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Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs Hardcover – Deckle Edge, August 17, 2004
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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.
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Top customer reviews
This is also a mind-expanding book. I learned so much about a field that I thought I already understood pretty well. It felt like the biblical scales fell away from my eyes and I was able to see so much better: the history of the FDA's role in protecting the public (or is it the drug manufacturers?) from medications that are unsafe, ineffective or too expensive. The tradeoffs between risk, effectiveness and cost of drugs, and doctors' astonishing lack of information about these is a major theme of the book. But he taught me about many other areas as well. For example, the differences between prospective, controlled and observational studies and the ego-personalities behind each type--and why we need both types. These are just a couple examples. I might add that Dr. Avorn is really not out to bash Pharma or doctors or anybody. He's just describing reality as it is. He does have some terrific ideas for solutions. I wonder how many billions of dollars we would save annually, and how much better U.S. health care would be if Jerry Avorn was head of the FDA. Hmmm...
This book must have been a labor of love for Avorn-a gift to his readers. My friends have thanked me for giving them copies. I should caution that if you haven't been to college, this isn't for you. This book is for doctors, clinicians, legislators, health care policy professionals, and for people who care about the decisions that doctors make about their health.
Tom Doerr, M.D.
Midwest Independent Research, mwir-improvinghealth.blogspot com.
"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?
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He is critical of the FDA because the agency analyzes submitted data instead of initiating its own...Read more