal and public responsibility, the perils of drug promotion, and the marketplace that usurps the role of scientific evidence in selecting treatments. Anyone looking for a quick muckraking read will be disappointed. But Avorn's views, literate and complex, will frame the debate on prescription drugs for years to come. --Barbara Mackoff

From Publishers Weekly
In this pragmatic volume, Avorn sets out an impressive plan for the American health care system to get helpful drugs to those who need them, protect patients from dangerous side effects and keep costs within reasonable limits. Avorn, chief of the division of pharmacoepidemiology and pharmacoeconomics at Brigham and Women's Hospital in Boston, argues, "[F]or a sum no greater than our current drug budget, medications could provide all Americans with the most productive and cost-effective interventions in all of health care." Avorn claims, "[W]e waste billions of dollars a year on prescription drugs that are excessively priced, poorly prescribed, or improperly taken." To remedy this situation, reform is needed in how new drugs are approved and marketed. In addition, practicing physicians need access to state-of-the-art information about new medications, including how well they compare to established (and often cheaper) products. Computer technology, Avorn shows, can bring together the latest information on treatment options and drug contraindications. But changes in the pharmaceutical industry itself—of which Avorn does not hold a flattering view—may be necessary to eliminate pressure to prescribe the most heavily advertised and costly new product when old standbys are equally effective. Though this informative and witty book is overly long, it makes a compelling case for prescription sanity and shows how constructive change can realistically be achieved.
Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.

From Booklist
Harvard pharmaco-epidemiologist Avorn's weighty volume authoritatively deconstructs and demystifies the current American prescription-drug debacle, placing it within the larger context of overall medical cost concerns. He frankly discusses what often goes awry when overworked physicians can't keep abreast of voluminous research, when patients are underinformed about generic drug availability, and when profits provide the sole motivation for pharmaceutical research. Although the U.S. currently outspends other industrialized nations by two-and-a-half times, per capita, for medical care, more than half those nations rank higher in life expectancy, lower in infant mortality. Avorn lays a large portion of blame for those facts at the feet of American capitalism and goes so far as to state that the U.S. doesn't have a health-care system at all but rather "a collection of lone entrepreneurs, warring conglomerates, cottage industries, aggressive vendors, embattled charities, and isolated consumers--all engaged in hurly-burly piecework transactions." Rather than simply whining, however, Avorn offers a selection of curative measures to help contain costs while increasing effectiveness. A comprehensive, interesting read. Donna Chavez
Copyright © American Library Association. All rights reserved

Customer Reviews

Erudite, authoritative, courageous, honest, and flawed
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.

Listen To This Doctor - Engrossing And Definitive
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.

a great, humorous read
This volume is heavy, but it is not ponderous. The author, Jerry Avorn, is one of the nation's premier epidemiologists, who takes a special interest in the elderly. For more than 30 years he's been researching issues in pharmacology and has published prolifically (about an article every other month) in the staid medical journals that our doctors should be reading to keep abreast of current events in their field. Avorn knows his stuff. In this book, however, he has been freed from the constraints of the dry language of peer-review journals. Sure, this book may tell you what's wrong with the prescription drug development and delivery systems. Sure, it may save you (or whoever pays for your drugs) some money. Sure, it may even save your life. But what it will certainly do is to kill you: you'll die laughing. Here are some examples of the type of humor that appears once or twice on each page, for almost 500 pages:

"Using the crude benchmark of $50,000 per QALY as the approximate threshold for a good buy, the analysis made Viagra look like an excellent deal. If we accept these results, any objection to the drug's cost, even at ten bucks a pill, goes limp. The difficulty arises in believing the inputs. The authors were astute enough to realize that cost-effectiveness analysis can rarely yield a single rigid number for such a complex issue, especially in the face of all those slippery assumptions. So they came upon an a posteriori list of plausible ranges for all the digits inserted into the model, to see if their output was sensitive to any of its members. This analysis shows that the findings stood up handsomely over a wide range of assumptions. It was, as the statisticians say, robust. But whether or not it was real is another matter; in the end, the flimsiness of the basic data used makes it difficult to consider this a hard number." (p. 257)

"How very...twentieth century. Case after case of multimillion-dollar adverse-event settlements involving withdrawn drugs have demonstrated that this just isn't good enough anymore. Ignorance of the flaw is no excuse." (p. 94)

"This is akin to asking your child how his day went at school and being told that he had a squabble with the teacher, when in fact he had hacked her to death with a machete. A fair report of the event would have mentioned something about stab wounds and not merely categorized it under the rubric `squabble.'" (p. 88)

As the above quotes suggest, Avorn doesn't mince words. The book's conclusion, supported throughout, is that "We waste billions of dollars a year on prescription drugs that are excessively priced, poorly prescribed, or improperly taken." (p 418) He doesn't just describe the problem-and the political, economic and administrative systems that have reared it; he presents a road-map for an overhaul so that "...for a sum no greater than our current drug budget, medications could provide every American with the most productive and cost-effective interventions in all of health care." Are the politicians listening?