Help Me With This…Please

Drugs or No Drugs

As you know the topic of the role of medications in health maintenance and enhancement is dear to me. I’ve dedicated my practice life to health without medication or at least as few medications as possible for myself and my patients. There is not a day goes by that I do not write prescriptions so I am not an absolutist about this. Still the fewer medications the better is not a mere motto, nor even yet a belief of mine but my reading of the medical literature itself.

I maintain this even in the face of some difference between my prescribing practices and those of many of my professional peers. There have been several important papers lately that illustrate this. I’ve mentioned these two papers on my blog site, and on the when you are serious Facebook page, so they may be familiar to some of you. Still they are important enough to warrant a newsletter discussion.

The first is about hypertension. Treating mild or borderline hypertension is part of the foundational dogma one is taught in medical school; has been so for decades and remains so. Treat it early and well and you will save millions of lives; save them from kidney and heart disease: Or so we have all been taught.

You would be forgiven for thinking there must be a lot of statistical evidence that this is true; turns out there isn’t enough such evidence.

August 15, 2012 in the Cochrane Database of Systematic Reviews by Dr Diana Diao (University of British Columbia, Vancouver) and colleagues presented a meta-analysis of all available statistically valid studies that have looked at the effect of treating blood pressure in the 140-159 mm Hg systolic and 90-99 mm Hg diastolic range and they found no benefit. With this analysis, “[using] the best available evidence . . . we have a clear answer that we do not know that the benefits of treatment outweigh the harms for this population,” senior author Dr. James M Wright (University of British Columbia). Now my profession oscillates somewhere between slandering the authors and ignoring the results; take your pick as it varies by practitioner. Most say something like well the study wasn’t large enough; as a meta-study it is the largest ‘study,’ word used with the implied limitations of a combined study, ever done and the claim is it wasn’t big enough, which surely begs the question “if this study wasn’t big enough to show benefit then why and how have all practitioners for decades been told to treat this group due to the benefits of doing so?” Untold, heck untellable, millions have been on drugs for decades based on no, give them a little break, based on poor to non-existent evidence. There is something wrong here.

Now the other study is a little less troubling but maybe more important as it bears on why the first study is probably true and why there is a chance that my profession will hear the message that not all drugs are good.

JAMA, October 3, 2012:  β-Blocker Use and Clinical Outcomes in Stable Outpatients With and Without Coronary Artery Disease. Conclusion In this observational study of patients with either CAD risk factors only, known prior MI, or known CAD without MI, the use of β-blockers was not associated with a lower risk of composite cardiovascular events.

Not very loose translation: this drug, prescribed to millions for decades – quote from the article “Treatment with β-blockers remains the standard of care for patients with coronary artery disease (CAD), especially when they have had a myocardial infarction (MI).” – is of no benefit in the very group for which it is most often used and intended. Well, from other studies we know it increases your chance of developing diabetes, impotence, sleep disturbance, weight gain, depression, on and on but other than that it must be good for you. I try to avoid sarcasm but that one slipped past my sensor. Of course it is used for high blood pressure too.

Now my purpose in rehearsing these two papers and the question they put to the medical profession’s use of certain medications for certain indications is not to question the need to have or obtain lower blood pressure in some circumstances, nor to deny the reality that too many people die from cardiovascular disease. No, I am actually up to my old trick of eliciting our, i.e. docs’ and patient’s, obligation to shoulder the job of fixing these problems as medications simply do not ‘fix’ the problems and in many, possibly most, cases they make the problem worse no matter what the loudest voice in the dialog asserts.

Still people won’t take responsibility. Help me with this. I know the stories; I tell them myself: too busy, too stressed, don’t care in the moment the cost in the future, “I can afford to be dead but not to be sick.” What I would like is help constructing a tool, a method, a structure that would support those of us, all of us, that know that medications are the answer to the wrong question but don’t know a better question. Well here is a better question: how can I, how can professional medicine, help you to be clear there is no ‘magic bullet’ in medications, and that your health is one of the most important assets you will ever have, and attention to it is worth every penny, drop of sweat and moment of chocolate cake self-denial you can offer?

I once thought, for those of you who were there, I once thought that Tempus Clinic was the answer to that question and for almost everyone there it was; except that it, like many businesses, failed in late 2008 so it may not have been the answer after all. What is? Software to display graphs, nutritional direction, exercise physiology, trainers, tests, sound interpretation and application of medical and scientific methodology. All of that and it is not enough, often enough. Help me with this, please.

Smile, Have Fun, God Speed,

Dr. Mike


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