OVERMEDICATION Part Two

THE CRIMINAL RECORD OF THE MIRACLE DRUGS

SIDNEY KATZ January 5 1963
OVERMEDICATION Part Two

THE CRIMINAL RECORD OF THE MIRACLE DRUGS

SIDNEY KATZ January 5 1963

THE CRIMINAL RECORD OF THE MIRACLE DRUGS

OVERMEDICATION Part Two

SIDNEY KATZ

Antibiotics can — and do — bring on a myriad of ailments from deafness to blood disease. Yet we constantly use more of them for no good reason. The new “mood chemicals” can have side effects as serious as death. Yet they’re gaining new addicts every day. A further report on the least publicized problem in medicine today

WHEN THE NEW “wonder” drugs began to flood the market some years ago, a farseeing physician repeatedly warned his medical students: “Gentlemen, never forget that the age of dangerous surgery is drawing to a close but the age of dangerous medicine is just beginning.”

This disturbing prediction has come true. In addition to saving millions of lives, overuse and abuse of the new, powerful, quick-acting drugs have caused — and are causing each year — an indeterminate number of cases of illness and death. We now consume, annually, forty-three million prescribed doses of antibiotics, tranquilizers, psychic energizers, steroids (hormonal compounds), anticoagulants, diuretics and other chemical agents. That’s two and a half times the per capita consumption ot twenty years ago.

A number of forces have combined to produce the present drug binge. The Hippocratic principle that we should depend chiefly on the body's built-in curative powers to restore health, rather than on drugs, is largely ignored. Doctors, too often, yield to the patient’s plea for the latest nostrum even though it can't do him any good and may do him harm. Some physicians are being unduly influenced by the hard sell of “Medicine Avenue,” as the drug industry is sometimes called. “Many of the ads for the new drugs are so unreliable,” says Dr. Solomon Garb of the Albany Medical School, New York, “that a physician trusting them can be seriously misled.” Several new drugs have been marketed without adequate testing; others are being liberally prescribed without their dangers being fully known. None of these statements depends on the authority of a single doctor:

I believe them to be a consensus of the most responsible medical opinion in this country and the U. S.

The antibiotics arc a case in point. The scores of bactcriakilling antibiotics developed since the introduction of penicillin in 1941, have saved millions of lives. But, due to misuse, they have also done — and are doing — incalculable harm. “Any drug that can poison germs can also poison the patient,” one doctor told me. No antibiotic yet developed is entirely free from possible adverse side effects. Some of these unwanted effects arc mild and temporary; others are serious, prolonged and may lead to death. Yet, in the opinion of Dr. A. L. Chute of Toronto's Hospital for Sick Children, “About twenty-five to fifty percent of the doses of antibiotics given to children are unnecessary.” In a unique and painstaking study of an entire South Dakota community it was demonstrated that, during a five-year period, ninety-two percent of the population had received an average of four doses of antibiotics. In fifty-three percent of the cases, there was no valid reason for treatment.

T he side effects of the antibiotics arc only now being fully catalogued. Neomycin, for example, can produce dizziness and impaired hearing. “Some patients remain permanently deaf,’’ says Dr. T. E. Roy, a University of Toronto bacteriologist. Streptomycin, dihydrostreptomycin and vanomycin can also produce the same result. Neomycin and bactiracin may seriously impair the functioning of the liver. At the Montreal Children's Hospital and elsewhere, physicians are seeing an increasing number of children with yellow teeth — the result of being treated with a commonly used antibiotic, tetracycline. The drug damages the cells that produce the white tooth enamel. Familiar drugs like aureomycin and tcrramycin are frequently associated with nausea, digestive distress, rashes, shock and inflammation.

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Doctors have forgotten Osier’s simple dictum: "Above all do nothing to harm the patient”

Bui perhaps the most dangerous of all antibiotics now on sale is chloramphenicol (Chloromycetin). Since the introduction of this drug twelve years ago, medical journals and government agencies have repeatedly warned that this powerful agent can cause blood dyscrasias — the technical term for a group of blood-wasting diseases. For this reason, most authorities suggest that chloramphenicol only be used on a relatively small number of patients wdth such severe infections as typhoid fever, psittacosis and Rocky Mountain spotted fever. But many doctors, evidently, have for-

gotten Sir William Osier's simple dictum, “Above all, do nothing to harm the patient.” A limited study in the U. S. reveals hundreds of patients suffering from chloramphenicol-related blood diseases, many of them with a high rate of mortality. There are also such cases in Canada, but nobody know's how many. We don't even bother to investigate.

Many of the chloramphenicol tragedies need not have occurred. While home for a weekend in Fullerton, California. Brenda Elfstrom, a college girl, complained of a sore throat. Her doctor gave her chloramphenicol. That was in September, 1959. In January, he repeated the prescription for a light urinary infection. In April, he gave the girl still another dose for a sore throat. (A sore throat is sometimes an early symptom of blood disease.) In May, she saw the doctor again because a slight bump had mushroomed into a huge, unsightly bruise. To any knowledgeable physician this is another possible symptom of blood disease, but still no hematological tests were made. In early June, Brenda Elfstrom died. The cause of death was aplastic anemia, a blood disease almost certainly brought on by repeated doses of chloramphenicol.

Other such cases can be cited. A twenty-year-old girl died from the same disease after being given chloramphenicol for an infected finger bite. Another victim was a two-year old child who had received five doses of the drug for a cold, a sty and an infected finger. In the last tw'o years, at least twenty patients have sued the manufacturers of chloramphenicol for

at least seven million dolí W of the litigants, Mrs. Carne. ;e, of Palo Alto, California, w¿ arded $334,046 in 1961. In spit • these tragedies, chloramphenicol (tinnes to be overused. Describing his preparations for a summer camping trip, a writer in a large American newspaper informed his readers that he was taking along a supply of chloramphenicol for dysentery, "at the direction of our family physician.”

The unnecessary use of antibiotics less powerful than chloramphenicol has reached alarming proportions. Antibiotics are indicated only for bacterial infections such as bacterial pneumonia, strep throat, tonsillitis and boils. They are useless against such viral infections as viral pneumonia. measles, polio, influenza and the common cold. The correct medical procedure is for the doctor to formulate a diagnosis and then prescribe an antibiotic if it is appropriate.

“Antibiotics have made bad doctors"

Unfortunately, this sane and safe procedure is often disregarded today. Antibiotics are prescribed for a fever, even before a diagnosis is made. “We frequently use antibiotics as a better form of aspirin.” says Dr. Henry C. Kempe of the University of Colorado. Thus, pills become a substitute for painstaking diagnosis and clinical judgment. Under this method of practising medicine it's possible to remove the symptoms without knowing what the disease was. “Antibiotics have made a lot of bad doctors.” says Dr. Alton Goldbloom, formerly the pro-

fess r.uiatrics at McGill Uni-

verflty. Sometimes a shot of antibiotic — not needed in the first place — causes “antibiotic fever.” When this persists, the doctor may try a second drug and perhaps a third. Many such cases of overmedication end up in hospital.

“We see many children who have been given antibiotics without reason and have been harmed by them,” says Dr. A. L. Chute of Toronto's Hospital for Sick C'hildren. “I sometimes stop all medication and the fever vanishes.” Dr. Goldbloom adds, “I have cured more people by taking away drugs than by giving them drugs.”

Some doctors continue to use antibiotics “prophylactically”. as a preventative to ward off infections. Authorities like Dr. Kempe regard this as nonsense. “A germ can't be killed before it appears,” he says. Numerous studies attest that the prophylactic use of antibiotics seldom does good and is more likely to do harm. Dr. W. B. Spaulding of the Toronto General Hospital has pointed out that of thirty premature infants given chloramphenicol preventatively, nineteen died of what has been termed “the gray disease.” Reviewing two hundred and fifty “clean” surgical cases Dr. Kempe concluded, "Bacterial complications are five times as high when antibiotics were used preventatively.” In one study of measles, the prophylactic use of antibiotics doubled the number of cases of bacterial infection; in bulbar poliomyelitis. it trebled the infection rate. “There's little justification for the use of antibiotic prophylaxis against the bacterial world at large," says Dr. T. E. Roy, a University of Toronto bacteriologist.

One reason that this advice is well worth heeding is that many people

_an estimated five to ten percent of

the population — are sensitive to penicillin. one of the most popular antibiotics. The more people exposed to a drug, the greater the number of people developing a sensitivity to it. It's estimated that as many as three hundred people in North America die everv year from penicillin shock alone. "The number of cases is multiplying," says Dr. W. B. Spaulding.

Another reason for cautious use of antibiotics is that these drugs can upset the germ balance in the body and thus open the way for diseases far more serious than the ones they were intended to cure. Our mouth, throat and intestinal tract are inhabited by billions of fungi and bacteria. They exist in a state of delicate balance and are necessary to normal life. If w'c take a certain antibiotic, it selectively kills off a certain type of bacteria and upsets the balance. Thus, some bacteria are given the opportunity to multiply with lightning speed and cause an infection know n as a superinfection. One such infection is staphylococcal enterocolitis, frequently found in surgical wards. It has a mortality rate of forty percent.

Promiscuous use of antibiotics is largely responsible for the epidemics of staphylococcal infections which have been sweeping through our hospitals for the past several years. The more antibiotics are used, the more the development of resistant strains of bacteria is encouraged. When first introduced, penicillin was able to vanquish the staph germ. But certain variants survived and multiplied. When streptomycin was discovered it w'as a match for these super-staph bacteria. In time, however, it lost its punch because certain strains w'ere able to resist it and multiply. Then along came tetracycline. It. too, became ineffective. A new powerful anti-staph antibiotic was introduced about a year ago. How long it will retain its potency depends, in part, on how sparingly and wisely it is used.

A single antibiotic given unnecessarily is cause enough for alarm because of the dangers of side effects and sensitization. But a real nightmare to the conscientious physician is the growing use of “mixtures” — pills which contain two, three or as many as five different kinds of antibiotics. About two out of every three “new" drugs on the market arc mixtures. “With few exceptions, there is no reason for using any of these mixtures." says Dr. Alek A. Rozcntal,

of St. Louis University, an associate professor of economics w ho for several years has specialized in the study of the pharmaceutical industry in Europe and the U. S. A. The present widespread consumption of mixtures has been condemned by a long list of similarly qualified men. Dr. Maxwell Finland, of the Harvard Medical School, calls the proliferating mixtures “a vicious distortion of the best use of medicine.” Dr. Finland says, “I know' only three diseases in which combined antibiotics have proved really useful — tuberculosis, subacute bacterial endocarditis and brucellosis.”

When used in other circumstances, mixtures may do incalculable harm. Dr. Roy, the bacteriologist, points out that a combination of penicillin and streptomycin is frequently given to infants. Streptomycin can cause deafness — a condition difficult to recognize in the very young. Of fifty-six recent cases of drug-related blood disease. chloramphenicol was used in half, in combination with other drugs. Some mixed drugs can only be described as weird. One combines antibiotics with vitamins, antihistamines and steroids. The latter compounds can cause anything from emotional disturbances to severe weakening of the bone structure.

One of the most outspoken critics of mixtures is Dr. Isaac Starr of Philadelphia, chairman of the American Medical Association Council on Drugs. He points out that in the treatment of pneumococcic meningitis, more deaths arise from using a combination of penicillin and tetracycline than when penicillin is used alone. “One wonders.” says Starr, “how' often penicillin, given in such mixtures, is the cause of sensitization w'hich is now' becoming such a serious clinical problem.” Some manufacturers justify the use of mixtures because, they say, one ingredient eliminates an undesirable side effect of another. "This almost always fails.” says Starr.

High on the list of drugs which are being unnecessarily prescribed are the new mood-altering chemicals. There are two main types. The tranquilizers w'hich pacify and calm: the psychic energizers which stimulate, cheer up and vitalize the depressed patient. In medical literature these drugs are known as psychochemicals, psychopharmaceuticals. ataractics, and phcnotropics. The first of them, the tranquilizers chlorpromazine ( Largactil) and reserpine (Scrpasil), appeared about ten years ago. Since then, they have heen supplemented by about forty-five additional agents. Last year, the American people gulped down almost one and a half million pounds of psychochemicals at a cost of two hundred and fifty million dollars. "The situation must at least be comparable in Canada,” says Dr. T. F. Rose, a Victoria internist. It is estimated that five million prescriptions for psychochemicals arc now being written each year. This situation has led physicians to sound a double warning: psychochemicals, besides

weakening the moral fibre of the patient, can seriously injure his body as well.

Originally, t h c psychochemicals were designed to treat neurotics and psychotics in mental hospitals. But today, the majority of tranquilizers and energizers are taken outside of hospitals b)T people who, Dr. Rose says, “are not sick. They want to protect themselves from the normal pin pricks of living.” Manufacturers, in their advertisements, have recommended tranquilizers for the following situations: homesickness, restlessness in children, fear, fatigue, itching, working in a noisy place, going to weddings and funerals, giving a speech, having differences of opinion with somebody. One advertiser boasted in print that his product so alleviated “hostilities” that the average patient wouldn't even be able to start an argument after a dose!

Obviously, these are ordinary, usual situations which every normal human being must be prepared to face without leaning on a drug. The drug may also, on the other hand, conceal serious psychological difficulties in urgent need of psychotherapeutic treatment. In making a final assessment of the mood drugs. Dr. Rose says, “In mankind’s naïve but age-old search to get happiness out of a bottle, the tranquilizer will rate a good deal more expensive than phenobarbitone but a good deal less honest than whisky.”

The manner in which a psychochemical can corrode the body, however, is more easily measured than the possible damage it might do to a person's character. The most notorious tranquilizer is thalidomide, which was removed from the market this spring because it caused deformed babies. But other, far less publicized agents have had to be withdrawn as well because of their injurious side effects. Amphenidone (Dornival), a tranquilizer, was sold for a year and a half before it was associated with agranulocytosis—a blood disease with a forty percent mortality rate. One medical officer collected a file of eleven cases, with three resulting deaths. Etryptamine acetate (Monase), a psychic energizer, which caused the same disease, was available for a period of one year. Iproniazid (Marsilid). prescribed for seven years as an anti-TB drug and an energizer, was withdrawn only last June because it was identified as a cause of hepatitis.

Many people believe that because a psychochemical is still being sold it can be taken without danger. This is untrue, despite the ads in the medical journals which contain such phrases as, “Safe continuous relief without impairing normal behavior” . . . “Sound and secure” . . . “Outstanding effectiveness and safety.” For a more scientifically accurate description of the possible side effects of the psychochemicals, one has to search elsewhere. Recently, Dr. Jonathan O. Cole, chief of the Psychopharmaceutical Service Centre at the U. S. National Institute of Health, listed some of the undesirable effects of the fortyseven most commonly used mood chemicals. These were summarized in the New York Post as follows:

Autonomic reactions are the result when the nonvoluntary nervous system is upset: headaches, nasal congestion, difficulty in urinating, excessive perspiration, dry mouth. Of the forty-seven chemicals, thirty-three are known to have caused these effects; four more may.

Behavioral toxicity means dizziness, punch-drunkenness, depersonalization,

excessive drowsiness, hallucinations, shortened attention span. Thirtyseven of the drugs sometimes have these effects; five may.

Skin disorders can occur after taking any of twenty-two; some experts think that these and other drugs are now the leading cause of dermatitis.

Convulsions can he caused hy twelve of the drugs. Nineteen lower blood pressure in some patients; seven raise it; some can do both but presumably not in the same patient.

Severe cardiac involvement has been attributed to eight of the drugs. At least eleven and perhaps sixteen can damage the liver. At least eleven and perhaps nineteen of the drugs can cause destructive blood dyscrasias.

One side effect of the psychochemicals which is hardly ever discussed is the manner in which they interfere with sex. One of the outstanding authorities on psychochemicals. Dr. Nathan Kline, research chief of Rockland State Hospital, Orangeburg, New York, says, “temporary impotence is not at all infrequent among males who take tranquilizers.” It is the opinion of many doctors that sexual debilitation by psychochemicals occurs quite frequently but remains unpublicized because of the reluctance of the male to discuss any lessening of his sexual potency.

There is one important lesson to be learned from a careful review of the published medical studies which deal with the action of the new psychochemicals in the body: they are to be used sparingly and only in cases of dire necessity. For example, few laymen arc aware that many of the mood chemicals “soup up” or potentiate the action of other drugs taken at the same time. An anesthetic plus a tranquilizer can become potent enough to cause illness or even death. Some of the psychochemicals make one drink of alcohol as strong as two or three. Like alcohol, some of the tranquilizers are habit forming. Dr. R. Gordon Bell has been treating an increasing number of “tranquilizer addicts” at his Toronto clinic. “It's a far more serious addiction than alcoholism,” he says.

A more potent but less frequently prescribed group of drugs is the steroids, which are hormonal compounds.

They were hailed with great enthusiasm in 1948 when a Mayo Clinic physician first demonstrated the miraculous way in which cortisone banished the symptoms of rheumatoid arthritis. It was soon learned that the side effects of steroids can be devastating. Steroids can ignite peptic ulcers; reactivate tuberculosis; kindle diabetes in the susceptible; cause a form of psychosis in an emotionally stable person. Arthritic children, carelessly treated with steroids, may end up with bones so deficient in calcium that they suffer from merely walking. Some steroids, the sex hormones, can do great harm. Men dosed with them have developed large breasts; women have grown beards.

The anticoagulants — drugs used to thin out the blood and prevent blood clotting — are not an unmixed blessing. Recently, Professor John McMichael of London University, urged that anticoagulants be prescribed less frequently for people who had suffered heart attacks. “We're producing a bleeding disease in order to prevent a clotting disease,” he says. “Unless we're going to save more lives, I don’t think we should take the risk.”

Not long ago, Dr. William Bean of the University of Iowa's medical school, threatened to write an article entitled, Recent Setbacks in Medicine. Dr. Bean was irked by the enthusiastic publicity which has greeted every new drug during the past twenty-five years. Like most qualified observers, the Iowa physician questions whether the majority of new drug products, most of which are mixtures, represent any real advance in therapeutics. If over used or abused — as they so often are—the new drugs may actually represent a step backward as far as the welfare of the patient is concerned. More and stronger drugs is not the physician's most urgent need today. What he does need is to develop the kind of wisdom and caution which tells him when to keep his hands off the patient or when to tread lightly. “It might be better,” said Dr. F. M. B. Allen of London, England, addressing his colleagues, “if we pondered, more often, on when to treat and when not to treat.” ★