We have a problem. More people are taking more medications than ever before and that is cause for concern. Use of prescription drugs has skyrocketed since the middle of the last century: Americans now take ten times as many as they did in the 1950s. About half of us are now taking at least one, an increase of over 20 percent just since 1994. Use of over-the-counter (OTC) medications has exploded just as dramatically. And more of us than ever are consuming dietary supplements, herbal remedies, and other products promoted for their health benefits, even though scientific evidence is often lacking for the safety and efficacy of many of them.
How many medications do you take? How about your parents? Your children? Your friends? Do you know what they’re for? How they work? What their benefits and risks are? How they might interact—with one another and with other products you may be taking? Whether there are alternatives to drugs to manage the health conditions you or your loved ones might have?
Too often, drugs fail to correct the problems they are meant to solve or simply reduce symptoms without addressing the root causes of disease. Too often, they are seen as quick and easy fixes for conditions that would be better addressed by changing dietary patterns, increasing physical activity, correcting sleep disturbances, and practicing techniques to neutralize the damaging effects of stress. At best, the benefits of many of the most widely used medications fall far short of the claims made by manufacturers, who also downplay their risks. At worst, many of those medications do more harm than good.
“All doctors do is give you pills” is a complaint I hear from many patients. More and more doctors tell me they are not comfortable with this. One recently told me she was “tired of being a pill pusher.” Another, a psychiatrist, said he was dismayed that most psychiatric patients see a physician only four times a year—at a fifteen-minute appointment for adjustment of their medications.
In my role as director of the University of Arizona Center for Integrative Medicine I have taught hundreds of physicians, allied health professionals, medical residents, and students about the benefits and risks of drugs. One question I always ask is “How did we come to believe that medication is the only or the most effective way to treat disease?” Medicine and medication both derive from an ancient Indo-Iranian root meaning something like “thoughtful action to establish order”; the same root gives us the words measure and meditate. How curious that “thoughtful action” has become synonymous with the giving and taking of chemical substances.
Drugs are powerful. Some are miraculously effective—like opium and its derivatives for pain and antibiotics for bacterial infections that commonly killed throughout most of human history. The discovery of insulin saved many people with type 1 diabetes from an early death. Chemotherapy agents have cured forms of leukemia and lymphoma that had always been fatal. Antiviral drugs have turned HIV infection from a death sentence into a manageable chronic illness. No responsible physician today would reject medication as a method of treating disease and maintaining health.
But it is one method only. Many other interventions exist that do not involve drugs; sadly, they are not taught in conventional medical schools, and that is one reason that most doctors rely on medication. One example is dietary change. When I write a treatment plan for a patient, my first recommendations always concern diet: what not to eat, what to eat more of, how to change eating habits to improve health. As a primary treatment strategy, dietary change can be remarkably effective. Following an anti-inflammatory diet can so improve arthritis, allergies, and other conditions that medication can be reduced and in some cases eliminated. Much evidence links the Mediterranean diet with good health, longevity, and low risk of disease. The DASH diet is an effective intervention for lowering high blood pressure (DASH is an acronym for dietary approaches to stop hypertension). Eliminating cow’s milk products from the diet often leads to marked improvement of recurrent ear infections in children and chronic sinusitis in adults. Eating whole soy foods regularly, beginning early in life, offers significant protection against hormonally driven cancers—breast cancer in women and prostate cancer in men. But because doctors are not trained in nutritional medicine, most of them are unable to give this sort of advice. Instead they rely on drugs.
Botanical remedies have been mainstays of folk medicine in many cultures throughout history. Many modern pharmaceutical drugs are derived from plants or are variations of molecules originally discovered in plants. Herbal medicines can be both safe and effective. For example, a freeze-dried preparation of the leaves of stinging nettle (Urtica dioica) relieves hay fever symptoms (itchy eyes, sneezing, runny nose) just as well as antihistamine drugs without any of their side effects. Extracts of the root of valerian (Valeriana officinalis) work well for many people to induce sleep. Extracts of the seeds of milk thistle (Silybum marianum) protect the liver from toxic injury (by alcohol, volatile solvents, and pharmaceutical drugs known to harm that organ). But because doctors are not trained in botanical medicine, most do not know how to use plant remedies. Instead they rely on drugs.
Mind-body medicine is a general term for therapies that take advantage of the connection between mind and body. These include hypnosis, guided imagery, visualization, biofeedback, meditation, and other techniques that are both cost and time effective. I frequently refer patients to practitioners of mind-body medicine and routinely see them bring about striking improvement and sometimes complete resolution of problems as diverse as atopic dermatitis (eczema), irritable bowel syndrome, and autoimmunity. But because none of this is in the conventional medical curriculum, most doctors do not know when and how to make such referrals. Instead they rely on drugs.
Breath work—learning how to change breathing habits and practicing specific breathing techniques—has remarkable effects on physiology. It cannot cause harm, requires no equipment, and costs nothing. It can correct some cardiac arrhythmias and gastrointestinal problems, for example, and is the most effective treatment I know for anxiety, as well as the simplest method of stress reduction. But because information on breath work is totally absent from conventional medical training, very few doctors can instruct patients about it. Instead they rely on drugs.
Evidence for the health benefits of exercise is overwhelming. Increased physical activity can effectively prevent and treat depression, help normalize high blood pressure, and, along with dietary adjustment, put many cases of type 2 diabetes into complete remission. Doctors get some training here, but they are not trained in ways to motivate patients to exercise. Instead they rely on drugs.
Manual medicine, such as chiropractic and osteopathic manipulation and various forms of massage, is a safe and effective treatment, not just for musculoskeletal disorders but for other health conditions as well. Cranial therapy, an osteopathic technique, can end cycles of recurrent ear infections in children with none of the adverse effects of frequent courses of antibiotics. Visceral manipulation, also performed by some osteopathic physicians, can correct malfunctions of abdominal organs. But because most doctors are unfamiliar with manual medicine, they do not know when and how to refer patients to it. Instead they rely on drugs.
Traditional systems like Chinese medicine and Ayurveda comprise a variety of therapies, including dietary adjustment, herbal remedies, massage, and specialized techniques like acupuncture in Chinese medicine and detoxification regimens in Ayurveda. They can effectively manage some chronic health conditions, such as asthma, allergy, and inflammatory bowel disease. Acupuncture can dramatically improve acute sinusitis as well as reduce back pain and depression. But because doctors do not learn about these systems in their training, most do not know when to refer patients to them or how to find competent practitioners. Instead they rely on drugs.
The makers of those drugs, collectively known as Big Pharma, profoundly influence physicians. They fund research, which then drives practice. In the studies, drugs are measured against placebos to determine efficacy but almost never against lifestyle changes that may work as well or better. The information that doctors rely on when prescribing comes more often from industry sources than from objective ones. And despite attempts to curtail their influence, representatives of those companies are still very much present in medical offices, doing their best to persuade doctors to push their products. Pharmaceutical ads are the major revenue source for medical journals, compromising the objectivity of these journals in accepting or rejecting articles that report research findings with drugs and in deciding which to feature prominently.
Add to all this the strong desire of American patients to be medicated. Their belief in the power of drugs is as great as their physicians’. If the average doctor were told to manage a case without medication, he or she would likely not know what to do. If the average patient knew that no prescription would be forthcoming at the end of a medical visit, he or she would likely feel cheated and seek another practitioner to give one, especially for a product advertised on television. In recent years, direct-to-consumer advertising of prescription drugs has greatly increased consumer demand for them. New Zealand is the only country other than the United States that allows such promotion, which has been a boon for drug manufacturers and a disaster for medical practice.
Consider also that nondrug therapies require active participation of patients and may take more time to produce results. Lifestyle modification is particularly demanding. People will not change their eating habits or start exercising unless they are motivated to make the effort. Many patients would rather skip the effort and take a pill. The cost of the pill is often covered in whole or in part by insurance. There may be no reimbursement for dietary supplements, herbal remedies, or the nondrug therapies I have mentioned.
It’s no wonder how we came to believe that medication is the only or the most effective way to treat disease.
So why is this cause for concern? Two reasons: the safety and the efficacy of the medications we rely on.
No difference exists between a drug and a poison except dose. (Pharmacology comes from the Greek word for poison.) All drugs become toxic as the dose is increased, and some poisons are in fact useful therapeutic agents at very low doses. Medicinal plants are usually much safer than their purified derivatives, because the active components are present in low concentrations, rarely more than 5 or 10 percent of the dry weight of the plant, and often less. Herbal remedies are dilute forms of natural drugs. Of course, they can be concentrated into liquid or solid extracts, but these products are still relatively low in potency compared to isolated purified compounds. And those compounds can be altered to make them even more potent—a favorite strategy of pharmaceutical chemists. The most widely used pharmaceutical drugs are extremely potent. Potent drugs may be necessary in cases of critical and severe illness, but we now use them for all disease conditions, even those that are not severe. Unfortunately, concentration of pharmaceutical power inevitably also concentrates toxicity; the two are inseparable.
Doctors have come to believe that the best medications are those that work quickly and powerfully. The consequence of reliance on such strong drugs is the very high incidence of adverse reactions to them that range from transient discomfort to permanent injury and death.
My own interest in learning how to treat common forms of illness without medication grew as I observed more and more cases of drug toxicity. One early experience I will never forget involved the death of a patient during my internship year at Mount Zion Hospital in San Francisco in 1969. On a month-long neurology rotation, I participated in morning rounds with two attending physicians and two medical residents. One day we saw a newly admitted patient who had suffered a massive stroke, a man in his late eighties. He was in a coma, unresponsive, with little chance of recovery. The immediate concern was that he was having frequent seizures, which soon became continuous. The senior attending physician was about to stop them with an intravenous dose of the tried-and-true anticonvulsant drug, phenytoin (Dilantin), but I spoke up to say that a lecturer at Harvard Medical School had told our class that intravenous diazepam (Valium), newly approved for treating continuous seizures, was superior. “Go ahead and try it,” said the attending.
The rest of the team moved on. I asked a nurse to bring me a syringe of Valium and, following the directions on the product, slowly injected the appropriate dose into the patient’s intravenous line. His seizures stopped within a minute. Pleased with myself, I left the room to rejoin the group. Minutes later, I received an emergency page. The drug had stopped not only the patient’s seizures but also his breathing. He was dead from respiratory arrest.
No matter that he was moribund before I injected him with Valium or that he had a peaceful exit. I was devastated. Needless to say, I never again shot anyone up with Valium (nor with any other powerful pharmaceutical).
Hundreds of thousands of deaths occur each year in the United States as a result of adverse drug reactions. And we are not talking about medication errors here: in these all-too-frequent cases, the right drug is given to the right patient in the right dose for the right indication. Adverse drug reactions are the fourth leading cause of death in our country and rank between the fourth and sixth most common cause of death in hospitalized patients.
The US Food and Drug Administration (FDA) requires manufacturers to disclose all possible adverse effects of drugs in labeling and advertising. Often these are so numerous that they take up most of the space in print ads. I have on my desk a three-page advertising spread from a national news magazine for brexpiprazole (Rexulti), headlined “It’s time to feel better about facing the world.” Rexulti is an antipsychotic drug, developed originally to treat major mental illness but now approved for treatment of depression in combination with antidepressant medications. (Studies increasingly show the most widely used antidepressants to be not that effective, but the combination is not much better. You can read about this questionable practice in chapter 9.) The ad exhorts people who have been on an antidepressant for at least eight weeks and are still feeling depressed to ask their doctors “if adding Rexulti is right for you.” The fine print that fills most of the three pages describes the side effects and toxic calamities that can befall those who take the drug, including confusion, suicidal thoughts, uncontrolled body movements, metabolic problems, stroke, and death.
In television and radio ads for pharmaceuticals, announcers have to speak comically fast to list all the warnings and dire possibilities, an easy target for parody. But there is nothing funny about experiencing a severe adverse reaction to medication.
Keep in mind that all drugs have multiple effects on various organs and body functions. They are marketed, prescribed, and consumed for one desired effect, with the others relegated to fine print under the heading of “Possible Side Effects.” But for some unlucky individuals, one of those side effects might turn out to be the main event. The most popular class of antidepressant medications—the selective serotonin reuptake inhibitors, or SSRIs—increase brain levels of the neurotransmitter serotonin. We tend to ignore the influences of these drugs on muscle and sexual function, unless those overwhelm any positive effects on mood. Antibiotics that we use to kill or inhibit the growth of disease-causing bacteria may alter liver and kidney function and interfere with digestion. A decision to take medication should take account of these risks, which are much greater than risks of lifestyle change and most nondrug therapies.
Consider, too, that individuals vary in how they respond to medication, a stubborn fact rarely emphasized in the training of physicians or in the marketing materials of drug manufacturers. For example, some people cannot tolerate statins, because they experience severe muscle pain or weakness from them. If significant numbers of people are affected by an adverse reaction, it is called a “side effect.” If few are affected, it is an “idiosyncratic reaction”—that is, one peculiar to the individual. Variations in response to the same medication may reflect genetic differences or quirks of biochemistry. A new era of targeted drug therapy is on the horizon: genomic analysis may reveal who will respond positively to a drug and who will not. For now, most doctors’ prescribing habits adopt a “one size fits all” mentality.
Do not assume that OTC medications are free of toxicity. They can cause serious adverse reactions on their own and can also interact with prescribed medications in ways that increase risk. Today, you can buy OTC forms of NSAIDs (nonsteroidal anti-inflammatory drugs), steroids, and the acid-blocking drugs indicated for GERD (gastroesophageal reflux disease). Their availability without a prescription encourages casual use without regard to the problems they can cause. As you will read in the pages that follow, it is also easy to get into trouble with popular OTC sleep aids and cold and flu remedies.
Many medical interventions (and many activities we choose to engage in) involve risk. The key is to determine the balance between risk and benefit. Immunization can cause harm, but to my mind and in the consensus opinion of medical science, the benefits of immunization greatly outweigh the risks. That is to say, the harm done by the diseases immunizations prevent is much greater than any harm done by immunizing. That may be small consolation to the parents of a child who suffers a severe adverse reaction to a vaccine, but it is nonetheless true.
I often ask doctors and medical students to compile a list of the medications they would take with them if they were going to live on a desert island. My list would include aspirin, penicillin, morphine, prednisone, and a few other drugs whose effectiveness in our collective experience is great enough to make for a favorable risk/benefit ratio. I would include none of the pharmaceutical products now so vigorously advertised on television, radio, and in print media. My general opinion of those is that manufacturers consistently exaggerate their benefits and consistently downplay the harm they can cause.
Drugs often appear to be most effective near the time of their introduction, becoming less so with the passage of time. Indeed, a much-quoted adage in medicine advises us to “use new medications as much as possible before they lose the power to heal.” The reason has to do with the placebo response—healing from within initiated by belief in a drug or other treatment. Both doctors and patients tend to believe more in the power of new drugs, and that belief can add a halo of mind-generated efficacy to a drug’s intrinsic action. I’m all for placebo responses; rather than trying to rule them out as most researchers want to do, we ought to be looking for ways to make them happen more often. After all, they represent the activity of the body’s innate healing system. My preference is to elicit them not by deceiving patients with sugar pills but by presenting effective treatments with conviction, favoring gentler rather than harsher ones whenever possible. I would rather give less potent than more potent medications, always with the goal of increasing the likelihood of favorable responses and decreasing the likelihood of harm.
The SSRIs offer a case in point. When fluoxetine (Prozac) first came on the market in 1986, it was hailed as a breakthrough treatment for depression. In the years following, it and related medications were prescribed to millions of people. The effectiveness of SSRI antidepressants was documented in numerous randomized controlled trials (RCTs), the “gold standard” of scientific evidence for medical treatments. But by the turn of the twenty-first century, the power of SSRIs seemed to wane. Not only were there increasing reports of serious side effects and adverse reactions, it also became harder for researchers to distinguish response to SSRIs from that of placebo treatments. Enthusiasts for the drugs conceded that might be true in cases of mild depression, but they continued to believe in the value of SSRIs for moderate to severe depression. Further studies failed to demonstrate efficacy in moderate depression; the last holdouts still believe that they are useful for managing very severe depression. As the efficacy of SSRIs has steadily waned, the pharmaceutical companies have persuaded doctors to beef them up by combining them with other drugs, especially antipsychotics like Rexulti.
The fact is that all the regulations we have and all the testing we do, including RCTs, have not kept many worthless and dangerous drugs from coming on the market. Trials can be designed, data manipulated, and results interpreted to make new medications appear more effective than time and experience will prove them to be.
And even when medications work, they may not do what we want them to do. The bone-building drugs widely used to treat age-related loss of bone density (osteopenia) do increase bone mass, but how effective are they at preventing fractures, which is the benefit we want? As you will see in chapter 15, the answer is “not very.” Statins are very effective at lowering LDL (“bad”) cholesterol levels in blood, but does that translate to better health and reduced risk of heart attack? As you will find in chapter 2, the answer is “not necessarily.”
Moreover, when used long term, many of the most widely prescribed medications can actually prolong or worsen the conditions they are meant to relieve. The reason has to do with homeostasis, a basic principle of physiology that designates a living organism’s tendency to maintain equilibrium. (The word homeostasis derives from Greek roots, meaning “standing still.”) If an external force disturbs the body’s balance, the body reacts against it to regain balance. Reduce caloric intake and your body compensates by slowing metabolism—to the great frustration of dieters.
Most of our medications counteract or suppress aspects of physiology. You can quickly get a sense of this by considering the names of drug categories. We use antispasmodics, antihypertensives, antidepressants, anti-inflammatories, anti-this and anti-that. Strong counteractive medications are indeed useful for short-term management of health conditions resulting from severe imbalances of body function. When they are continued long term, however, especially without attention to the root causes of illness, they are likely to ensnare patients in the homeostatic trap. The body reacts against the pharmacological actions, making it difficult to lower dosage or discontinue medication because of rebound symptoms.
Put a patient with GERD on a drug that blocks acid production in the stomach and guess what? The body will try to make more acid, so that if the drug is discontinued, the symptoms of GERD come right back, often with a vengeance. In fact, if you put people without any gastric problems on one of these medications for a couple of months, then stop it abruptly, most will develop acid-related symptoms. And you can imagine the result of maintaining depressed patients on SSRIs. The homeostatic reaction of the brain to the increased levels of serotonin they cause is to produce less of that neurotransmitter and fewer receptors for it, not only making it hard to get off the medication but also prolonging or intensifying the depression.
In the following chapters, you will learn about other examples of unintended consequences of reliance on medications that illustrate the body’s natural tendency to resist disturbance. I’m afraid these are all too common today. They should motivate both doctors and patients to explore ways of managing chronic health conditions without relying solely on medications. Let me repeat that drug therapy can be lifesaving in cases of critical and acute illness and is an important component of treatment of chronic illness in the context of comprehensive care that also includes lifestyle modification and nondrug therapies. Long-term use of medications as stand-alone treatment, though, is simply not wise.
My reason for writing this book is simple. I believe that few people on popular medications understand how they work, whether they work well enough to justify the risks of using them, and what other effective methods of treatment are available to use along with them or in place of them. I began this project by drawing up a list of the categories of medications I find most concerning, the ones that are most overprescribed and misprescribed, overused and misused:
Antibiotics
Statins
Medications for GERD
Antihistamines
Medications for the Common Cold and the Flu
Sleep Aids
Steroids
NSAIDs
Psychiatric Medications
Medications for ADHD
Opioids
Antihypertensive Drugs
Medications for Diabetes
Medications for Osteopenia and Other Preconditions
Because I am not an expert in all these categories, I asked medical colleagues in appropriate specialties to help me gather and assess relevant information on them. Most of the contributors are graduate fellows or faculty members of the University of Arizona Center for Integrative Medicine in clinical practice. In addition, I asked a pediatrician to write about overmedication of children and an internist who works with older patients to provide data on overmedication of the elderly; I regard both as areas of concern. And, finally, I invited a pharmacist to write a chapter on her view of the overuse and misuse of medications.
Let me explain that last decision. Of all health professionals, pharmacists are the most knowledgeable about medications, OTC products as well as prescribed ones. They are trained to advise both doctors and patients about proper ways to use medications, including their possible interactions with one another. Sadly, pharmacists are underutilized for this purpose. (Ideally, they should also be able to give advice about herbal remedies, dietary supplements, and other natural products promoted for improving health and treating disease and to warn consumers about how they might interact with medications, but I find pharmacy education in this area to be deficient.) In chapter 18, Kim DeRhodes, RPh, explains how you can take advantage of a service pharmacists are trained to provide: a medication therapy management session to help you use medications wisely and avoid getting into trouble with them.
Each chapter includes one or two case presentations—stories of actual patients who experienced the problems these common classes of drugs too often cause. I will explain their actions, benefits, and risks. In addition, I will inform you about other ways of managing the conditions they are meant to treat and suggest what integrative treatment for those conditions might look like.
The consequences of overmedication go beyond adverse reactions, drug interactions, ineffectiveness, and unintended worsening of health problems. The cost of medicines, especially prescription products, is a huge burden, both on patients and families and on our failing health care system. The markup on pharmaceutical drugs is greater than on any other commodity in the marketplace. Big Pharma justifies this by citing the high cost of research, but what the companies spend on research is a small fraction of what they spend on advertising and promotion. If you are an American, you should also know that you pay much more for prescription drugs than people do in other countries—sometimes twice as much for the same product.
The expense of medications is often hidden in the modest copays of insurance plans, but you can be sure that the manufacturers get their money; in the end, we all pay. Per-person spending on drugs in our country is close to $1,000 annually, almost twice as much as per-person spending in other industrialized nations. US spending for prescription drugs is close to $300 billion per year—a significant contributor to the escalating cost of health care. In nearly every case, integrative treatment based on lifestyle modification and judicious use of natural products and nondrug therapies is less expensive than long-term medication treatment for common health conditions.
Much less attention is paid to the effects on the environment of all the medication being consumed. Many pharmaceutical products are neither digested nor changed in the body. They leave it and enter the environment, as do drugs that we flush down the toilet and those that wind up in landfill. They accumulate in water supplies, in soil, and in the foods we eat. We may be absorbing low levels of them constantly, but we have no data on how they might impact our health over a lifetime. We do know that a major cause of increasing resistance of bacteria to antibiotics—now a serious threat to public health—is the constant presence of those drugs in the environment, much of it from agricultural runoff. (Almost all animals we raise for food, including farmed fish, are put on antibiotics to promote growth.)
The information in these pages can help you become a wise consumer: to know whether pharmaceutical products are really needed, to be able to weigh their benefits against possible risks, to be wary of the persuasive efforts of Big Pharma. I want you to know, too, that many of the health conditions discussed in the following chapters can be managed without drugs or with integrative treatment plans that use fewer of them or less potent ones or lower dosages of them in combination with other methods.
When I was growing up in the late 1940s and 1950s, doctors wrote prescriptions in Latin in order to keep patients in the dark about medications. To fill a prescription, you had to hand it to a pharmacist who stood behind a high counter intended to prevent you from seeing what he did. Few patients asked questions about these practices. Of course, times have changed. The paternalistic and authoritarian style of doctors of the last century has gone out of fashion, and the Internet has made medical information available to anyone with access to a computer. In my opinion, however, people still do not ask enough questions about their medications, and that also contributes to the problem. Taking a drug just because a doctor says so is never a good idea. Always try to understand why you need it.
You might want to read this book from cover to cover, but please feel free to browse through it or use it as a reference work as needed. If you are on any of the medications I discuss, you will probably want to read about those first. If what you read makes you uneasy about staying on them, keep this advice in mind:
• Never stop taking a prescribed medication suddenly.
• It is always best to wean off medication gradually and under the supervision of a health professional.
• Never attempt to discontinue medication without first putting in place other measures to manage the condition being treated.
Physicians you consult may be unfamiliar with the nondrug treatments and integrative approaches suggested in these chapters. My colleagues and I are working to encourage doctors and allied health professionals to learn about them. If doctors you consult are not open to it, seek out practitioners trained in integrative medicine. (See the Resources section on here.)