Our new issue is out now. Print subscriptions are $10 off if you follow this link.

Quitting Cold Turkey

Drug trials run by pharmaceutical companies are a disaster for public health. Fortunately, there’s an alternative.

Assorted pills, 2013. ParentingPatch / Wikimedia

Nearly nine thousand people wrote in to the New York Times last week to share their experiences of withdrawal from long-term antidepressant use. Many said their attempts to stop taking drugs like Paxil, Prozac, and Zoloft resulted in fatigue, headache, dizziness, flu-like symptoms, night sweats, tremors, panic attacks, and mood swings. Several reported an electric shock sensation they referred to as “brain zaps.”

“I have cut down from 200 milligrams to 100,” wrote one typical respondent to the reader query, “but when I go lower I get horrible side effects, like nausea, jumpiness, crying a lot which I never do. I’m nearly 75; at this point I will continue because I cannot go through the withdrawal.”

A week prior, the New York Times published its analysis of the available federal data on long-term antidepressant use. Researchers found that in the United States 15.5 million people have been taking antidepressants for more than five years, a number that has more than tripled since 2000. 25 million people have been taking them for more than two years. That’s nearly 8 percent of the United States at risk of these prohibitive withdrawal symptoms.

Antidepressant users often emphasize that having drugs available during depressive episodes literally saved their lives. The problem is what happens when patients continue taking them year after year, and become unable to stop. Many indicate that health professionals never communicated the hazards of discontinuation. As antidepressant use exploded in the US, starting in the mid-1990s, why didn’t doctors warn patients about difficult withdrawal? The answer is simple: Doctors didn’t know, because no research had been conducted.

This is because pharmaceutical companies are responsible for clinical trials, and they have no incentive to undertake expensive studies about what it’s like to quit consuming their products. Corporations exist to maximize profit, so naturally the research that interests them is research that gets the drug on the market and boosts sales. Consider the case of the patient quoted above: she plans to take a drug she feels she no longer needs for the rest of her life, simply because the consequences of quitting are too great to handle. The pharmaceutical company profits from every prescription refill; why would it fund tests that might reveal information that would put a stop to those refills?

Public Health, Private Profits

At base the problem is that while information about drugs is a public health concern, its provision is left up to the private corporations that profit from those same drugs. That leads to constant conflicts of interest.

Free-market folk wisdom holds that the private sector’s interests align with the public’s. In this case, that would mean drug companies are best suited for the task of performing clinical trials for new medicines. In theory those companies, motivated by profit and spurred by competition, will invest their own resources in designing the best drugs possible. The public will get the benefit of those drugs, which they will pay for at whatever price the market naturally dictates based on patient need, while profits from those drugs will then go back into research for yet more life-saving drugs — a virtuous circle.

But that’s not really how it works. Pharmaceutical companies angle aggressively to corner whatever market they can. They stifle competition by forming monopolies, and then hike drug prices the moment they see a business opportunity. This pricing is done with no regulation in the US, leading to arbitrarily high drug prices and isolating millions of patients from the treatment they need. The vast majority of the profits go to shareholders, executives, and marketers, not to new drug discovery and testing. And the drug research and development that does occur is, as we see in the case of antidepressants, limited in scope and geared primarily toward helping companies gain a competitive edge — often at the expense of collecting information that patients and providers need to make wise health choices.

Economist Dean Baker proposes a solution to this problem: publicly funded clinical trials. In a paper presented to a United Nations fact-finding panel, Baker suggests that governments should set aside money to finance drug trials without corporate money. Long-term federal contracts would be awarded to researchers who demonstrate interest in testing a specific compound or working on a particular disease. All the results of the clinical trial would then be publicly available, so doctors and patients could consult it freely to make the best decisions about care. If a new drug is successfully developed, no corporation would hold an exclusive patent, so cheap generic versions could be produced right away.

Clinical trials, Baker writes, are “the portion of the process where conflicts of interest and concerns about misrepresentations of data provide the greatest grounds for concern,” but they’re also the portion that “most easily lends itself to public oversight.” When corporations motivated by profit control the process, distortion and omission of data are almost a guarantee; when the public sector takes responsibility, the process becomes more democratic and more oriented toward actual public health needs. Eventually, Baker suggests, an ideal system would rely entirely on publicly funded clinical trials — that is, no corporate-funded testing of drugs at all.

The public needs to know which medications are safe to take, for how long and under what circumstances, and how to safely quit them. But our current system assigns responsibility for gathering that information to entities whose goal is to make as much money as possible, often at the expense of the public good. In drug development, as in insurance, the best way to ensure public health is to increase public funding and control.