Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs

If you believe that the latest blockbuster medication is worth a premium price over your generic brand, or that doctors have access to all the information they need about a drug’s safety and effectiveness each time they write a prescription, Dr. Jerry Avorn has some sobering news. Drawing on more than twenty-five years of patient care, teaching, and research at Harvard Medical School, he shares his firsthand experience of the wide gap in our knowledge of the effectiveness of one medication as compared to another. In Powerful Medicines, he reminds us that every pill we take represents a delicate compromise between the promise of healing, the risk of side effects, and an increasingly daunting price. The stakes on each front grow higher every year as new drugs with impressive power, worrisome side effects, and troubling costs are introduced.

This is a comprehensive behind-the-scenes look at issues that affect everyone: our shortage of data comparing the worth of similar drugs for the same condition; alarming lapses in the detection of lethal side effects; the underuse of life-saving medications; lavish marketing campaigns that influence what doctors prescribe; and the resulting upward spiral of costs that places vital drugs beyond the reach of many Americans.

In this engagingly written book, Dr. Avorn asks questions that will interest every consumer: How can a product judged safe by the Food and Drug Administration turn out to have unexpectedly lethal side effects? Why has the nation’s drug bill been growing at nearly 20 percent per year? How can physicians and patients pick the best medication in its class? How do doctors actually make their prescribing decisions, and why do those decisions sometimes go wrong? Why do so many Americans suffer preventable illnesses and deaths that proper drug use could have averted? How can the nation gain control over its escalating drug budget without resorting to rationing or draconian governmental controls?
Using clinical case histories taken from his own work as a practitioner, researcher, and advocate, Dr. Avorn demonstrates the impressive power of the well-conceived prescription as well as the debacles that can result when medications are misused. He describes an innovative program that employs the pharmaceutical industry’s own marketing techniques to reduce use of some of the most overprescribed and overpriced products. Powerful Medicines offers timely and practical advice on how the nation can improve its drug-approval process, and how patients can work with doctors to make sure their prescriptions are safe, effective, and as affordable as possible.
This is a passionate and provocative call for action as well as a compelling work of clear-headed science.


From the Hardcover edition.

Profiteeering pharmaceutical companies and the FDA have met their match in Dr. Jerry Avorn, a Harvard Medical school researcher and clinician. In Powerful Medicines, he brilliantly combines patient vignettes, scientific critique, and statistics to create a risk/benefit balance for prescription drugs. His premise: "Every drug is a triangle with three faces--representing the healing it can bring, the hazards it can inflict and the economic impact of each." Avorn's gifts as a writer are apparent in the prologue, an edgy account of the mismanaged medications of several stroke patients. He then details the intellectual history of drug assessment and benefits, including the biblical food police in the Book of Daniel, the deer in the headlights Estrogen debacle and the current infatuation with Ginseng and other alternative medicines. Turning from benefits to risks, Avorn examines diet pills, Viagra, cold medicines and diabetes drugs with comparisons the decisions of Dr. Fautus--who makes life-changing bargains between safety and effectiveness. Other insightful chapters offer views of prescription drug economies, and comparative healthcare around the globe. The final chapters create an insightful template for emerging public policy. Throughout, Avorn pulls at common threads: the line between personal and public responsibility, the perils of drug promotion, and the marketplace that usurps the role of scientific evidence in selecting treatments. Anyone looking for a quick muckraking read will be disappointed. But Avorn's views, literate and complex, will frame the debate on prescription drugs for years to come. --Barbara Mackoff

I am beyond fortunate that I now qualify for a prescription drug benefit care of the state of Oklahoma. And that is only because I am classified as disabled and my income is low enough to trigger the state program. Medicare, which covers me for some other health costs, did not, until quite recently, have a prescription drug benefit of any kind. The full amount of the cost of the medication I take in a vain attempt to control my seizures, as represented above, is for a single month. I used to take twice the dosage, back before I had any drug coverage at all. The retail at that time would have come to $440 per month, equivalent to the mortgage payment on my house. Since Lamictal was developed and is manufactured outside the United States, I was able to purchase a month's supply of that higher dose from Canada for about $180 per month, or about 40% of the price charged by US pharmaceutical distributors. Distributors. Who buy it from the same place the Canadians do. and charge over twice as much for it. American drug distributors represent a bottleneck in the system. There are only a handful of them, and they are not in competition with one another. Last year's changes to the Medicare program was said to introduce a prescription drug benefit, in a multi-tiered system run by a spate of outside companies. This means each potential recipient has to navigate a veritable mine field of complicated plans to determine which, if any, provide them with good value for money. Turns out, many of them provide no real savings at all, once the monthly fee plus deductions are taken into account along with the sliding spending requirements. And further, and most criminally, the new legislation explicitly forbids Medicare, the largest single potential purchaser of drugs, from negotiating with the industry for better pricing. Never mind that other government agencies are allowed to negotiate prices based on bulk purchases, were Medicare allowed to do so, it would singlehandedly drive the artificially inflated cost of drugs down, and we can't have that, can we? Once these new questionable drug programs are in place, it is likely states will abandon their own programs, leaving anyone under Medicare basically shit out of luck. The truly pathetic thing about all of this is that not only do Medicare recipients get the shaft, so does everyone else. Drug prices remain artificially high, driving up the cost of insurance premiums, state health programs dance along the edge of insolvency trying to keep up, and many people simply go without the medications they need to be healthy. And the only people making out are those within and connected to the pharmaceutical industry, perennially the most profitable industry in the entire world. It's obscene.

I just refilled Daniel's novolog pens. My husband recently changed jobs, and our insurance company changed. A couple of weeks ago I was trying to figure out what our yearly costs would be for diabetes treatments based on the descriptions of the different plans in the booklet his new company provided. What a headache! All I know is that I'm in the wrong business. Does anyone want to start a health insurance company with me? Seems to be a real moneymaker.

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