April 9, 2005


Physicians aren't much better off than their patients in learning about adverse reactions to prescription drugs.


One reason for this is time. A medical journal article appears on the Internet and within minutes, its news -- good or bad -- is in the hands of not only doctors, but also patients and the news media. A 24-hour news cycle, combined with a huge increase in instantaneous medical reporting, means that my patients are likely to know about an adverse reaction before I do.


Lack of time is also a factor. Family physicians are now so busy with patient care that unless we make a point of logging on to the Internet every day, we could well fall behind our patients in knowing what drugs have suddenly been decreed dangerous.


I receive three or four advisories a week from Health Canada or drug companies about adverse reactions that have surfaced from currently used drugs. For the most part, they're pretty routine -- drug interactions or exaggerated drug effects in compromised patients.


But when we receive an advisory such as the apparent increased risk of suicide in teenagers treated with the antidepressant Paxil, doctors are more likely to feel annoyed than worried. We know from our medical school days that there is an increased risk of suicide in a patient as the veil of depression lifts. We also know that the outstanding success of the SSRIs as a class of antidepressants has made it the candy of treatment options and a glut of prescriptions have been written. The real effects of many more patients being treated may be an increased risk of the very thing we are trying to prevent.


The advisory prompts doctors to question both the criteria for diagnosing depression and alternative treatment choices. Even so, doctors view the advisory more as a self-protective manoeuvre on the part of the pharmaceutical companies.


Doctors are used to dealing with risk management and they spend inordinate amounts of time doing just that with patients when they prescribe drugs to them. They do this in good faith, armed with the fatCompendium of Pharmaceuticals and Specialties, which provides hundreds of pages of possible adverse outcomes. It sits on every physician's desk.


In addition, we depend on reports from the pharmaceutical representatives who catch us rushing between patients as they drop off samples of new drugs for office trials.


There is a lot of mutual faith and goodwill in this relationship.


But when it becomes clear that adverse results are ignored by a drug company in favour of stressing only what it wants published or when the government's watchdog agency is seen to have dropped the ball, the medical profession blushes.


A recent study of family practitioners in Canadian Family Practice concluded that more than one-third of practitioners now believe that the drug companies are unlikely to present adverse data unless they are forced to.


Family doctors acknowledge that their available time will never allow them to sift through the information that deluges them. Often the first clue of an adverse reaction for a busy practitioner is a drug representative's uncharacteristic defensive posture about his product. This becomes the signal to get on-line or check the journal's "hot page" and see what has been reported.


Still, in my 30 years of medical practice, I have never found those overworked sales reps deceptive about the drugs they promote for their living,


In a 2,000-patient practice such as mine, without an electronic record system, it is impossible even to know how many patients may be taking what is suddenly a problematic drug. Nor do most family practices have the human resources to call 100 people and tell them to get off the Vioxx you have prescribed.


As our population ages, the number of prescription drugs it is taking rises. A 65-year-old with virtually any medical condition takes, on average, an astounding 12 different pills a day. This does not count what he may take as a result of talking to his neighbour over the fence. The number of prescriptions written for drugs in North America increased 60 per cent in the past 10 years and the number of adverse drug reactions reported after drugs have gone to market doubled in the same decade.


At its best, both the U.S. and Canadian drug-approval systems are designed to show that the drugs work rather than that they are safe. It's only when millions of patients are taking them that the post-marketing reporting system kicks in and even then, the reporting of adverse reactions is largely passive.


The exposé of the adverse cardiovascular effects of the arthritis drug Vioxx emerged last year because it was being tested for an entirely different use in a younger population -- one with few or no cardiac problems.


A physician's consolation in all this is that, for the most part, our patients don't hold us liable when they say, as one of mine did recently: "Let's hope they don't take this one off the market. It's a honeymoon for me without the pain."


My advice? In Canada these days, you have to take your health into your own hands and become your own patient advocate. If you're taking a prescription drug, get on-line to find out more about it. Talk to your pharmacist and get to know him or her on a personal level. Click on Health Canada ( ) and log on to its health products and food branch and get into drug product safety.


And, oh yes, do ask your doctor.

Dr. Jean



Doctor. Writer. Athlete.

Advocate. Adventurer.