Episode 246 | Rethinking Medications | ft. Dr. Jerry Avorn - The Aging Well Podcast

Episode Transcript
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(00:03):
Welcome to the Aging Wall podcast where we explore the
essential elements of longevity,wealth centered fitness, and
proactive health crisis. Today we are diving deep into
the world of prescription medications with Doctor Jerry
Eagle, a distinguished physician, researcher, and
professor at Harvard Medical School.
Doctor Avorn is widely recognized as a leading voice in
the evaluating drug safety, efficacy, and policy.

(00:25):
His latest book, Rethinking Medications, Truth, Power, and
the Drugs You Take, exposes the hidden forces that shape our
pharmaceutical system, from the FDA's shifting approval
standards to powerful lobbying of the Pharmaceutical industry.
He challenges to rethink how drugs are developed, marketed,
and price, while offering actionable solutions to ensure
medications are safe, effective,and accessible for all.

(00:47):
In this episode, we'll explore critical issues such as why the
US pays the highest prices for prescriptions, how regulatory
oversight has weakened, and whatsteps we can take to protect
ourselves as consumers. Get ready for an eye opening
conversation about the medications we rely on and the
system behind them. Doctor Ayborne, welcome to the
Aging Well podcast. Can you tell us a little bit

(01:08):
about yourself and your path to medicine and rethinking drugs
and how they are evaluated and prescribed?
Sure. I guess I wanted to be a doctor
since I was about 7 years old and hardly ever wavered from
that. There was a period in college
where I thought maybe I would just become a clinical
psychologist because that's whatI thought I wanted to do in
medicine. But then I decided that I would

(01:29):
just go the medical school route, in part because I needed
the draft deferment, because if I didn't go to medical school, I
might have gotten sent to Vietnam.
So I went to medical school at at Harvard and got a bit of a
look at psychiatry and said I think I'd rather be an internist
and went through training in internal medicine in the various
Harvard hospitals and then decided that one of the most

(01:52):
exciting and important parts of internal medicine was
geriatrics. So I helped to get the
geriatrics program at Harvard Medical School started back in
the 80s, and we set up what we thought was going to be a really
dynamic world class program to train the next generation of
geriatricians. And then for reasons that are

(02:15):
still not clear to me, both Harvard and the teaching
hospital that I worked at decided in 1997 to end their
geriatrics programs. And my friends and I would joke
about, well, is that because they figured out that the
population is getting much younger and we don't need
geriatrics anymore? But for whatever reason, both
Harvard Medical School and one of its main teaching hospitals

(02:36):
said we're not going to do geriatrics anymore.
So I had had a major interest inmedications and the elderly.
And so I ended up studying them not from the elderly clinical
perspective, but from the medications perspective.
And I was given my own division to run in which I was able to do
my research on medications and the elderly from the medications

(02:57):
and and not from the elderly. And because for some reason
people didn't want to have programs in aging anymore.
So I continue that work and to this day, I've been particularly
interested in medication use in older people and have now
developed a research unit that has about 80 people in it and a
lot of grants, at least until recently, from the federal

(03:20):
government to the NIH and the National Institute on Aging.
And we study patterns of prescribing and adverse effects
and beneficial effects and whether people can afford their
medications, again with primarily an interest in older
patients. So that's my history in a
nutshell. And what inspired you to write
Rethinking Medications? Well, it seemed like there was

(03:43):
an awful lot that we had found in our research in my research
group at Harvard that was not widely known to people.
That seemed to me to be awfully important, whether from the
perspective of a prescriber, which I have been for many
years. They're from the perspective of
my patients or from the perspective of policy makers.

(04:04):
Well, frankly, anyone who pays health insurance bills or pays
taxes because the financial issues end up being shared by
everybody, whether people want to or not.
And there was a lot that is not widely known about how FDA
decides whether a drug works or not, how companies decide what
they're going to charge for a drug, how side effects are

(04:26):
detected. And I said, wow, this is really
interesting stuff. I don't want people know about
it. So I decided to write Rethinking
Medications to let more people find out about all this neat
stuff that I've been studying for the last 40-5 years or so.
And can you share some of those key moments in your career that
have shaped your views on the Pharmaceutical industry and drug

(04:47):
policy? So up early, I mean, the
industry looms large, the FDA looms large, the insurance
companies and prescription benefit managers loom large.
What has interested me is the way all those pieces kind of fit
together, who is doing what to whom in terms of the way the FDA
is influenced by industry, the way both of them are influenced

(05:08):
by Congress, The way Congress and the executive branch are
influenced by industry lobbying dollars, The way doctors are
influenced by ads, the way patients are influenced by ads.
And so it's really this very fascinating mix.
One example, for instance, was that I remember taking care of a
wonderful older woman who had high blood pressure, and no

(05:29):
matter what I prescribed, I couldn't get her blood pressure
down. And, you know, we all know that
you want to control high blood pressure, especially in older
patients. And so I kept adding meds to try
to get on top of her blood pressure.
And he just remained hypertensive.
And then there was a long weekend that I was out of town
with my family, and I come back and found that she's admitted to

(05:50):
the intensive care unit. And the reason was that she had
come into the emergency room with something unrelated.
They looked at the long medication list that I had
diligently put in her record. She needed to be admitted.
So they put her on all the medications that I thought I had
prescribed. And she dropped the bottom out
of her blood pressure. And it turned out many days

(06:10):
later and for after her getting quite sick and then recovering,
that she had not been taking anyof the medications because she
didn't have good health coverageand she couldn't afford them.
And she was too embarrassed to tell me as her doctor that she
couldn't afford what I had prescribed.
And so she just were, you know, let me give her a prescription
after prescription. I never knew they weren't

(06:32):
getting filled. And when then when she finally
was given them in the hospital, that was some, you know, more
than she could handle. And her blood pressure, you
know, went out to dangerously low levels.
So I guess the fact that so manyof our patients, especially
older patients, even though Medicare does cover drugs, still
cannot afford whether it's the co-pay or whether it is perhaps

(06:55):
an older person who is maybe 63 and not yet on Medicare.
The financial burden is just so enormous that we have all these
wonderful medications that we'vediscovered over the years that
our patients are not able to payfor.
So that was one kind of key experience that really made me
try to understand why are drugs so expensive?
Why do Americans pay twice as much for any given drug as

(07:18):
people in Canada and Europe and Japan and Australia?
And what can we do to fix that? And the story of that Lady was
told in greater detail in my last book, which was called
Powerful Medicines, and that waspublished by Knopf quite a while
ago. But it actually turns out that
the section on medications of the elderly that I wrote in
Power for Medicines is every bitas true today in many respects

(07:42):
as it was back when I first wrote it many years ago.
I was blown away reading your your current book that this is
the price of some of these medications and and many of
which are not even demonstrated to work.
I read the chapter on the muscular dystrophy drug and it
was like a 30 some odd thousand.And this was bought back in the
80s a year for a medication thatmaybe worked a little bit but

(08:06):
not much to make it really worthtaking.
Same with Alzheimer's drugs and.Right, right.
And Jeff, it's particularly galling when some of these
medications were developed mostly with taxpayer dollars.
And that that strikes me as really kind of a double whammy
that if if a researcher gets a grant, let's say from the NIH or

(08:27):
from some other source that is acharitable or governmental
entity, and they use that to develop a drug.
And then they say, great, I now own the drug in my company and
now I'm going to charge whateverI want for it.
That is even more annoying than just the run-of-the-mill drugs
are expensive problems. And so how has your research at

(08:48):
Harvard Medical School influenced your understanding of
prescription drug safety and regulation?
The the real £500 gorilla arounddrug safety for me was an
anti-inflammatory drug that manyof your listeners and viewers
will have taken back in the day called Vioxx.
And for a while it was the best selling drug on the planet.

(09:11):
That it was made by Merck and itwas a non steroidal kind of like
Advil or Motrin. That it had the added property
of reducing the risk of stomach and intestinal bleeding, which
was a good thing, but there was a concern that it might in
exchange for that increase the risk of heart attack and stroke.
And the company said no, no, no,that can't be.

(09:33):
And the drug was selling at a level of billions and billions
of dollars a year. And our research group at at
Harvard and at the Brigham and Women's Hospital, which is the
teaching hospital that I work at, said maybe there's more to
be discovered here because the company says, no, no, no, it
can't cause heart attacks. There was evidence, especially

(09:53):
from some of the clinical trialsthat they were more heart
attacks than one would expect inthe people who were randomly
given Vioxx. So to make a Long story short on
the the full details, which are actually pretty interesting on
rethinking medications. But essentially I decided to do
a study with my colleague Dan Solomon and look at the patterns

(10:14):
of use of Vioxx and drugs like it in 10s of thousands of people
for whom we had other medicationuse and all their clinical
events. And we stripped everyone's name
and identifiers off because I didn't really care who they
were, but I wanted to trace their use of drugs over time and
try to understand, did people who took Vioxx have more heart

(10:36):
attacks and strokes than people who took similar meds?
And as it turns out, they did. And we made that finding.
And Merck said, oh, no, these people don't know how to do
research that can't possibly be.They turned us.
Don't publish it. You'll become a laughingstock in
the medical community. But Solomon I and Sebastian
Schneevice and others in our group, we're convinced we got it

(10:57):
right and that the world needed to know that that was the case.
So we published our findings andit turns out that we were right
and Merck was wrong. And within a year they had to
take the drug off the market because it tripled the risk of
heart attack and stroke. And so that for me was a very
telling example of how we could do such a better job in tracing

(11:19):
drug side effects than just saying it's FDA approved and let
people figure it out from there.And FDA actually after the Vioxx
debacle, as I described in the book, they, they did initiate a
very ambitious program that is now in place that enables them
to track side effects of drugs once they're on the market,
which amazingly they were not doing very well before that and

(11:42):
now they are. So I think we're in a better
place because of that, but that you could have the best selling
drug in the world, triple your risk of heart attack and stroke,
particularly in older patients and have no one know for five
years. And it was on the market taken
by 20 million Americans. We spent as a nation billions
and billions of dollars on the drug and it was so dangerous

(12:02):
that it's not available anymore.So that that's a wake up call
for me that Gee, we could be doing so much more to understand
drug side effects than we were at that point doing.
So you argue in the book that the US prescription drug system
is at a crossroads. What are the biggest threats to
the integrity of the system today?
That, that's a very good question.

(12:23):
I, I, I think the biggest is, and God only knows now that
we're in a new administration that has its own ideas about
many things in healthcare that don't always match what most
people who look at the science end of it believe about
healthcare and medicines. But we are at a point where we
need to really think hard about how old does FDA give the green

(12:45):
light to a product? As I was writing the book, which
has taken about four or five years, it looked like maybe we
might be inching toward more carefulness and not having FDA
approve a drug just because it makes a particular lab test look
better, which unfortunately is away a lot of drugs are being
approved these days, even if themanufacturer doesn't show that

(13:08):
the drug actually helps people. And we're still under studying
drugs in older patients. And it's ironic that even though
older people by far take more drugs than younger people, they
are studied less and less in clinical trials.
Unless you know you, you got to study older people because it's
about Alzheimer's. But if it's about diabetes or

(13:29):
high blood pressure or heart disease, companies would much
rather would not have people much over 65 because they think
it's too complicated. And yet, you know, those are the
patients that I would be prescribing the drugs for most.
So I, I'd hoped until November 5th, just to pick a random date
of last year, that FDA could be coerced or cajoled or educated

(13:53):
into having higher standards forapproving drugs.
And not just say it makes this so-called surrogate measure like
a lab test look better, but it actually, you know, if it's a
drug for cancer, it actually helps people to live longer,
better lives. Not that it makes some marker
look better or an imaging study look better and then leave it at
that, which FDA and the industryhave been more than comfortable

(14:16):
doing. And I thought we're kind of
sounding the alarm bell on theseissues pretty loudly now as we
look at what's going to happen with the new administration and
its general approach of not wanting to regulate things too
much. I worry that we may not make the
progress that I had hoped that we might make, and we might even
backslide a bit and continue to be a little too loosey goosey

(14:38):
about. OK, it improves the lab test.
Fine. You, you can have your drug on
the market and you have 10 yearsto show whether it helps people,
which is what the FDA said aboutthe notorious drug for
Alzheimer's that it approved even though it didn't work and
then had to take off the market.So, yeah, that's.
So we're going to Crossroads, sure enough.
But I just don't know if we're going to have things get better

(14:59):
or get less good as a result of the politics involved now.
Yeah. And I think that's the sad part
of this always that politics have gotten so involved in the
whole process and, you know, andfinances have gotten into it as
well with, you know, like the pharmaceutical companies and and
what role do the pharmaceutical companies play in shaping drug

(15:23):
policies and influencing some ofthese medical guidelines?
That is really a key issue, Jeff, because a lot of us
believe that this ought to be only about the science and
people can be liberal, conservative, progressive,
whatever. But at the end of the day, our
health policy and our decisions about medications, especially

(15:44):
for more vulnerable people like those over 65 who really depend
on medications to not just live well, but to live and who also
don't have a ton of disposable income to throw around that for
everybody, but particularly older patients, we really ought
to let science call the shots. And unfortunately, we have

(16:06):
gotten into a situation where science is sometimes not the
only determinant of whether a drug gets approved.
Often it is lobbying, often by the manufacturer.
Often it is the involvement of these prescription benefit
management companies that are inthe middle and take their cut of
whatever profits there are. Often it's the politics of,

(16:29):
well, we need a drug for this, let's approve it even if it
doesn't work and I would like tosee us return to or get to, I'm
not sure we ever were there. A situation where at the end of
the day, and again, vaccines come up as a timely example,
whether vaccines ought to be used or not and whether they are
safe and whether they work oughtto be only about the science.

(16:52):
And if the sign says this is a crappy vaccine, if it doesn't
have a lot of effectiveness, it causes bad side effects, great,
that's how we should make our decision.
But if the sign says this is a very effective vaccine and it
prevents a lot of illness with hardly any side effects, then
that ought to be what drives thedecision both of patients and

(17:13):
with the government and payers. But I worry the politics has now
begun to infiltrate so many of our decisions as a country about
whether a given product is a good one or a bad one.
Then it becomes really distorted.
And we're no longer looking at facts.
We're looking at ideology, doesn't really have a, we're
looking at lobbying in the case of a lot of medications.

(17:33):
And, you know, neither ideology nor lobbying really ought to
have a place in decisions about approving or using a medication.
Yeah, we've kind of thrown around this idea follow, we
follow the science. Over the last few years that
became a popular phrase in COVID.
And it's like, yeah, you're really following the science,
you know, and that goes for bothsides, I think.

(17:55):
You know, if it's science, then you're talking randomized
controlled studies, and you're talking data and data only, and
you're talking probabilities andnot possibilities.
And, you know, I think we need to wake up to that quite a bit.
And I think another big questionis about why we are paying such

(18:15):
high prices. You know, you're talking in the
book how the US pays the highestprices for prescription drugs.
What are some of the forces thatare driving these high costs?
It's an interesting problem because we are the only country
on Earth that allows the manufacturer of the drug to have
the sole say in what that drug is going to cost.
And we do a lot of work with colleagues in Europe and Canada

(18:38):
and Australia and many other countries.
And they have scientists who look at a drug when it's
approved and they will evaluate what does it do for patients.
And they will come to conclusions either this is a
wonderful new product, it's helping a ton and we ought to
really pay a lot for it versus this is no better than what

(18:59):
we've already got on the market.So why would we want to pay more
than for maybe even some genericdrug that costs a 10th the
price. We do not have that here.
And for for older patients, we have this added layer of the
Medicare program, which it's wonderful that Medicare covers
the cost of drugs because that'slike one of the most important

(19:21):
things we do for patients. On the other hand, when that was
put in place, the legislation was written that Medicare cannot
ever ask any questions about what a drug costs.
And for most of the most important drugs, it's got to
cover everything that's out there on the market.
And this was presented as a way to protect older people, you

(19:41):
know, from from the government making bad decisions.
That really what happened was that it became open season for
companies to charge whatever they want, know that Medicare
was going to have to pay for it.The same, by the way, is true of
Medicaid in many instances. And we read this legislation
back into the three that createdthe Medicare drug benefit.

(20:03):
The congressman that wrote it from Louisiana immediately
thereafter, quick Congress to become the head of the lobbying
group for the Pharmaceutical industry and, you know, kind of
reveal where his heart was all along.
But we're left now with this really kind of nonsensical
approach that no other country has.
That the price is whatever the manufacturer wants it to be.

(20:24):
And that unfortunately, besides really making our healthcare
costs way more than nearly everyother advanced industrialized
country. And by the way, we don't have
better outcomes for that extra price.
We have outcomes that are actually sometimes in the middle
of the pack or toward the bottomcompared to countries like

(20:44):
France and England and Australiaand Japan and, you know, most of
mainland Europe and so forth. So we're not getting more for
our bigger expenditure, but we are really stocking it to
patients. And even with the Medicare drug
benefit, older patients are at particular risk of getting hit
with with very unbearable drug bills that sometimes can push
them over the edge financially. Now, back in the Biden

(21:07):
administration, some legislationwas put into place to protect
older patients against that problem of high drug costs.
But I understand that the new administration wants to undo a
lot of those protections, and we'll have to just see where
that goes. Yeah, I was shocked and reading
the book, I think it was one of the muscular dystrophy drugs

(21:28):
that was formulated by a companythat claimed to be so poor that
they couldn't do really large randomized control study.
They had to study with like, what, 12 patients, right?
And then they turn around and they were charged like $32,000 a
year for the drug. Yep, they're like they're like
300,000 a year for the drug, yes.
And that's right, yeah. Yes.

(21:49):
And and you know the, the then deputy head of the FDA said,
well, she was concerned about the economic well-being of the
company. And last time I looked, FDA's
job was to make sure that drugs are safe and effective and
they're not out there to line the coffers of drug companies.
And that company actually went on to say, wow, that's a pretty

(22:12):
easy way to make a buck. And they introduced several
similar drugs, none of which worked, that according to that
principle that FDA is there to help drug companies make money.
Each one of them came onto the market for around 3300 grand a
year. Each one of them doesn't really
work hardly at all. And you know, we don't get to
pay for that as taxpayers, as people who have health

(22:35):
insurance, as people who it's not a big drug for older
patients. So it it doesn't loom large in
Medicare and many of the other drugs that I I write about it
and rethinking medications do get covered by Medicare.
So whenever a horribly expensivedrug that doesn't work gets paid
for by Medicare, it's actually everybody in Medicare that ends

(22:56):
up getting hit with the responsibility of of paying for
that in their premiums. And many people assume that FDA
approved drugs are thoroughly vetted.
What should consumers know aboutthe approval process that might
surprise them, other than some of the things you've already
alluded to? Right.
Well, a lot of people, I'm, whenI say a lot of people, I include
a lot of doctors, maybe even most doctors and probably most

(23:19):
patients believe that FDA tests drugs and decides if they're if
they work or not. FDA does not test drugs.
It is almost always the manufacturer that is seeking to
market the drug that does the testing of the drug.
Now, FDA looks at the results pretty carefully.
But the way these trial is set up and the company's initial

(23:43):
spin on it before FDA looks at all the data is clearly going to
be oriented around the company'sneeds.
And, you know, you can't fault them for that.
They've got shareholders they want, you know, people don't
invest in a drug company to, youknow, in their retirement
account to do good works. They do it because they want to
have a nest egg they can retire on.
And the company says fine, we'rehere for our shareholders.

(24:06):
The way we enrich them is by charging a lot for our drugs and
with no pushback on the part of government, they do charge what
they want. And if the testing of the drug
ends up being a little skewed asin the description of of the the
drugs for either Alzheimer's, therefore some of the other
examples in rethinking medications, if the company says

(24:29):
says we're paying for the study,we'll do it the way we think we
need to. That's really an open door for
the results to maybe not be everything that the actual
patient or doctor using that drug wants to know.
Another thing said in the book was, you know, when you see
that, you know, you have patients that are so desperate
for help that they end up pleading for certain medications

(24:50):
to be approved just because it has a little bit of an effect
and it gives them that slightestamount of hope and they're not
realizing how they're going to get screwed in the end.
Exactly right, Jeff, especially if the drug works pretty much
not at all. And I write about what happened
with muscular dystrophy drugs that you mentioned where, you
know, lots of kids in wheelchairs were paraded into

(25:13):
the FDA hearing room. The parents and the kids would
say, please don't let little Johnny die.
We need this drug. And, you know, I can understand
that if I had a child with muscular dystrophy, I would, you
know, certainly want everything to be done.
But it's not doing, you know, little Johnny a favor to have
him on a medication. It actually is ineffective.
But but but these are kind of displays of sort of public

(25:35):
pressure. And sometimes the patients are
flown in by the company that makes the drug.
And it's hard for the advisory committee to say, I'm not
convinced this drug helps. And so we're not going to
approve it. And when I describe some of
those hearings, and you can see how torn the the outside
advisors are. They want to do the right thing.
They want to help the patients and the families that it's not

(25:55):
clear that it's doing anyone a lot of help to approve a drug
that's ineffective. So how can patients and
healthcare providers better evaluate the safety and
effectiveness of the medicationsthey are prescribed when.
I send in the manuscript of Rethinking Medications to Simon
and Schuster, my editor there said part of the section that is
for patients. And tell them exactly the

(26:17):
question that you just asked, Jeff.
Tell them what they can do for themselves.
And so there's an entire appendix in the book that is
what you ought to know about thedrugs you're taking and how to
ask the right questions, where it'll look up more information,
how to think about whether thereare alternatives that might be
better for you or safer or more affordable.

(26:38):
And that kit, which was not originally part of the book, but
I'm glad he made me do it, is something that for readers who
may be interested in some of thetales of how drugs get approved
and how we learn about side effects and the politics of why
they are so expensive. But there was that appendix that
also says here's what you, Mr. and Missus public, can do when

(27:01):
you're prescribed something to understand more about what your
doctor is giving you and how youcan work with your doctor or
your nurse practitioner to understand what you're getting.
And to have a conversation with them about the choices that
you're being asked to make. And have that be a discussion
and not just, you know, hear something.
I phoned it into the pharmacy. Take it, But really make the

(27:22):
patient into kind of a full partner in those discussions.
I was going to ask who who should have that discussion
with. We've had a few physicians on
the podcast who had suggested it's a wise idea to have a
conversation with your pharmacist about the drugs that
you are taking because they sometimes know a little bit
better than the physician what all these interactions could be

(27:44):
and some of the efficacies of drugs and things like that.
Would that be the case in your mind?
I think pharmacists say that oneof the most talented and
underused resources in the healthcare system, they know, as
you say, they know a ton about medications.
That's the good news. The bad news is especially in
the chain pharmacies, they are put on such a short leash by the

(28:06):
companies that run the pharmacies that they are
expected to just churn things through at a rapid, rapid pace.
And the companies, and cuz we'veactually talked about this with
senior people and some of the bigger chain pharmacy companies,
they said like our business is, is filling prescriptions and
putting them through as quick aswe can.
We don't really have room in ourbudget for the pharmacist in the

(28:30):
local drugstore setting to take the patient aside and talk with
them about this Med and the other meds they're on and what
to watch out for. You still do get that in some of
the smaller mom and pop pharmacies that can still afford
to do that. You know, which is I talked to
pharmacist, you know, they say that's why they wanted to go
into pharmacy. But in a lot of the chain stores
and many of your listeners and viewers will have experienced

(28:52):
this themselves. Things are run at such a rapid
clip, but you know, you may get to talk to a pharmacy
technician, but they're not a full pharmacist and the emphasis
really is on throughput. So if you can find a pharmacy,
and again, it may be a small independent pharmacy where you
can actually get the pharmacist to talk to you, that is great.

(29:12):
Some practices actually employ pharmacist in the practice, and
we see this more in these big integrated healthcare systems
like Kaiser Permanente or the Veterans Affairs system, where
the pharmacist is seen as a member of the healthcare team.
And if you have a practice that you're in like that, that's
wonderful too. But good luck if you're trying

(29:34):
to fill a prescription and manage or to get a pharmacist on
the telephone at some of these large chain stores, you simply
can't do it. So I think at some point it's OK
to sit your doctor down or your nurse practitioner and in
effect, say, look, you just toldme to take this complicated
chemical that's going to cost a lot.
I want you to explain to me what's it for?
Why are we using this one? What side effects should I watch

(29:57):
out for? And all their doctors and nurses
are also subjected to that same kind of conveyor belt approach
that seems to dominate medicine so much now.
Nonetheless, if you can kind of grab them by the lapels and say,
look, I need you to spend 5 minutes talking with me about my
medicines, that is going to be worth it.
Even if the doctors or the nursesays I got 25 people in the

(30:17):
waiting room. I'm really kind of pressed
today. I used to what what I was doing
a more primary care, I would have my patients bring in, but
we used to call them brown bag sessions.
And I used to say, bring me everything you're taking in a
brown bag. I want to go over what you're
prescribing the first time they might bring in what I prescribe
for them. But what I said, are you seeing

(30:38):
other doctors for other problems?
And they said yes, you want me to bring in those medicines too.
I said, yes, they're all going into your body and then they'd
come back and they'd bring me the other doctor's medication,
some of which might be duplicative of what I prescribed
or interact with it. I say, are you taking any
supplements or over the counter medicines?
Oh, you want me to bring those in also?
Yes, I do. That's going into your body and

(30:59):
those are chemicals that can have an effect.
So finally what I would get the patient to and I learned
eventually is to tell him the first time around, every doctor
you're seeing, every over the counter, every supplement, just
bringing them the same bag. I would learn amazing things
that you know, you're, you're still taking that.
I thought we stopped that, you know, a year and a half ago.

(31:20):
Oh, well, the drug still keeps refilling it or, oh, you're
getting a supplement. What do you think it's supposed
to do? Don't you know it interacts with
your blood thinner? No, nobody told me that.
So those may have been some of the more useful moments that I
ever spent with any of my patients.
And by the. Way if your doctor doesn't ask
for that, I think the patient can initiate that, you know,
just come in with your own brownbag and say, doc, I'm, I'm

(31:42):
really kind of perplexed. I'm taking these things from
various sources. Can we just spend 5 minutes
going over all of my little amber bottles and tell me what I
should keep taking and tell me which ones I shouldn't be on?
And tell me if there's any supplements I'm on that are
either useless or dangerous. I think that's an important
characteristic to look for in a,you know, in general physician.

(32:02):
You know that they're going to be asking you those questions.
I remember, you know, my, my grandmother commenting to my
grandfather's doctor when he prescribed something.
She's like, well, should he be taking that because he's also
taking this and he's. Oh, you're right.
That's. Yeah.
And he changed the prescription.It's like you're the stinking
Dr. My grandmother had a high school education and she was
able to pick up on the fact thatyou were prescribing something

(32:25):
that was going to have an adverse interaction with
something else you prescribed for him.
It wasn't like he was even taking it from another doctor.
Yes, I think that because you know, a lot of people either
don't no to raise it or to timidto raise it.
But hey, it's your body, you know, you only have one of them
and you got to be proactive and making sure that what you're
getting is the best thing for you.

(32:45):
And in the doctor's defense, too, I mean, they have hundreds
of other patients that they're dealing with as well.
And, you know, I don't know how they could possibly keep track
of all the medications some of our older population are taking.
I mean to see some. Jeff, Especially if they're
getting here for another doctor.So I may know exactly what I
prescribe somebody, but if they're going down the street,
you know, for their arthritis ortheir heart disease to somebody

(33:09):
else who may not be in my system, I will never know about
that. And the pharmacist sometimes
catches those things. And pharmacists are often the
unsung heroes of the healthcare system.
But unfortunately people are sometimes obliged to go pharmacy
shopping because the place down the street has got a better deal
on my heart medicine. So I'm going to fill that there

(33:29):
and I'm going to fill my blood pressure medicine here.
And that makes it impossible even for the pharmacist to know
everything you're taking. So what role do you think like
AI and the Internet play in thiswhole question?
Good and bad. Let me take the easier part
first, which is the Internet. Actually I was with just last

(33:49):
week. I was with my wife at her
doctors and I mentioned something about a side effect of
one of the meds that she was taking and he said, oh, who told
you about that? Doctor?
Google. And I said, actually, no, I read
the original paper in the medical literature about it.
But yes, the Internet is a mixedblessing in that it is a way of
finding out about a lot of things that you used to have to

(34:12):
go to a medical library to learn.
That said, some of that information is very valuable and
some of it is garbage, and it's not always easy to know which is
which. In the book, in that appendix I
mentioned about advice for patients, I say stick to
reputable sources. Like for example, the Cleveland
Clinic or the Mayo Clinic or Johns Hopkins.

(34:35):
All have very big Internet presences.
If you just go to look up a condition or or medication, if
it's on the Mayo site or the Cleveland Clinic or the Hopkins
site, you can know that it is very likely to be correct.
If it's on the side of some fringy supplements peddler, I
would not even spend time reading it.
So that that that is how to use the Internet for what it's best

(34:59):
at. Unfortunately, FDA is kind of
useless in this regard because if you go to thefda.gov website
and you look up a drug you want to know about, it has got the
most user unfriendly, irrelevantlisting of garbage of every
meeting FDA ever held about thatdrug and all the actions they
took. You can't get through it.
I have trouble getting through it as a Doctor Who studies these

(35:21):
things. But I think if you go to the
Internet and you stick with sites like Mayo or Hopkins or
Cleveland Clinic, you'll get good information.
Artificial intelligence is, I think, at least at this moment,
so far, a mixed bag. Because the one of the kind of
shocking anecdotes that I talk about and rethinking medications
is that there was something thatactually when Google was last

(35:43):
year rolling out its new AI function, where instead of
giving you links, which I like because then you can go back to
the original paper and see wherewas it published and was it peer
reviewed. Google decided they're going to
give people an AI summary, whichis instead of the links, it'll
give you a couple of paragraphs summarizing everything.

(36:04):
And then them that struck my eye, which got a lot of
notoriety, was somebody had put in a question about keeping your
calcium levels normal. And Google's fancy new AI
overview said geologists at Stanford recommend eating a
small rock every day to elevate your your calcium levels.

(36:25):
And there it was for all the world to see with, you know,
courtesy of Google. It turned out that when Google's
AI system was scraping the Internet and looking at
everything that they could find about a given question, they
found an article that was in TheOnion, the satirical magazine.
They just made-up something funny about You can keep your

(36:46):
calcium levels up if you eat a rock every day.
The AI program didn't know that it was The Onion and not the New
England Journal of Medicine, butthey put that in and that ended
up at the top of the list of Google recommendations about
your calcium level. So I cite that as an example of
how it will get better. And no doubt there will come a
time when AI is better at being able to tell The Onion from the

(37:09):
New England Journal of Medicine.We're not there yet and we need
for that to be a little bit moremature before we can really take
that stuff as a guidepost, especially for something where
your health is involved. The sad thing is there's a lot
of humans out here that they can't distinguish between, you
know, something in The Onion, what's satirical versus what is

(37:31):
real. And I think we we really lack
some of the scientific literacy that we need to be able to say,
OK, I've seen this article and they're talking about like one
that I've brought up before as an exercise scientist is an
article that talked about a glass of wine is equivalent to a
day, an hour at the gym. And it's like, OK, let's kind of

(37:51):
tease through that. Yeah, there might be some
physiological changes that are affected by drinking a glass of
wine, but there's more calories.You're putting calories in
rather than burning. And you're not building muscle.
You're not working your hard. Let's be a little bit more real
here, people. And I think a lot of people,
they read these headlines and like, oh great, this is what I
need to do. And they don't look at the

(38:13):
source. Exactly correct, right?
So what are some common misconceptions about miracle
drugs that get marketed marketedas.
You know, the companies are an interesting situation because I
guess the SEC, assuming we stillhave an SEC later this year,
requires that when a company finds out something that can

(38:35):
materially affect their share price, they've got to
immediately reveal it to the public.
And I can kind of feel for the companies sometimes in that if
they do a clinical trial and there are some promising
findings, they feel they're legally obliged to blurt them
out in a press release to fulfill the SEC requirements.
The trouble is those often are, you know, not only not peer

(38:58):
reviewed, but it may be just a big glimpse at one aspect of the
study and very incomplete. And, you know, most of us wait
for the actual paper to be to appear after peer review in a
real journal. And it it's important, I think
for for consumers when they hearall there's a great new
treatment, you know, for a lung cancer or Alzheimer's disease or

(39:20):
diabetes to ask themselves, where is this coming from?
And is it something that is a peer reviewed study or is it a
press release from the manufacturer or is this just
hype from some, you know, supplements maker?
And, you know, there's a lot in the book where I ventilate about
how supplements are not under the auspices of FDA or really

(39:41):
anyone. And they get to make these crazy
claims. And the ones that are about, you
know, this will restore your memory and this will enable you
to lose 80 lbs. You know, you can never say that
for a prescription drug if it wasn't true.
But if you call yourself a dietary supplement and there's a
little tiny print on the bottom of the.
Visual part of that that will say this statement has not been

(40:04):
evaluated by the FDA and this product is not designed to
diagnose or treat any medical condition, which of course
negates everything that they say.
But that's the little fig leaf that they get to put out there.
I don't think people should takeany of those claims seriously
and you know, go to, you know, one of the respected sources
that I mentioned or another one that is not commercial or

(40:27):
selling you a product and see what they say there.
But you know, there are too manyhealthcare claims out there.
It's almost like 100 years ago before the FDA had any standards
for a lot of these claims that get made outside of the rubric
official, official statements that are vetted and peer
reviewed. Yeah, I have.
My 15 minutes of fame was. I was quoted as saying I will

(40:49):
not be intimidated in the New York Times based on some
research that I had done for a pharmacy for a weight loss
supplement back in the late, I guess early 2000s.
And it turned out I was deposed twice for this product.
And one case finally went to court.
And they found that of the sevenstudies done, ours was the only

(41:13):
one that did not flat out fabricate data or design the
study to be designed specifically to get the results
that they wanted. And they were threatening me
with a lawsuit if I didn't pull an abstract, 2 abstracts that
were submitted to a conference. They wanted me to report that
there was like a 750 some odd greater percent fat loss in the

(41:34):
supplement versus the placebo. And I'm like, well, that's
technically true, But first of all, we don't report data that
way in science. And second of all, 750% of
nothing is still nothing. And I bring that up to my
students constantly because you see those kind of numbers and
I'm trying to remember what I saw it in recently.

(41:55):
And I think it was even a kind of a drug treatment that they
were talking about that kind of effect.
And it's like, well, let's let'slook at this data here.
I wish I could remember exactly what it was, but it was dealing
with number of people. And I was like, even if you what
was like one in 1000, people have this condition, 800 times
better than that is not still that significant of a number.

(42:19):
And we're probably dealing with numbers in the millions, you
know, one in a million, you're talking nothing.
And I think goes back to that literacy piece.
You know, we have to be able to understand that stuff and it's
probably something that needs tobe taught better in school.
Or you said it, I think at everylevel, you know, not just health
professional or science programs, but also I think

(42:40):
regular people ought to be help to be better consumers of
information. Because as you say, those are
the kinds of things that you know, you and your colleagues
and me and my colleagues obsess about.
But it can't be reduced to a bigheadline in the in a 32nd TV
commercial. So in the book you discuss case
studies from cancer drugs to opioids.

(43:00):
Can you share a specific examplethat illustrates the dangers of
the weak oversight? Sure.
Let me let me briefly pick one of each.
On the opioid front, I tell the story of ATV crew that came to
interview me and they said we want your reactions to this
interview. We just did.
And they put on the screen a guytalking about how he was really

(43:22):
out to make a ton of money selling this new version of
opioids that were particularly addictive.
And he was not above bribing doctors.
And he told his sales force to wait outside of these pill mills
because those are doctors that you can get to prescribe a lot
of stuff. And my first reaction was, this
is a joke, right? I mean, nobody actually talks
like this. This is if you want to make fun

(43:43):
of the drug industry and opioids, you know, why don't you
just stick to reality? And they said, no, this is
actually a guy who was just convicted and sort of do a lot
of prison time because he was pushing a particularly addictive
kind of opioid for a company that was the best selling IPO
initial public offering company in its year.
So this was not just some weird off the wall thing.

(44:04):
This is a tremendously successful company.
And this came to light of me. I, as I described in the book
you, it was on frontline, the PBSTV series.
I think you can still find it easily on the Internet.
And so there are that was one ofthe more striking things where
FDA was so asleep at the switch and nobody was really paying
attention to the utilization of these drugs.

(44:25):
You know, FDA approved it for very rare kinds of intractable
pain in terminal cancer patients.
And then they kind of lost interest and didn't realize it
was being pushed into people whohad a sprained ankle.
That for me was an illustration of how off the rails things had
gotten around opioids. And there was literally nobody
paying attention at any level ofof government And that, you

(44:46):
know, companies without much oversight will do what they got
to do to make money. And this company sure did.
So there there's that was the striking example.
And the other category you mentioned, Jeff, was besides
opioids, cancer. Cancer.
Yeah. In the course of not just
writing the book, but doing the research in my group with my
wonderful colleague Aaron Kesselheim, who's a lawyer as

(45:08):
well as an internist, I have learned so much.
And I tried to summarize it and,and rethinking medications that,
you know, I think most of it, I as a Doctor Who thinks about
these things all the time and I'm sure most of my colleagues
and all of my patients figure that if you have a drug for
cancer, somebody has shown that it's useful for treating cancer.
Duh. But as it turns out, FDA over

(45:32):
the years has become so willing to just use what they call
surrogate markers that if it makes either a lab test look a
little better or an imaging study look a little better, the
company is not really obliged inpractice to follow up and say,
does this help the people with cancer?

(45:52):
Does it make them live longer? Does it enable them to have a
better quality of life? The FDA and in fact, there was a
report just last month by the Inspector General of Health and
Human Services that said that FDA had pretty much gone off the
rails and allowing this so-called accelerated approval
program to become so undisciplined their companies

(46:13):
were not bothering to do the follow up studies that the law
requires them to do that. OK, let's get drugs out there if
they're promising and let's if it makes a lab test look better,
great. And then the law then goes on to
say, and the FDA has to force the company to then do the
follow-ups to show that it's notjust the lab tests that gets
better, it's the patient that gets better.

(46:35):
And there has been this real deterioration in in cancer
drugs, but also other drugs as well, in which FDA just kind of
loses interest and doesn't pay attention when the company does
not do the follow up studies andthe company gets to keep sell on
the drug at full price. The doctors don't always know
that this was approved based on a little lab test change.

(46:58):
They don't know that no one's ever shown that this cancer drug
actually enables people with cancer to live longer.
And that's again, this is an interesting time because it's
one of those periods in history where I think we need more
careful regulation, not let's unleash the private sector and
let them do their thing and get government out of their way.
I want government to be in theirface at least when it comes to

(47:21):
substantiating the claims that they're making about their
products of cancer was the otherexample where I was surprised.
And that's why I thought it was important to put it in the book
at how many of the cancer drugs that we commonly use were
approved based on this accelerated approval pathway.
And then everyone kind of lost interest in the follow up.
And psychedelics is another areathat's gaining attention.

(47:43):
We interviewed Neil Markey of Beckley Retreats in I think it
was episode 230. How do you view its potential
benefits and risks from a regulatory perspective?
Oh boy. I think that psychedelics
represent a really interesting and promising way of managing a
whole variety of conditions, from PTSD to terminal cancer to

(48:07):
severe depression. And the problem is that the
government made it illegal for about 40-45 years to even do
research in very carefully controlled circumstances on
these drugs. You know, they got swept up in
the war on drugs. And Timothy Leary at Harvard
didn't do us any favors by seeming a little out of control

(48:28):
and giving people LSD whether they wanted it or not.
I think that gave the field a bad name.
And the war on drugs just kind of demonize these products as if
they were as bad as heroin, which, you know, they are not.
And so for 40 years, very conscientious, smart scientists,
we're not allowed to do studies.And we're only now beginning to
see some good research come out.And there's a a whole section in

(48:53):
Rethinking Medications about some work that I became aware of
around use of MDMA or ecstasy totreat PTSD.
I'd gotten into the field, actually, when I was a medical
student in the 70s, fresh out ofmy hippie days as an undergrad.
And I heard that there were people giving LSD to terminal
cancer patients to help them die.

(49:14):
And that seemed fascinating. And I spent a month down in
Maryland where that work was being done.
And there's some remarkable casestudies of people describing
what they went through in the inthe book in in a very inspiring
way. And then not long after I had
that month tutorial over in Maryland.
That research was shut down by the federal government, as was

(49:35):
all other research in psychedelics until really just
the last few years. So I think it's, it's going to
turn out to be when we look back, a real missed opportunity
because we've had these compounds around for, you know,
decades or in the case of drugs like psilocybin for thousands of
years. And they have great promise.

(49:55):
They also have potential risks. And the way we study medications
that have promise at risk is youdo careful double-blind
randomized trials. And it is only now that those
are beginning to get off the ground.
And the MDMA or ecstasy study of, of PTSD in, in home in which
I, I knew a number of the principles that were conducting

(50:18):
that research came to a really bad end just last summer,
because there were some real issues with the conduct of the
trials. And FDA got very nervous about
it and ended up saying, no, we're not going to approve this
research, even though there was some life changing anecdotes
that seemed very tantalizing. But we're going to need to go

(50:39):
back to the drawing board for all these drugs, LSD,
psilocybin, MDMA, ayahuasca, anddo the kind of studies that we
subject other drugs to to learn about them.
There's one really interesting footnote, which is, you know, if
you're doing a study of cholesterol levels or blood
pressure, you can do a double-blind study where the

(51:02):
patient of the doctor don't knowwho's getting the placebo.
You can't really do that with psychedelics, as I explained in
the book, for obvious reasons. And so we're going to need to
figure out a new way of how do you study these very promising
drugs if you can't do a double-blind study because
somebody who gets one of these is going to know damn sure we're

(51:22):
not in the placebo group. And so we got to get a new way
of doing clinical trials. But it's doable.
We just have been too afraid. And a lot of very conscientious
doctors are still afraid of the federal government because these
drugs remain illegal. And so it it, it is is shut down
a very promising field. And I think we're going to look
back in 30 years and say, wow, how did we let so many decades

(51:46):
go by without even doing this research?
Because there is going to be some enormous benefit.
We just need to understand what it is and for whom and how to
use these drugs well. And we lost what, maybe 2
generations of researchers on that?
Right. Yeah, there was such promise in
the 70s when, you know, people said this is the biggest

(52:07):
breakthrough in psychiatry in 100 years.
And look at these folks who are doing so much better.
And then when I checked back with them a couple of months
later, they said no, the studieswere all shut down, and that
that desert lasted for four decades.
And think about how many lives could have been affected post
Vietnam. You said it.
Yeah. They were finally starting to

(52:28):
see, you know, post Gulf War andyou know, the Iraqi wars and
things like that, that, you know, PST PSTD that people are
coming back with are hugely benefiting from taking some of
these treatments abroad. Exactly.
And we can't use them domestically except underground
because, you know, the government says they're still
illegal. And, you know, we we just need

(52:50):
to get across that that barrier.But it's been very slow in
coming. And they're legal.
They're legal in Oregon, where I'm at.
But I think that legality is a bit, you know, unstable, you
know, at any given election year, we could, you know, lose
that as well. You said it, I think it's only.

(53:10):
We had a referendum here in Massachusetts last November for
legalizing some uses of psychedelics, and it got shot
down. And I know Colorado's been
experimenting, and so there are little enclaves around the
country, but it's in a very tenuous state.
So what practical steps can policy makers take to improve
drug affordability and access? Well, you know, it's, it's

(53:31):
really important question because there's a lot of people
who basically, especially those who are retired or on fixed
incomes that are spending a ton of their disposable income to
just pay for their medicines. So there's things that patients
can do and doctors can do and the government can do.
I can mention the government piece quickly because the

(53:52):
government in the Biden administration actually did do
some very important thing is like having negotiations of
price by the government in Medicare.
And it looks like that may or may not survive the current
administration. They set up a cap on out of
pocket spending for drugs in Medicare, which was a real boon
to a lot of older patients. I don't know if that's going to

(54:15):
get undone as well. I think whatever it happens out
of Washington, I think patients can definitely, when they are
prescribed a medication by theirdoctor, they can always say, do
you know how much this is going to cost?
The doctor will inevitably say no, I don't know.

(54:36):
And that's not the doctor's fault because it depends on what
your insurance is. Is there a rebate?
Where did your insurance and your prescription benefit
management company place this drug on their tier of co-pays?
And any given doctor will have maybe 50 different insurance
plans covering his or her patients, including the ones

(54:59):
that do the Medicare drug benefit.
And so no doctor can literally sit there and say, you Missus
Jones, this is going to cost you$83 out of pocket a month.
So it is often only when they get to the pharmacy that the
pharmacist says, OK, your co-payon this is going to be X
dollars. And at that point, many patients
say, I can't afford that. So I think the thing to do for

(55:21):
the patient is to start the conversation on the doctor's
office. It's not the doctor's fault if
she or he can't tell you what it's going to cost because it
can't know the current deal withyour insurance company and the
PBM and the manufacturer. But what you can say is, is
there a generic of this available?
Because you know the generic is going to be way cheaper.

(55:42):
And you can say to your doctor, if it's one of these more
expensive new biologic drugs, which are are the ones that are
advertised endlessly on the Evening News and we're on the
clock on TV. And of course, the reason
they're advertised so much is that they are incredibly
expensive and the drug companiesare making a bundle off of them.

(56:03):
But some of them are also available in a cheaper form for
a biologic. We call that a biosimilar and
not a generic. But it's the same idea that
patents have expired and other companies can make it.
And very often it is pretty muchthe same drug.
And so ask your doctor, is therea generic or a biosimilar of
this available, which I know will be cheaper for me.

(56:26):
And on the doctor side, I think we as prescribers have a
responsibility for making sure that not only the drugs we
prescribe are effective and safe, but also that they're
affordable. And I try to help my colleagues
think about, you know, if you'represcribing X, do you know that
there is something else you can prescribe that works every bit

(56:47):
as good but is now made by 12 manufacturers and not just one
and will cost a 10th the price. And those are conversations that
doctors need to have with patients.
Patients need to start with their doctor.
And then, you know, again, unfortunately, sometimes the
harm's already been done by the time you get to the drug store.
But when the pharmacist says youknow that's going to be $130.00

(57:08):
copay after your insurance kicksin, you still got to pay that
out of pocket to say to the pharmacist, what alternatives
are there? And if it's if you're lucky and
you get a pharmacist that is notbeing swamped with needing to
talk to 20 other people cuz there's only one pharmacist on
the drugstore, they may be able to make a recommendation.
But then someone's got to go back to the doctor, either the

(57:30):
pharmacist or the patient, and say, oh, I understand there's a
biosimilar for my very expensiveHumira prescription.
Could I be prescribed that? And then the clock starts all
over again and the doctor writesa new prescription.
It's a crazy way to do it, but it's unfortunately something
that I think all of us, doctors and patients and pharmacists
need to get engaged in. Otherwise, we just have

(57:53):
everybody getting the most expensive drug, whether it's
better or not. And then unluckily, if it's like
my patient who ended up in the ICU with no blood pressure, the
problem is often that they patients just can't afford to
take it and then their conditiongoes untreated all together.
I relate in the book the story of me trying to fill a routine
prescription at the drug store and having this, you know,

(58:15):
lovely elderly woman in front ofme online.
And she said to the pharmacist, how come my drug is going to
cost $120.00? I have health insurance and the
pharmacist says where last year copay, the health insurance paid
the other $800.00 for the drug. And she said, well, you don't
feel it because I can't afford that.
And she walked away. And in the book I talk about

(58:37):
wondering was this for a heart disease medication and she got
to land in the hospital now witha heart attack or is it for a
cancer treatment that is going to impair her survival if she
can't get it? Was it just for a drug that if
anybody thought more about it, they could have given her a
generic and they would have or bio similar would have cost much
less and she could have had her medicine.

(58:58):
But you know, the system is so deranged that patients and
doctors and pharmacists know only to kind of lean in and try
to make the system not be as abusive of them as they can.
So if you had the power to reform one major aspect of the
drug approval and pricing system, what would it be?
Wow, great. Great question, Jeff.
I would say that FDA needs to goback to his roots and demand

(59:22):
that every drug it approves doesn't just show that it makes
a lab test better, but that the the company is obliged to show
that it actually makes the patient better.
I suggest in the book that we could have such a thing as a
conditional approval where they say, OK, we're going to let this
out there because maybe it, it'll help people.
You know, you've got a year to finish your studies and show

(59:44):
that it actually benefits peopleand doesn't just change a lab
test. That was what we had in mind as
a nation back in the 60s when FDA was given the power, really
it became a model for the world to say you can't sell a drug
unless you show it helps patients.
And we've really drifted away from that.
I just want us to go back to that, at least on the
effectiveness side and and say that FDA has got to return to

(01:00:08):
its roots and not sort of take the shortcut and say, well, you
know, the lab test is better go market the drug.
And we may or may not remember to ask you to do the follow up
studies. And if, if I may, Jeff, let me
sneak in one other if I ruled the world answer.
And that is if we could also do what most every other wealthy

(01:00:29):
nation on earth does. But we have made it illegal in
this country to really look at how cost effective a drug is.
There is literally language on the books making it illegal to
do cost effectiveness research on drugs to the extent that it
might influence whether the drugis paid for by Medicare or
Medicaid, which is crazy. You should make research

(01:00:49):
illegal. And we got to use it carefully.
But we want to have people in place, as they do in Germany,
France, Canada, Australia, Japan, who are commissioned to
look at these new drugs and say,Yep, this is a great
improvement, Let's pay a lot forit.
No, this is not any better than what we got.
We should pay only what the generic cost.
We need that to happen as a function funded by the public in

(01:01:12):
this country and not say, oh, what are they doing in Germany?
You know, we ought to be able todo that for ourselves.
So that's on the cost piece. You would rapidly find that a
lot of these drugs that are not worth their weight in gold and
frankly are not worth much of anything would immediately not
be able to get away with the prices that they are getting
away with if we have that kind of analysis.
So that's my other if I ruled the world thing I would put in

(01:01:34):
place well. We're going to give you some
more power. All right, I'll take it.
So what are you doing personallyto age Well, this question we
ask of all our guests. All right.
You know, I think as you no doubt know, Jeff, and as I think
a lot of your guests have probably said, it really does
come down to stuff that, you know, one's grandmother probably

(01:01:54):
would have told you, namely, eata reasonable diet, you know, fat
foods, nothing. There's no magic bullets.
You know, not too many calories,not too much fat, not too much
sugar, a lot of vegetables, a lot of grains, that kind of
stuff that that is probably one of the more important things
people can do for themselves. The other important thing I
don't do what you just get enough exercise.

(01:02:16):
I always could do more. I do way less than I should, but
that's kind of an obvious everyone should do that.
And I think the third thing is sort of maintain relationships
because I don't know any great randomized trials because you
couldn't randomize this. You know, people who seem to
stay engaged in their communities and with friends and
with family seem to do better into old age than people who

(01:02:38):
live isolated lives. So, you know, get out more is
something I again, could do moreof, but that I think is the
third pillar of, you know, diet,exercise and socialization are
probably the best things we know.
And as you implied earlier, at least a fat of the moment
things, whether it's, you know, red wine or, you know,

(01:02:59):
cauliflower or cider vinegar or whatever.
I've not seen any of those really subjected to the kind of
rigorous evidence that we would like to see for an intervention.
So I'm I'm sticking with the oldgrandmother common sense things
for now. Yeah, it is a lot of common
sense and we I started off really with four pillars.

(01:03:19):
I teach in pathophysiology and exercise class as part of my
curriculum and teaching that class I realized, you know, if
you do these four things, if youa regular physical activity and
exercise, maintain a healthy body composition and what was I
let's see I'm missing one in there.
Exercise, healthy body that comes with healthy diet and then

(01:03:40):
don't smoke. Those were my 4:00 to start.
And then we've since kind of since doing this podcast, I've
added on top of that sleep hygiene and purposeful social
connections. And because that just keeps
coming back up. And I think those six things, if
we do those, we're going to these issues with all the cost
of these drugs will, will minimize a little bit more.

(01:04:02):
And then we'll be able to focus on getting the people that are
the most sick the healthiest. I think you're, you're
absolutely right about that. And I guess what one sort of
overarching thought about meds is that, you know, they are
neither of the devil's brew nor a, a godsend from heaven.
And I think there's a lot of faddish prescribing that goes
on. And there's also a lot of

(01:04:23):
faddish de prescribing which goes on.
And I think the right way to do it is, as with so many other
things in life, is to just do it, you know, in moderation
based on the evidence. You know, drugs are neither our
biggest salvation or our biggestcurse.
We just need to use them based on the evidence, intelligently
and carefully. It's good.
And have we missed anything in the conversation?

(01:04:43):
Matt, I think you had great questions.
I think we covered everything. And I'm glad you got me to
mention that appendix in the book because that's that's what
I think people can turn to. You know, even if you skip the
first many 100 pages and just say, OK, my next, I got a visit
with a doctor coming up on Thursday.
I'm going to look at this and see what I should ask and hear
some websites I can use. And you know, even if you're not

(01:05:03):
interested in the fascinating story of how come drugs are so
expensive and why they sometimesdon't work, you know, there's
that. But you know, drugs, drugs are a
good thing, as I might have saidwhen I was in college, I'm
really into drugs. I believe in them.
I think that they. You were in the 70s, right?
Exactly. Used to wear.
They're like one of the best things we have.
We just need to use them, you know, intelligently and based on

(01:05:26):
the evidence. And so where can our listeners
and viewers learn more about your work?
And more importantly, where can they find the book?
Is is this gets released? It's going to be, I think about
a day or two before the book actually gets physically
released. And so right where can they find
it? It is already up on Amazon as of
this recording date, and so people could even pre-order it,

(01:05:49):
although this will probably not air until closer to the pub
date. You know, they can have it, you
know, in bookstores and in theirdeliveries right around April
22nd. And you'd go to your favorite
bookstore if they still have bookstores in the book.
I mentioned a lot of the kind ofacademic websites of my research
division at Harvard where we putall of our findings up for

(01:06:11):
anyone to just look at, you know, for free because that's
why we do it. And so there's a lot of websites
about our studies of medicationsand our studies of drug policy
that are listed among the kind of news you can use mentions in
in the appendix so that describeall the studies.
We've got dozens of pages of notes so that if somebody wants

(01:06:31):
to look up the paper that I might have cited or a media
article describing an FDA hearing or a website that is a
useful one for patients that arelisted there, and you can just
type right in and go right to that side as well.
Well, the book is a great read. You know, I still have a little
bit more to read on it, but I'm finding it kind of a good view

(01:06:54):
of the history, the policy needs, as well as, you know,
where we are politically. And I think it it's something
that can inform the consumer. And then maybe we as consumers
can push back and help facilitate some of the many
changes that you talked about inthe book.
And as we've talked about in thepodcast here, I thank you for
writing that book and I encourage all of our listeners

(01:07:17):
and viewers to to go out and getit.
I know I'm giving them quite a library of books to buy through
this podcast, but the more informed we are, I think the
better we're going to age well. Well, this will be the most
entertaining to read, I think, because I tried to keep it
light, even though the material is is is heavy.
And I think I remember people who read it in the editing
process said, yeah, I laughed out loud several times.

(01:07:40):
So, you know, and a lot of it issort of my own experience in it.
So I think people will find it entertaining as well as useful.
I hope they do. And I just again, thank you and
just keep doing what you're doing and keep aging well.
Thank you very much. I appreciate talking to you,
Jeff. Thank you for listening.
I hope you benefited from today's podcast and until next

(01:08:00):
time, keep aging well.

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Episode 246 | Rethinking Medications | ft. Dr. Jerry Avorn

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.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}Episode 246 | Rethinking Medications | ft. Dr. Jerry Avorn