THCB

What’s In Our Medicine Cabinets?

Recently published statistics show that the top-grossing medication in the U.S. for 2013 was the antipsychotic Abilify (aripiprazole) with over $6 billion in sales, narrowly beating out the previous few years’ winner, Nexium.

The past decade’s dominating pharmaceuticals have been Lipitor (atorvastatin) for high cholesterol and Nexium (esomeprazole) for acid reflux. Nexium was preceded at the top by Prilosec (omeprazole), and before that we had Pepcid (famotidine) and Zantac (ranitidine) somewhere near the top of the sales data.

A country’s medicine cabinets tell us something about its culture and its predominant issues.

From the late 1960’s to the early 1980’s the tranquilizer Valium (diazepam) was the top grossing drug. The 1965 US sales volume of tranquilizers was somewhere around 166 million prescriptions or 14% of all prescriptions filled in this country. Both “uppers” and “downers” were subjects of the 1966 best seller “Valley of the Dolls”. Valium rose to the top after the previous few years’ blockbuster tranquilizer Miltown (meprobamate) proved to have significant toxicity risks.

So, this country has gone from treating nervousness and suppressed emotions to heartburn and high cholesterol, the latter two sometimes self-inflicted through dietary indiscretion, and now back to psychiatric conditions like schizophrenia. True, there are other, “softer” indications for Abilify – bipolar disorder, treatment resistant depression and for chemical restraining of aggressive individuals, even children.

One cannot help but stop and reflect on this pharmaceutical sales phenomenon.

The postwar years, although portrayed in media as a time of health care advances, optimism and prosperity, were years of great anxiety. My own observation is that many of my patients and acquaintances who were children during World War II lack the emotional imperturbability of those whose childhood fell in the 1930’s, born in the early to mid 1920’s.

The 1950’s and 60’s were times of change, when traditions were lost and values challenged. They were years of optimism on one hand and of a beginning intolerance on the other hand for ailments our forbears viewed as part of life on this earth.

At least to this child of the 1950’s, the Lipitor and Nexium (and Viagra) years seemed a time of more mundane, selfish pursuits for many Americans, a change of course for healthcare after the victories against polio, tuberculosis and smallpox. The term “lifestyle drugs” is often used for pharmaceuticals that treat non-life-threatening conditions like erectile dysfunction and urinary control problems. Curiously, “lifestyle medicine” is different, defined as the practice of lifestyle interventions like diet and exercise to promote better health.

In the 2013 statistics, Viagra, the top grossing lifestyle drug, comes in only at the number 37 spot.

I don’t know what to think of an antipsychotic now topping the pharmaceutical statistics.

Is it a sign of an epidemic rise in rates of serious mental illness, or is it more an indication of an increasing intolerance of negative emotions and behaviors in our society? Or is it just the result of persistent, powerful pharmaceutical marketing to consumers?

Either way, it is a bit disturbing that such drugs outsell all others.

But there is another, even more disturbing trend in drug sales in this country, involving less spectacular individual drug statistics – the pain pill market.

OxyContin, the sustained release form of the pain medication oxycodone, at $2.5 billion in sales, is the eighteenth highest grossing drug in America, with twice the sales of Viagra. Even Suboxone, a medication used to treat opiate addiction, grosses more money in sales than Viagra.

One challenge in making sense of pharmaceutical sales data is this country’s two-tiered pricing system; brand name drugs can cost more than fifty times as much as generics, so even a niche drug can hit the top of the sales charts that are based on revenue instead of volume. This is the case with many drugs for autoimmune diseases like rheumatoid arthritis and Crohn’s disease, for example Humira, Enbrel and Remicade, the number 3, 7 and 8 drugs in 2013.

Among generic drugs, pain medications containing hydrocodone, available in the U.S. since 1943, accounted for 129 million prescriptions in 2012, as many as the 3 top cholesterol medications and 2 top blood pressure drugs combined.

This is where the data becomes interesting. The United States is reported to consume 80% of the world’s prescription opioids and 99% of all hydrocodone produced.

In comparison with the 1960’s, when tranquilizers were among the most prescribed medications, we now seem to be treating physical pain, rather than emotional distress. But, the lines between the two are blurry; dating back to the earliest use of opium and the centuries-old use of morphine for the anxiety and agony of fulminant heart failure, for example, more and more research has shown that physical pain and emotional suffering share many of the same neurobiological mechanisms.

Several research papers from 1969 pointed the way to where we are today, when they demonstrated that the tricyclic antidepressant and MAO inhibitors of that era had pain relieving properties.

One modern drug that made it to the number 5 spot in the sales data before going generic this year, the antidepressant Cymbalta, duloxetine, has been FDA approved to treat both depression and pain. In Europe, it is even sold to treat urinary control problems – a true “poly-pill” that treats psychic and somatic pain and one of the common lifestyle complaints of our era.

So it is tempting to conclude that the tranquilizers of the 1960’s and the opiates of the past few decades are treating the same thing – pain, be it psychic or somatic, is pain, and what dulls one also dulls the other.

What about the rest of the world? The top selling pharmaceutical worldwide is acetaminophen, called paracetamol in many countries; a pain medicine.

And the number two drug? The birth control pill, the first and perhaps most revolutionary “lifestyle drug”.

Our country’s reliance on stronger pain medications than the rest of the world is not likely due to a greater prevalence of severe disc degeneration or osteoarthritis here than anywhere else, and I’m not sure we have more schizophrenia here than countries with lower Abilify sales, in fact my reading suggests we have less. The difference is more likely cultural.

Ultimately, the question is how much of human suffering is truly a medical problem, best treated with medications, and how much belongs elsewhere? If healthcare is the new religion, maybe we need to shoulder all suffering, but I would prefer that were not the case: I don’t think we can take the place of religion, philosophy and the general culture of our nation.

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Steve RobbinHans Duvefelt, MDBrad FPeter1Saurabh Jha Recent comment authors
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Steve Robbin
Guest

You must differentiate between Units and Sale.

Brad F
Guest

You must distinguish sales vs units. In number of pills sold, Abilify #23.

Not chopped liver, but neither an epidemic.

Brad

Hans Duvefelt, MD
Guest

Well, given the prevalence of schizophrenia, even that ranking is high.

Brad F
Guest

Looking at the list, you will also notice the inordinate number of asthma drugs. The same could be said for that class of Rx.

Enoxaparin? Go figure.

I think the compilation has more to do with global phenomena (OR requires a more nuanced take), rather than an Abilify specific driver.

Saurabh Jha
Guest
Saurabh Jha

I can do no better than quote the irreverent Thomas Szasz.

“The old quacks peddled fake cures to treat real diseases. The new quacks peddle fake diseases to justify chemical pacification and medical coercion.”

and

“Formerly, when religion was strong and science weak, men mistook magic for medicine; now, when science is strong and religion weak, men mistake medicine for magic.”

Joel Hassman, MD
Guest
Joel Hassman, MD

At 15-25 dollars A PILL, who cares what is the top selling drug in America. It’s like movies claiming to be the top box office grosses when 3D movies are now 3-5 dollars more a ticket, yet the need for 3D is superfluous. Oh, and by the way, as a psychiatrist, Abilify’s role outside of psychotic management is marginal at best, but, think about it. Only 1-2% of people have schizophrenia, another 1-2% with primary psychotic disorders that warrant antipsychotic meds like Abilify, BUT, if 5-10% have possible mood disorder issues that Abilify’s manufacturer has found a way to get… Read more »

Don't Go Back to Rockville
Guest

Great analysis. We average a mass shooting every month. Our leading pharmaceutical is an anti-psychotic. We lead the planet in time spent watching television, time on the internet, time at work, time spent commuting, obesity, heart disease, hypertension, and most measures of distisfaction.

Peter1
Guest
Peter1

“We average a mass shooting every month.”

The NRA prescribes OTC guns as the solution. I guess if you rate drugs and guns we are at the top.