The Bitter Pills of American Medicine

In some people, an aspirin a day will prevent a debilitating stroke; in others, it increases the risk of life-threatening bleeding; and in many, it does both. Despite one of the safest risk-profiles, this same aspirin also rarely causes a fatal allergic reaction. No matter who we are, each time we take an aspirin we are not only swallowing its purported benefits, but its potential risks. The question is: As patients, are we sufficiently aware of what these risks are? Or, at the very least, are our doctors?

The sobering answers to these questions and more are answered in Dr. Jerry Avorn’s recently updated and thoroughly revealing guide to American pharmaceuticals, Powerful Medicines. Using a collection of colorful vignettes and evidence-based statistics drawn from his experience as a Harvard clinician, educator, and researcher, Avorn vividly illustrates the seismic gaps in knowledge about prescription drugs that plagues the American healthcare system. Anchored around the simple premise that all drugs hold the power to both heal and harm, and that we must decipher a better way to systematically assess which ones do which, Powerful Medicines is an expert’s look at the problems behind how medications are studied, approved, marketed, and prescribed in the United States.

Yet make no mistake: Avorn is no muckraker. Each story he tells of drug-induced bradycardia, inappropriate thrombolysis, or unaffordable antihypertensive medications strikes the realities that underlie our current crises of drug usage, safety, and cost: overburdened doctors confronted with an explosion of information; ineffective regulatory agencies; an insatiably profit-driven pharmaceutical industry; and the skyrocketing individual and societal costs of prescription drugs.

In four exquisitely researched sections, Avorn addresses the different pieces of this intricate formula (benefits; risks; costs; and information)—and with the acuity of an insider, he is decisive in his assessments and constructive in his solutions.

Powerful Medicines opens by exploring what we know about the effectiveness and side effects of prescription drugs—and how we know it. Answering how we decide that drugs actually work, Avorn vibrantly explains the value of randomized controlled trials; and in making the case for better surveillance of adverse events, he outlines their limitations. In tackling the Food and Drug Administration’s “better than nothing” approval process, he brings his skills as a pharmacoepidemiologist to bear on how the competing interests of Big Pharma and public health wage Faustian battles in the minds of physicians. New drugs are not required to be tested against existing ones for effectiveness or safety; so how are doctors supposed to know which drug is better if they’ve never been compared? And how much extra benefit is worth any additional risk? Using the fitting example of estrogen replacement therapy, he leads us through the process of drug discovery from the laboratory to the prescription pad—or, in this case, straight from the horses’ urine and into your mouth and back again.

With the conversational tone of a humorist, Dr. Avorn leaves no metaphor unturned in his quest to explain complex topics in common language. He relates statistical significance to flipping a coin, equates side effects to spoiled tuna salad, and injects his sharp sense of humor with the use of cheeky adjectives like “limp” and “climax” in describing the economic implications of Viagra. Yet, despite his casual tone, at no point does he sacrifice his rigorous attention to detail or the pragmatic focus of the book.

In fact, in this bullet-point, ADHD society we live in, it is refreshing to read a book that goes to such lengths to be both thorough in its diagnosis of the problem and progressive in its solutions. Avorn has truly written Powerful Medicines for the physician, patient, professional, and policymaker alike.

With drug-related news regularly making national headlines, the reissue of Powerful Medicines could not be timelier. We have recently seen the withdrawal of a popular painkiller and the successful litigation of its manufacturer; the complete reversal of consensus on the risks of hormone replacement therapy; and the dubious refusal by the FDA to grant nonprescription status to a safe and effective hormonal contraceptive. Coming from a physician who regularly prescribes medications as wide-ranging as aspirin and estrogen, if there ever was a time to examine the systems behind prescription drug approval, surveillance, marketing, and usage in the United States, it is now.

So while some of the information it contains may be tough to swallow, and the prognosis for sweeping change is poor, Powerful Medicines holds some very powerful prescriptions for much-needed reform. Take them wisely.