Winding back the harms of too much medicine

BMJ’s too Much Medicine Campaign should be welcomed. An increasing evidence base exists documenting the harms and costs of over diagnosis and over treatment.(1)

As a profession we have ourselves been guilty of unwittingly exaggerating the benefits of pharmacotherapy, often fuelled by the aggressive marketing of Big Pharma, who have even successfully managed to promote their products for unlicensed conditions. Peter Gotzsche is correct to state that many of these crimes would be impossible to carry out if Doctors weren’t willing to participate in them.(2) Academics with financial ties to the industry are also able to influence national guidelines which may in turn result in Doctors prescribing drugs under the belief that they are more effective and safer than they actually are.(3) In practice, this may also result in a greater reluctance for clinicians to discontinue medications even when the patient is experiencing side effects that significantly interfere with the quality of life.

In my view, increasing front line medical professionals appreciation of the numbers needed to treat (NNT)could mitigate these potential harms. For example the NNT for statin therapy in patients with known heart disease is 83 for mortality.4 This doesn’t mean that every patient benefits a little but that 82 of those 83 patients will receive no benefit over the 5 year period.

A greater appreciation by physicians on the modest gains of prevention at the time of initial prescription will help to curb unrealistic expectations by the lay public who may misunderstand media reports or drug advertisements.(5) In addition, we mustn’t forget that the phenomenal increase in longevity over the past century has been mainly a consequence of improvements in public health. Yet potentially lucrative markets in health care may exert a greater influence on modern medicine despite lack of evidence for improved longevity. A greater appreciation by clinicians in both primary and secondary care combined with open and honest communication of the concept of NNT to patients is vital if we are to truly reduce the harms of “too much medicine”.

1 Moynihan R, Glasziou P, Woloshin S, Schwartz L, Santa J, Godlee F. Winding back the harms of too much medicine.
BMJ 2013;346:f1271 (2 March)

2 Gotzsche P. Big Pharma often commits corporate crime and this must be stopped.
BMJ 2012;345:e8462

3 Malhotra A. Big Pharma Harms Patients For Profit But Doctors Must Also Share The Blame. Huffington Post March 14th, 2013

4 Newman D http://www.thennt.com/nnt/statins-for-heart-disease-prevention-with-know… June 03, 2010

5 O’Dowd P. Treating the many to benefit the few: The Modest Reach of Preventative Medications Medicine and Health. Vol 84; January 2001