Mind Over Meds

Too Many Meds: The Problem—and the Solution

We have a problem. More people are taking more medications than ever before and that is cause for concern. Use of prescription drugs has skyrocketed since the middle of the last century: Americans now take ten times as many as they did in the 1950s. About half of us are now taking at least one, an increase of over 20 percent just since 1994. Use of over-the-counter (OTC) medications has exploded just as dramatically. And more of us than ever are consuming dietary supplements, herbal remedies, and other products promoted for their health benefits, even though scientific evidence is often lacking for the safety and efficacy of many of them.

How many medications do you take? How about your parents? Your children? Your friends? Do you know what they're for? How they work? What their benefits and risks are? How they might interact—with one another and with other products you may be taking? Whether there are alternatives to drugs to manage the health conditions you or your loved ones might have?

Too often, drugs fail to correct the problems they are meant to solve or simply reduce symptoms without addressing the root causes of disease. Too often, they are seen as quick and easy fixes for conditions that would be better addressed by changing dietary patterns, increasing physical activity, correcting sleep disturbances, and practicing techniques to neutralize the damaging effects of stress. At best, the benefits of many of the most widely used medications fall far short of the claims made by manufacturers, who also downplay their risks. At worst, many of those medications do more harm than good.

"All doctors do is give you pills" is a complaint I hear from many patients. More and more doctors tell me they are not comfortable with this. One recently told me she was "tired of being a pill pusher." Another, a psychiatrist, said he was dismayed that most psychiatric patients see a physician only four times a year—at a fifteen-minute appointment for adjustment of their medications.

In my role as director of the University of Arizona Center for Integrative Medicine I have taught hundreds of physicians, allied health professionals, medical residents, and students about the benefits and risks of drugs. One question I always ask is "How did we come to believe that medication is the only or the most effective way to treat disease?" Medicine and medication both derive from an ancient Indo-Iranian root meaning something like "thoughtful action to establish order"; the same root gives us the words measure and meditate. How curious that "thoughtful action" has become synonymous with the giving and taking of chemical substances.

Drugs are powerful. Some are miraculously effective—like opium and its derivatives for pain and antibiotics for bacterial infections that commonly killed throughout most of human history. The discovery of insulin saved many people with type 1 diabetes from an early death. Chemotherapy agents have cured forms of leukemia and lymphoma that had always been fatal. Antiviral drugs have turned HIV infection from a death sentence into a manageable chronic illness. No responsible physician today would reject medication as a method of treating disease and maintaining health.

But it is one method only. Many other interventions exist that do not involve drugs; sadly, they are not taught in conventional medical schools, and that is one reason that most doctors rely on medication. One example is dietary change. When I write a treatment plan for a patient, my first recommendations always concern diet: what not to eat, what to eat more of, how to change eating habits to improve health. As a primary treatment strategy, dietary change can be remarkably effective. Following an anti-inflammatory diet can so improve arthritis, allergies, and other conditions that medication can be reduced and in some cases eliminated. Much evidence links the Mediterranean diet with good health, longevity, and low risk of disease. The DASH diet is an effective intervention for lowering high blood pressure (DASH is an acronym for dietary approaches to stop hypertension). Eliminating cow's milk products from the diet often leads to marked improvement of recurrent ear infections in children and chronic sinusitis in adults. Eating whole soy foods regularly, beginning early in life, offers significant protection against hormonally driven cancers—breast cancer in women and prostate cancer in men. But because doctors are not trained in nutritional medicine, most of them are unable to give this sort of advice. Instead they rely on drugs.

Botanical remedies have been mainstays of folk medicine in many cultures throughout history. Many modern pharmaceutical drugs are derived from plants or are variations of molecules originally discovered in plants. Herbal medicines can be both safe and effective. For example, a freeze-dried preparation of the leaves of stinging nettle (Urtica dioica) relieves hay fever symptoms (itchy eyes, sneezing, runny nose) just as well as antihistamine drugs without any of their side effects. Extracts of the root of valerian (Valeriana officinalis) work well for many people to induce sleep. Extracts of the seeds of milk thistle (Silybum marianum) protect the liver from toxic injury (by alcohol, volatile solvents, and pharmaceutical drugs known to harm that organ). But because doctors are not trained in botanical medicine, most do not know how to use plant remedies. Instead they rely on drugs.

Mind-body medicine is a general term for therapies that take advantage of the connection between mind and body. These include hypnosis, guided imagery, visualization, biofeedback, meditation, and other techniques that are both cost and time effective. I frequently refer patients to practitioners of mind-body medicine and routinely see them bring about striking improvement and sometimes complete resolution of problems as diverse as atopic dermatitis (eczema), irritable bowel syndrome, and autoimmunity. But because none of this is in the conventional medical curriculum, most doctors do not know when and how to make such referrals. Instead they rely on drugs.

Breath work—learning how to change breathing habits and practicing specific breathing techniques—has remarkable effects on physiology. It cannot cause harm, requires no equipment, and costs nothing. It can correct some cardiac arrhythmias and gastrointestinal problems, for example, and is the most effective treatment I know for anxiety, as well as the simplest method of stress reduction. But because information on breath work is totally absent from conventional medical training, very few doctors can instruct patients about it. Instead they rely on drugs.

Evidence for the health benefits of exercise is overwhelming. Increased physical activity can effectively prevent and treat depression, help normalize high blood pressure, and, along with dietary adjustment, put many cases of type 2 diabetes into complete remission. Doctors get some training here, but they are not trained in ways to motivate patients to exercise. Instead they rely on drugs.

Manual medicine, such as chiropractic and osteopathic manipulation and various forms of massage, is a safe and effective treatment, not just for musculoskeletal disorders but for other health conditions as well. Cranial therapy, an osteopathic technique, can end cycles of recurrent ear infections in children with none of the adverse effects of frequent courses of antibiotics. Visceral manipulation, also performed by some osteopathic physicians, can correct malfunctions of abdominal organs. But because most doctors are unfamiliar with manual medicine, they do not know when and how to refer patients to it. Instead they rely on drugs.

Traditional systems like Chinese medicine and Ayurveda comprise a variety of therapies, including dietary adjustment, herbal remedies, massage, and specialized techniques like acupuncture in Chinese medicine and detoxification regimens in Ayurveda. They can effectively manage some chronic health conditions, such as asthma, allergy, and inflammatory bowel disease. Acupuncture can dramatically improve acute sinusitis as well as reduce back pain and depression. But because doctors do not learn about these systems in their training, most do not know when to refer patients to them or how to find competent practitioners. Instead they rely on drugs.

The makers of those drugs, collectively known as Big Pharma, profoundly influence physicians. They fund research, which then drives practice. In the studies, drugs are measured against placebos to determine efficacy but almost never against lifestyle changes that may work as well or better. The information that doctors rely on when prescribing comes more often from industry sources than from objective ones. And despite attempts to curtail their influence, representatives of those companies are still very much present in medical offices, doing their best to persuade doctors to push their products. Pharmaceutical ads are the major revenue source for medical journals, compromising the objectivity of these journals in accepting or rejecting articles that report research findings with drugs and in deciding which to feature prominently.

Add to all this the strong desire of American patients to be medicated. Their belief in the power of drugs is as great as their physicians'. If the average doctor were told to manage a case without medication, he or she would likely not know what to do. If the average patient knew that no prescription would be forthcoming at the end of a medical visit, he or she would likely feel cheated and seek another practitioner to give one, especially for a product advertised on television. In recent years, direct-to-consumer advertising of prescription drugs has greatly increased consumer demand for them. New Zealand is the only country other than the United States that allows such promotion, which has been a boon for drug manufacturers and a disaster for medical practice.

Consider also that nondrug therapies require active participation of patients and may take more time to produce results. Lifestyle modification is particularly demanding. People will not change their eating habits or start exercising unless they are motivated to make the effort. Many patients would rather skip the effort and take a pill. The cost of the pill is often covered in whole or in part by insurance. There may be no reimbursement for dietary supplements, herbal remedies, or the nondrug therapies I have mentioned.

It's no wonder how we came to believe that medication is the only or the most effective way to treat disease.

So why is this cause for concern? Two reasons: the safety and the efficacy of the medications we rely on.

No difference exists between a drug and a poison except dose. (Pharmacology comes from the Greek word for poison.) All drugs become toxic as the dose is increased, and some poisons are in fact useful therapeutic agents at very low doses. Medicinal plants are usually much safer than their purified derivatives, because the active components are present in low concentrations, rarely more than 5 or 10 percent of the dry weight of the plant, and often less. Herbal remedies are dilute forms of natural drugs. Of course, they can be concentrated into liquid or solid extracts, but these products are still relatively low in potency compared to isolated purified compounds. And those compounds can be altered to make them even more potent—a favorite strategy of pharmaceutical chemists. The most widely used pharmaceutical drugs are extremely potent. Potent drugs may be necessary in cases of critical and severe illness, but we now use them for all disease conditions, even those that are not severe. Unfortunately, concentration of pharmaceutical power inevitably also concentrates toxicity; the two are inseparable.

Doctors have come to believe that the best medications are those that work quickly and powerfully. The consequence of reliance on such strong drugs is the very high incidence of adverse reactions to them that range from transient discomfort to permanent injury and death.

My own interest in learning how to treat common forms of illness without medication grew as I observed more and more cases of drug toxicity. One early experience I will never forget involved the death of a patient during my internship year at Mount Zion Hospital in San Francisco in 1969. On a month-long neurology rotation, I participated in morning rounds with two attending physicians and two medical residents. One day we saw a newly admitted patient who had suffered a massive stroke, a man in his late eighties. He was in a coma, unresponsive, with little chance of recovery. The immediate concern was that he was having frequent seizures, which soon became continuous. The senior attending physician was about to stop them with an intravenous dose of the tried-and-true anticonvulsant drug, phenytoin (Dilantin), but I spoke up to say that a lecturer at Harvard Medical School had told our class that intravenous diazepam (Valium), newly approved for treating continuous seizures, was superior. "Go ahead and try it," said the attending.

The rest of the team moved on. I asked a nurse to bring me a syringe of Valium and, following the directions on the product, slowly injected the appropriate dose into the patient's intravenous line. His seizures stopped within a minute. Pleased with myself, I left the room to rejoin the group. Minutes later, I received an emergency page. The drug had stopped not only the patient's seizures but also his breathing. He was dead from respiratory arrest.

No matter that he was moribund before I injected him with Valium or that he had a peaceful exit. I was devastated. Needless to say, I never again shot anyone up with Valium (nor with any other powerful pharmaceutical).

Hundreds of thousands of deaths occur each year in the United States as a result of adverse drug reactions. And we are not talking about medication errors here: in these all-too-frequent cases, the right drug is given to the right patient in the right dose for the right indication. Adverse drug reactions are the fourth leading cause of death in our country and rank between the fourth and sixth most common cause of death in hospitalized patients.

The US Food and Drug Administration (FDA) requires manufacturers to disclose all possible adverse effects of drugs in labeling and advertising. Often these are so numerous that they take up most of the space in print ads. I have on my desk a three-page advertising spread from a national news magazine for brexpiprazole (Rexulti), headlined "It's time to feel better about facing the world." Rexulti is an antipsychotic drug, developed originally to treat major mental illness but now approved for treatment of depression in combination with antidepressant medications. (Studies increasingly show the most widely used antidepressants to be not that effective, but the combination is not much better. You can read about this questionable practice in chapter 9.) The ad exhorts people who have been on an antidepressant for at least eight weeks and are still feeling depressed to ask their doctors "if adding Rexulti is right for you." The fine print that fills most of the three pages describes the side effects and toxic calamities that can befall those who take the drug, including confusion, suicidal thoughts, uncontrolled body movements, metabolic problems, stroke, and death.

In television and radio ads for pharmaceuticals, announcers have to speak comically fast to list all the warnings and dire possibilities, an easy target for parody. But there is nothing funny about experiencing a severe adverse reaction to medication.

Keep in mind that all drugs have multiple effects on various organs and body functions. They are marketed, prescribed, and consumed for one desired effect, with the others relegated to fine print under the heading of "Possible Side Effects." But for some unlucky individuals, one of those side effects might turn out to be the main event. The most popular class of antidepressant medications—the selective serotonin reuptake inhibitors, or SSRIs—increase brain levels of the neurotransmitter serotonin. We tend to ignore the influences of these drugs on muscle and sexual function, unless those overwhelm any positive effects on mood. Antibiotics that we use to kill or inhibit the growth of disease-causing bacteria may alter liver and kidney function and interfere with digestion. A decision to take medication should take account of these risks, which are much greater than risks of lifestyle change and most nondrug therapies.

Consider, too, that individuals vary in how they respond to medication, a stubborn fact rarely emphasized in the training of physicians or in the marketing materials of drug manufacturers. For example, some people cannot tolerate statins, because they experience severe muscle pain or weakness from them. If significant numbers of people are affected by an adverse reaction, it is called a "side effect." If few are affected, it is an "idiosyncratic reaction"—that is, one peculiar to the individual. Variations in response to the same medication may reflect genetic differences or quirks of biochemistry. A new era of targeted drug therapy is on the horizon: genomic analysis may reveal who will respond positively to a drug and who will not. For now, most doctors' prescribing habits adopt a "one size fits all" mentality.

Do not assume that OTC medications are free of toxicity. They can cause serious adverse reactions on their own and can also interact with prescribed medications in ways that increase risk. Today, you can buy OTC forms of NSAIDs (nonsteroidal anti-inflammatory drugs), steroids, and the acid-blocking drugs indicated for GERD (gastroesophageal reflux disease). Their availability without a prescription encourages casual use without regard to the problems they can cause. As you will read in the pages that follow, it is also easy to get into trouble with popular OTC sleep aids and cold and flu remedies.