Thursday, November 29, 2007

Pharmaphobia and Placebophilia

I really love compounding novel or at least semi-novel words from roots and stems. Perhaps I should consider a serious study of German.

If you whip out your copy of the Diagnostic and Statistical Manual of Mental Disorders, you'll see that a specific phobia is defined as an irrational fear of a specific object, situation, or environmental factor. Exposure to the phobic object typically produces classical symptoms of a panic attack--hyperventilation, increased heart rate, and feelings of anxiety. The phobic patient knows that his or her fear is irrational, but cannot overcome the fear through rational thought.

I've never met anyone who I would classify as a "pharmaphobe" in the sense that the sight of aspirin tablets caused them to collapse into a pile of terrified, quivering flesh, though it would certainly be interesting from a clinical perspective. No, what I'm talking about is a set of reactions to drugs and drug therapy that are associated with a mixture of misconceptions that many people I talk to seem to have. I have definite experience with people who say that they really don't like taking drugs. "Side-effect" is a really dirty word in the pharmacy business; patients want to know about them, but doctors and pharmacists don't want to scare their patients out of compliance. Part of effective patient counseling is knowing what side-effects a patient actually needs to be concerned about and communicating the issue of risks versus benefits.

I can sympathize with a desire to avoid drugs on some level. Taking medication is an acknowledgement that you are sick. I've heard stories about patients with chronic illnesses like high blood pressure or diabetes not taking their meds becuse it will mean facing their disease. They would much rather ignore it and hope it goes away instead of worrying about taking a lot of drugs. Patient compliance with a treatment course is a huge factor; drugs don't work if you don't take them. And when patients have to swallow a dozen tablets or capsules a day, if not more, many of them get discouraged and feel as though they have to structure their lives around taking their medication. There's a reason that once-daily dosing is preferred by both physicians and patients alike; it results in better outcomes due to increased compliance. Medical professionals sometimes call this "pill burden."

Likewise, it isn't necessary to take drugs for every ache. Not every headache calls for painkillers. Simple nausea, perhaps due to indigestion, will probably run its own course before any oral medication is going to have time to enter the bloodstream. A day with a stuffy nose doesn't necessarily require oral decongestants or nasal sprays to rectify.

The irony is that there's some overlap between the group that brandishes a holy symbol at your friendly pharmacist and the group that demands Benadryl after every sneeze.

Many people who have problems have a psychological need to feel like they're doing something to fix them, and sometimes they apply the same logic to their health. If something doesn't feel right, there must be a cure, and every moment they spent not seeking it is wasted in idleness. These people simply will not take no for an answer. They came to the pharmacy to buy something that will make them feel better, and they're going to find something, no matter what the pharmacist says. At some point, many of them eschew logic, close their ears, and leave us in the profession wondering why they ever asked for our opinion if they're already so knowledgeable about what will help with their symptoms. They really want to buy something, as though the act of purchasing a product will help more than anything else.

I had a conversation with a man yesterday of this very nature. He complained of a sore throat. No other symptoms. After further assessment of his condition and history, I recommended he try some acetaminophen.

"But I've already got that at home," he said, "and I wanted to get some Coricidin. Coricidin works well for me, and I have high blood pressure."

I've already talked about how much I hate marketing in medicine. It steers people in the wrong direction. It doesn't matter what's on the front label; that information is not regulated whatsoever. You have to turn the box around to get any useful information. I don't remember which product the man selected; there were probably five or six options. I think he chose the only one containing no pain reliever whatsoever and would not be dissuaded from his choice. He made his decision based on what seems like reasonable logic: I felt lousy before, I used this product, I felt better. Brand-name marketing is wholly reliant on this idea of recognition and loyalty. It wouldn't be so bad if it didn't obfuscate the issue for layman consumers thats what's in the tablets is everything and what's on the box is irrelevant.

But sometimes you can give no recommendation, or the patient is already doing everything they can. The common cold is the best example. I'll go through a patient's symptoms and necessary medical history. Once I have the information I need, they don't like any of my suggestions. "Antihistamines make me sleepy." Sometimes they're already taking a product containing everything I could logically recommend. "I'm already taking Advil Cold and Sinus, I thought maybe you could suggest something else."

(As an aside, the number of people who ask me for "non-drowsy Benadryl" is kind of staggering. Diphenhydramine, the primary ingredient in Benadryl, is also the primary ingredient in almost all OTC sleep aids. It's kind of like asking for non-alcoholic Everclear.)

That's when they get disenfranchised with what I have to say and start taking medical advice from their mother-in-law, their roommate, the internet, Oprah, whatever. I call it "second opinion syndrome." It might be legitimate to ask for a second opinion if you're considering major surgery. We're talking about the common cold. And it's not that they want another medical opinion--they want any opinion, as long as it's what they wanted to hear in the first place. Yargh. How can you compete with that?

Sometimes people die because they turn to so-called "alternative medicine" instead of scientifically-valid treatments, but most of my patients are fairly far from that stage. No one is (likely) to die from taking vitamin C to stave off a cold or because they wasted money on Airborne. And you get two kinds of people who lust after those boxes of Emergen-C on the pharmacy shelves: Those who "hate drugs" and would rather "take something natural" and those who have exhausted all the other plausible options for treating a cold and are just desperate to feel better faster. So desperate, in fact, that they are willing to spend $20 on Cold-FX or other similar remedies. One of the big claims of homeopaths in particular is that their remedies are less expensive than mainstream medicine. That's kinda funny, seeing as how 30 lozenges of Cold MD and Oscillococcinum, cost a lot more than generic diphenhydramine, which will dry out cold symptoms and might even help a sufferer get some sleep. I think I got a 100-count bottle for like $12 over the summer and still have a ton left.

The first group is the extreme pharmaphobes. They are so terrified of drugs, drug companies, doctors, and pharmacists that if you see them in the pharmacy it's because the GNC is closed. The FDA and the government are in league with pharma and poisoning babies because they're too proud to admit that all forms of cancer can be cured if you just IV push enough vitamin C. They just came from their naturopath and are on the way to the chiropractor and couldn't be bothered to drive to the health food store. They are extreme granola people. This is kind of a funny picture, but I think these types are pretty rare unless you live in California.

The second group are the pseudopharmaphobes who will drop off their prescription, pay for it, discuss it with you, and then start whining about how having to take drugs is ruining their life. I would go out on a limb and suggest that diabetes or hypothyroidism or depression or perhaps chronic pain are considerably worse, but I would probably get fired.

And the third group are the placebophiles.

I was talking to a friend online the other day about how much it bothered me when patients asked for advice and then promptly ignored me. He agreed that this sounded annoying. Since we were discussing the common cold, his response was, "yeah, the only thing you can really do about that is take vitamin C, right?"

No, not really. His idea was one step from correct. Like most well-informed patients, he knew that antibiotics were worthless against the common cold, it being a viral illness. But he still held the pervasive idea that the common cold was preventable or treatable with vitamin C--not because of his lack of intelligence, but simply due to the issue that "vitamin C treats colds" is a very commonly cited health misconception. I provided him with some information to read on the subject, which he found interesting. It was at that point when he said something that struck me.

"Huh," he said. "Well, it's not going to hurt anyone, so I don't see why people shouldn't just take vitamin C anyway. I don't have a problem with 'gentler' medicine as opposed to drugs that have side-effects."

I'll direct you elsewhere regarding the error of his statement. What I think he inadvertently hit upon is the idea that some people really like placebos. Not even in the sense of a sugar pill containing no active ingredient, but in the sense of taking some medication, even if it's one totally unrelated to their illness, like the Coricidin man. They don't care if a treatment works or not. In fact, if the treatment is going to be ineffective but is unlikely to do harm, they'd rather not know about its lack of good efficacy data, a reaction I get frequently from patients asking me about zinc lozenges, which might have some efficacy but probably aren't worth the money or the unpleasant taste. We report, you decide. What's important to most of these patients is feeling like they're doing something about their illness, whether it's effective or not. They feel better, psychologically speaking, which probably improves things for them at least a little. In fact, there are so many psychological components to why people choose to use certain treatments even if they know they're placebo treatments that I could probably write indefinitely on the subject. Which raises an interesting question; is a placebo a placebo if a patient knows it's a placebo? I think that, through the amazing power of doublethink, it still can be. My girlfriend actually tries to "induce the placebo effect" whenever she takes medication: "I know this medication will work, and by thinking about the fact that I know it will work, I can make it work better." That probably isn't true in the strictest sense, but having confidence in a chosen therapy certainly makes you feel better about using it and can relieve emotional stress.

So both supplement-popping health nuts and your poor guy with a cold who just wants to feel better have something in common. They both want to feel like they have control. The idea is terribly appealing for some; we can prevent ourselves from ever becoming ill if we only do the right thing and are on our "best behavior" from a health perspective. We can all live forever if we only get the right vitamins. And health practitioners, not wanting to trample patient autonomy or turn off the potential benefit of the placebo for self-limiting conditions, are tight-lipped because they're deathly afraid they'll do something that will ultimately have a negative effect on patient outcomes.

Until the medical industry can literally cure every known illness with simple treatment regimens, placebophilia is here to stay. It's a part of the human psyche.


Kelly said...

I think the issue of control is a huge one. The feeling of needing to *do* something so you are not feeling like a "victim" of whatever is going on leads to feeling like *something* must work. It's illogical -- but most emotional reactions are :) One thing confused me -- your link in the statement about your friend saying that Vitamin C doesn't hurt anything led to a paper on Alt med in general. I didn't see anything about vitamin treatment -- what is the connection that I'm missing?

N.B. said...

The link was less intended to say anything about the specific treatment and more to debunk the idea that "harmless" alternative treatments are automatically okay. "It can't hurt, but it might help" is one of the mantras of altmed that is especially problematic for real medical professionals. In order to do something that will help a patient, there are always risks involved, even if they are low. Real medical professionals have to deal with risk-benefit analysis as a daily part of work. Altmed practitioners dodge the issue altogether.