
An epidemic of unnecessary and unhelpful medical treatments - greendesk
https://www.theatlantic.com/health/archive/2017/02/when-evidence-says-no-but-doctors-say-yes/517368/?single_page=true
======
maxerickson
One interesting point made in the article is that an awful lot of the gains we
have made in life expectancy have come from public health rather than medical
advances. The article claims that the increase from the public health
revolution in the late 1800s did more to increase life expectancy than
antibiotics. Which makes sense, not getting sick is more effective than any
treatment once you are sick.

A sibling comment mentions that lobbyists worked to get the _21st Century
Cures Act_ passed, but a potentially bigger issue with the act is that it
transfers $3.5 billion of public health spending to medical research.

~~~
funkymike
> but a potentially bigger issue with the act is that it transfers $3.5
> billion of public health spending to medical research.

I would like to see much more public funding going towards medical research,
with the stipulation that the results must be open and cannot be patented.

In mentioning this I just had an idea that I don't remember seeing before. I
wonder if there should just be a sort of medical treatment lottery for pharma
companies. They come up with a treatment, get a patent, and prove it works as
normal. Instead of allowing the monopoly however, the FDA could buy out the
patent and make it public domain. The pharma company gets a guaranteed and
immediate profit (say 50% of the projected total profit over the life of the
patent). Meanwhile any company can then produce the drug/device/etc. competing
on the quality and price of the treatment, separate from the cost of the
research that led to it.

~~~
maxerickson
There's nothing wrong with public funding of medical research.

Taking funds away from public health to do medical research is highly
questionable.

~~~
woodandsteel
One of the reasons this happens is conservative economic philosophy. Public
health is carried out by the government, while drug sales are carried out by
private corporations, and according to conservative economic philosophy,
private corporations are better than the government.

~~~
killjoywashere
The problem is conservative economic philosophy depends on letting a problem
get bad enough that the typical customer becomes informed. How many people do
you want to get MDR TB before people are sufficiently interested in the topic
to become informed enough to make rational decisions in a well-developed
market?

I'm not sure people realize how much the public health labs do that would
simply never pay, yet saves lives: who's going to speciate and sequence rare,
but highly contagious or virulent organisms (like MDR TB) isolated from some
one homeless person, who, by virtue of their unfortunate circumstances, serves
as a canary in the coalmine of the modern city.

------
arafa
Adding to this article (I'm not a medical professional and not giving advice),
the same inferior medical outcomes are attributed to most, if not all forms of
back surgery. Physical therapy outperforms most or all back surgery with much
fewer side effects, etc. This is covered extensively in the book How Doctors
Think ([https://www.amazon.com/How-Doctors-Think-Jerome-
Groopman/dp/...](https://www.amazon.com/How-Doctors-Think-Jerome-
Groopman/dp/0547053649/ref=mt_paperback?_encoding=UTF8&me=)) as well as
articles like this Ars Technica one:
[https://arstechnica.com/science/2017/02/doctors-lower-
back-p...](https://arstechnica.com/science/2017/02/doctors-lower-back-pain-is-
like-a-cold-minor-annoying-and-temporary/). You see the same with exercise
outperforming anti-depressants in most cases, again with much fewer side
effects. (For example:
[https://www.theatlantic.com/health/archive/2014/03/for-
depre...](https://www.theatlantic.com/health/archive/2014/03/for-depression-
prescribing-exercise-before-medication/284587/))

The kicker is that doctors will often refuse these same treatments when
offered, which is not a good reflection on their efficacy (again covered in
How Doctors Think). This is not an indictment of modern medicine (which is
often very effective on acute care), just a recognition of the limitations.

~~~
seibelj
Exercise helped reduce my depression and anxiety, and I tried to cure it
without medication for 2 years. Finally I gave in and went on a low dose of
lexapro, in addition to my usual exercise and healthy diet, and I recovered
within weeks. Completely changed my life. I know this is just my anecdote, but
when natural remedies fail, don't be afraid of medicine.

~~~
tcj_phx
> but when natural remedies fail, don't be afraid of medicine.

SSRIs frequently create their own problems. They are sometimes effective
because of their effect on the neuroactive steroids:

[https://en.wikipedia.org/wiki/Neuroactive_steroid#Role_in_an...](https://en.wikipedia.org/wiki/Neuroactive_steroid#Role_in_antidepressant_action)

Depressed people frequently have a metabolic problem, where they don't make
enough ATP. This is caused by thyroid imbalances, poisoning with excess
Omega-6 polyunsaturated oils, etc.

~~~
throaway343467
I've been on anti-depressants since I was 17. I'm 30 now. Buproprion works
best for me, to which I later added lamictal.

Prior to that, I'd been depressed since I could remember. In hindsight, I may
have had mild aspergers like symptoms, mostly related to reading social cues.
This wasn't "just growing up" despite shrinks for years telling me it was.

Finding the right anti-depressant changed my life for the better. Absolutely
changed my life. After college, I went off them for a year just to see if I
"needed them" any more. Within 6 months, I noticed my thoughts slip into old
patterns of hopelessness, counterproductivity, loneliness, and general loops
of existential pain, and this outlook effected everything and everyone around
me. I do need them, it turns out.

So I wish people around me hadn't been so against drugs. In my case, they
should have tried them earlier in treatment. That would have saved me some
years of suffering.

Also, I tried prosac, lexapro, and effexor before buproprion. If I'd listened
to the many drug critics, I'd have stopped looking after prosac (side effects
there included sexual disfunction and _mania_ ). I notice no notable side
effects with my current cocktail.

Also, I've exercised and been in good shape both pre and post taking anti-
depressants. I feel better if I'm exercising than not, but it's not even in
the same ballpark as what the drugs do for me. Everyone should exercise, not
everyone benefits from anti-depressants. No exaggeration, I'd be dead without
them.

~~~
tcj_phx
One of the mental hospitals gave my friend Wellbutrin. They took it away when
they found her insufflating it. Thereafter they didn't care about her
complaints of depression, and just forced her to take the suicide ideation
pill ("anti-psychotic").

I guess Wellbutrin has mild stimulating properties. SSRI drugs were approved
on the basis of fraudulent science. The MAOIs were reasonably effective, but
caused high blood pressure when the patient also ate fine cheese.

~~~
throaway343467
I've heard of people doing that with Wellbutrin, always struck me as strange
-- it takes a couple weeks to notice any effects orally. A move of
desperation, no doubt.

I will say some weird side effects have been cigarettes taste like shit and
aren't addictive, cocaine doesn't work quite right, and MDMA doesn't work at
all. Something about Wellbutrin binding strongly to the same receptors and
blocking the others. Probably for the best though...

~~~
tcj_phx
> A move of desperation, no doubt.

Certainly. Well-said, thanks.

> cigarettes taste like shit and aren't addictive

I learned from a hacker news comment that current thinking is that tobacco is
addictive because of the combination of nicotine and chemicals that have an
MAOI effect.

------
jbob2000
This is only a problem in the US (aka "list of countries with private
healthcare"). In Canada, we are actively trying to prevent any medical
procedure possible because of the huge expense.

I just completed a huge app to educate and prevent diabetic foot amputations.
It costs $70,000 to remove a foot and the government is really trying to cut
down on these if they are preventable. Patient gets to keep their foot,
government doesn't have to spend money - win win!

In the US, a hospital would be stupid to make an app like this. Why would you
want less foot amputations? You don't get the $70k from the surgeries and you
also don't get to subscribe them to a lifetime of therapy and prosthetics.
Chop off more feet, I say!

~~~
graeham
There is different math for each system.

In the USA:

if riskFromTreatment <= riskFromNoTreatment: doTreatment

In most public systems:

if (treatmentCost <= someThresholdPerBenefit) && (riskFromTreatment <=
riskFromNoTreatment): doTreatment

In practice, treatment outcomes are pretty similar, but more treatments are
preformed in the USA system. Being a for-profit system is one cause, but so is
the litigation culture. Not doing every possible treatment and test can lead
to the physician being accused of being negligent.

~~~
jbob2000
That's a bit of a strawman argument. In your math, you need to include the
point that the article makes - that the American system always considers
riskFromNoTreatment to be close to infinite. The risk is completely skewed on
the American side, doctors are saying "EVERYTHING WILL KILL YOU TREAT IT NOW"!

~~~
nradov
That's an overbroad generalization. Not even close to all doctors constantly
push for aggressive treatment of all medical conditions.

------
speeder
Sadly, the problem is not just excessive treatment, but also lack of them, for
the exact same reason: medics seemly hate science.

Example: Thyroid disease diagnostic and treatment problems are so common, that
there are organizations made solely to support thyroid patients, including
having lawyers specialized in suing doctors to force them to start
treatment...

The reason for that, is that although there is plenty of research showing that
the 80s blood tests are too conservative (they only show positive to people
that are usually too damaged beyond any repair), many doctors insist in using
solely those tests, and ignore symptoms and newer blood tests.

This does have to do with pharmaceutic industry though, some of the
organizations pushing for the 80s tests are all supported by pharma companies,
and the same companies also have lobbists that try to get in the way of
allowing research of treatments that would skip such companies, for example
many patients only improve when using "alternative" but centuries old methods
that were known to work for centuries, yet lobbists and pharma companies try
to convince doctors and politicians that these ancient methods are "wrong
because they are old", and don't allow even research to proceed properly, the
leading manufacturer of thyroid medicine that works is in Thailand, because in
most other countries their business is considered shady or sketchy.

Same thing happen in psychiatry, problems that are popular in the public mind
are overdiagnosed, specially when they have expensive medication, yet when the
problems aren't popular, psychiatrists refuse to treat sufferers. I found a
strange case with ADHD: kids are being pumped full of meds due to the fact
that they keep disrupting classrooms and ADHD is a "popular" disease with
kids, but all adults I know that are actual sufferers from ADHD to the point
of disrupting their adult lives, struggle to find treatment, with the usual
excuse from doctors being that the meds are "too dangerous" (then why give it
to the kids by the boatload?) or that people in their 20s seeking meds must be
some kind of junkie looking to boost academic performance, nevermind if non-
academic symptoms are there too.

~~~
nradov
Which specific thyroid organization sues doctors to force treatment? That
seems highly unlikely. Refusal to provide treatment doesn't constitute
malpractice.

------
skolos
>The 21st Century Cures Act—a rare bipartisan bill, pushed by more than 1,400
lobbyists and signed into law in December—lowers evidentiary standards for new
uses of drugs and for marketing and approval of some medical devices.

It shows again that we will not have sane healthcare system when there are
thousands of lobbyist working to keep it insane.

~~~
Symmetry
Here's a semi-random blog post with a handful of examples[1]. Generally
speaking European countries are much quicker to approve most drugs and tend to
have better health outcomes on average even though you can point to individual
disasters like Thalidomide. But on the other hand beta blockers were available
in Europe about a decade before they were in the US and would have saved about
10,000 lives a year during that time.

[1][http://www.advicegoddess.com/archives/2017/01/11/the_fda_pro...](http://www.advicegoddess.com/archives/2017/01/11/the_fda_protect.html)

~~~
maxerickson
The article discusses beta-blockers.

 _The overall picture of beta-blockers is complex. For example, some beta-
blockers have been shown clearly to reduce the chance of a stroke or heart
attack in patients with heart failure. But the latest review of beta-blockers
from the Cochrane Collaboration—an independent, international group of
researchers that attempts to synthesize the best available research—reported
that they “are not recommended as first line treatment for hypertension as
compared to placebo due to their modest effect on stroke and no significant
reduction in mortality or coronary heart disease.”_

~~~
Symmetry
Well, that'll teach me to post in Hacker News without reading all parts of an
article.

------
alkonaut
Surprised every time I'm in the US and see commercials for drugs and
procedures that are administered by doctors being directed towards patients
with the ending "ask your doctor about xyz".

I'm fairly sure this kind of thing ends up with patients asking/pressuring
doctors for treatments they don't need.

~~~
coldcode
I find these utterly idiotic: you are telling patients about side effects of
some drug with pretty pictures and a pleasant voice but only a doctor can
prescribe them and you would assume understand the side effects and
contraindications. What is the point? Other than obviously make drug companies
more money.

~~~
noxToken
That is the point. Drugs x, y, and z are all the market. They do the same
thing with the same side-effects for the same cost. An ailment that the drug
cures pops up in someone's life. When they go to the doctor, they can ask
specifically for drug z, because they saw drug z in a commercial.

If our drugs, for all intents and purposes, are the exact same, then there is
no point in a doctor prescribing drug x or y when the patient specifically
asked for drug z.

~~~
randcraw
Any two drugs are most definitely _not_ the same unless one is a generic of
the other. And even then, because different manufacturers package drugs
differently, this can slightly affect a compound's delivery.

Even when two drugs use the same mechanism of action (an agonist or antogist
toward the same receptor active in the synthesis of a target protein),
different generations of drugs often produce significantly different
pharmacodynamic profiles of efficacy and toxicity that affect people
differently. A good example are the diabetes drugs Actos vs Avandia -- same
MoA (glitazones), but the latter has proven to be toxic.

Fact is, no two drugs are the same, unless they both do nothing.

~~~
noxToken
> _If our drugs, for all intents and purposes, are the exact same_

This include the above. The point was that the drugs are the same in every way
possible. Although this is most certainly not the case for drugs x, y and z,
our example hinges on them being the same. Otherwise the doctor always should
prescribe the best medication for the given situation.

------
greendesk
Is there a process or technology to avoid unnecessary medical treatment?

The article mentions how one patient googled his condition and sought a second
opinion. I imagine that this direction is common among patients.

I am afraid that once I get old I will also be pushed to have unnecessary
treatments.

~~~
maxerickson
The ProPublica version of the article has a chart at the end showing an
evaluation of the benefit vs risk of a treatment (search "A Different Way to
Think About Medicine"):

[https://www.propublica.org/article/when-evidence-says-no-
but...](https://www.propublica.org/article/when-evidence-says-no-but-doctors-
say-yes)

So one way to avoid unnecessary treatments is to seek out doctors who are
willing to discuss treatments in similar terms. They may lack the information
to build such a precise estimate, but they should still be willing to talk in
a clear way about the risks and benefits of a given treatment.

~~~
randcraw
I think you're describing "Number Needed to Treat" (NNT, or 'How many patients
need to be treated with a drug or procedure for one patient to get the hoped-
for benefit?'), which is described briefly just before the graphic you
mention.

NNT is a great idea, but not as practically useful for individuals as for
policymakers, IMHO. I suspect few primary care clinicians can discuss current
and precise NNT figures. More likely they will rely on standard of care advice
from the AMA or their subspecialty board that itself was shaped by NNTs.

~~~
maxerickson
No, I was specifically talking about the sort of framework used in the
graphic, where the outcome of a treatment may be beneficial, benign or
harmful.

I'll repost my second paragraph too:

 _So one way to avoid unnecessary treatments is to seek out doctors who are
willing to discuss treatments in similar terms. They may lack the information
to build such a precise estimate, but they should still be willing to talk in
a clear way about the risks and benefits of a given treatment._

Yes, it will be difficult for providers to have detailed information. They
should still be open to discussing downsides and tradeoffs. It's a red flag if
they hesitate to talk in terms of tradeoffs or to take the time to discuss the
expected benefits and potential downsides.

------
taxicabjesus
Sometimes medicine helps patients, sometimes the medical-industrial complex
makes work for itself. I took a lot of medicaid patients to & from doctor
appointments where nothing much was accomplished.

> In 2012, Brown had coauthored a paper that examined every randomized
> clinical trial that compared stent implantation with more conservative forms
> of treatment, and he found that _stents for stable patients prevent zero
> heart attacks and extend the lives of patients a grand total of not at all._
> In general, Brown says, _“nobody that’s not having a heart attack needs a
> stent.”_ [...] Nonetheless, hundreds of thousands of stable patients receive
> stents annually, and one in 50 will suffer a serious complication or die as
> a result of the implantation procedure. [emphasis added]

(This comment recycled from the earlier submission of the propublica version
this story:
[https://news.ycombinator.com/item?id=13705761](https://news.ycombinator.com/item?id=13705761)
)

------
AnsemWise
This is a very important issue. Doctors are over prescribing and jumping to
unneeded surgeries. The question is, are they doing it out of fear of a
malpractice lawsuit for denying a patient what they need or is it from
kickbacks, incentives and the knowledge that the persons insurance will pay
them?

Just because something works doesn't mean it's not a broken system.

Suprised that no one else has commented on this article.

~~~
AnsemWise
> Suprised that no one else has commented on this article.

Didn't refresh

------
e40
_Three months later, his cholesterol had improved markedly, he had lost 15
pounds, and the chest pain never returned._

And it just goes to show you, that Dr. Brown might have saved the executive a
stent procedure, but they are still promulgating the myth that cholesterol
causes CHD. It's a side effect not the cause. There are plenty of people that
have high cholesterol and don't have blocked arteries.

<sigh>

~~~
regardmore
It's not a mere side effect.

If it were, treatment with anti-cholesterol drugs such as statins (the most
used) or even a new class of drugs called PCSK9 inhibitors wouldn't have such
a clear cause-and-effect on reducing cardiovascular events and mortality.

Since removing cholesterol from circulation reduces cardiovascular disease,
you can view it as a cause and not as a mere marker of disease.

~~~
e40
_If it were, treatment with anti-cholesterol drugs such as statins (the most
used) or even a new class of drugs called PCSK9 inhibitors wouldn 't have such
a clear cause-and-effect on reducing cardiovascular events and mortality._

I've read that studies show it only has an effect for men > 50 yrs, but that
the effect isn't due to reducing cholesterol.

I have notice a huge increase in the last 10 years in the number of
researchers reporting no causal link between cholesterol and CHD.

On the first page of a Google search:

[https://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines...](https://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines/news/2016-06-13-study-
says-theres-no-link-between-cholesterol-and-heart-disease/)

Evidence abounds that there is no link.

------
un-devmox
I have, according to my MRI, severe cervical stenosis. I also have carpal
tunnel, which was diagnosed first. Based on my symptoms and the awful looking
MRI, 4 highly regarded spine surgeons recommended a 2 level fusion right away.
The 5th doctor, instead recommended carpal tunnel and ulnar nerve releases. My
symptoms abated by 80+% and is something I can live with comfortably.

None of the 4 other doctors even considered dealing with my carpal tunnel
first, which, combined with stenosis causes what's called a 'double crush'
scenario. Only one surgeon recommended the least invasive and risky procedure
for me! Even though a fusion in the future is likely, for now the risk -
reward for such a procedure does not warrant immediate action.

I also think it's worth noting that that 5th doctor is the only female of the
group. She was the only one that didn't seem gung-ho about the fusion. I'm not
saying gender plays a role but...

~~~
nommm-nommm
[https://www.statnews.com/2016/12/19/patients-female-
physicia...](https://www.statnews.com/2016/12/19/patients-female-physicians-
live-longer/)

>Public health researchers at Harvard found that elderly patients were less
likely to die or be readmitted to the hospital within 30 days if treated by
female doctors rather than male. The study doesn’t explain why this happens,
but prior studies have found that female doctors tend to spend more time with
patients, communicate better, and follow clinical guidelines more often than
their male colleagues.

------
Gatsky
The article gives an introductory example of a patient that was referred to
two different cardiologists, both of whom wanted to do an angiogram. The
article doesn't mention of course that the cardiologists get paid per
angiogram performed. The remuneration per unit time for seeing the patient in
clinic and carefully discussing the options and evidence is drastically less
than just doing the angiogram. Some cardiologists will also have a target
number of angiograms they need to perform every year specified by arrangements
with the angiogram facility.

So although it is widely known that doing angiograms and inserting stens in
patients with stable coronary artery disease is a waste of time, perverse
incentives in a fee for service model result in these outcomes. As such it
isn't a good example of evidence-free medicine. In Australian public
hospitals, the cardiologists are paid the same salary regardless of whether
they do zero or 1000 angiograms a year. They are very happy not to do
unnecessary angiograms in line with the current evidence. If anything, this
introductory example shows that a health system needs to be set up to
facilitate and encourage evidence-based practice.

Otherwise this article rehashes many points about clinical trials and
interpreting medical evidence, without a really coherent theme, except maybe
to (yet again) criticise doctors.

Things have improved in the last 10 - 15 years. Clinical trials come under
more scrutiny, trial pre-registration has become more common (although not
strictly enforced), health systems gather more and more data about patient
outcomes outside of clinical trials and manipulative marketing practices by
pharmaceutical companies have been curtailed drastically.

In my opinion, the challenges for evidenced based medicine in the next decade
are:

1\. Getting some decent data about nutrition. There are really remarkably few
useful things we can say about how nutrition relates to health.

2\. Reducing unnecessary interventions towards the end of life in an ageing
population. Healthcare and healthcare research is not well suited to de-
escalating care.

3\. Transitioning from a one-size-fits-all approach doing clinical trials in
1000s of undifferentiated patients, to collecting 1000s of data points about
each individual patient (blood and metabolic variables, genome sequencing,
immune profiling, microbiome etc) and using that data to get them healthy and
keep them that way. Needless to say, the difficulties in doing this will make
doing a randomised controlled trial look like a walk in the park.

4\. Fighting pseudo-scientific diagnostic tests and treatments. Examples of
this are everywhere - Theranos, gene therapy clinics in undisclosed locations
in South America, quantified self services that have no proven health
benefits, virtually every supplement ever sold, multivitamins...

5\. Fighting the politicisation of health care. This is a very worrying trend
that can easily render all our scientific efforts irrelevant - eg anti-
vaxxers, far-right intolerance of harm minimisation measures like abortion and
decriminalising drug use.

~~~
Hnrobert42
6\. Studies on how to most effectively treat people with non-invasive
treatments. "Take this pill once a day" has a far higher compliance rate than
"exercise more."

I am thinking of the example mentioned in "The Power of Habit" where one group
of knee surgery patients was given a brochure about post-surgery treatment,
like PT, exercise, etc. The other was give the same brochure with blank pages
to write out a specific plan for following the recommendations. Of course, the
second group fared much better.

------
darkerside
Does anyone know what the problem is that the 21st Century Cures Act is
solving? The claim was made that treatments are being withheld pending FDA
approval. Is it illegal to use FDA-unapproved drugs, or is it that insurance
is not covering unproven treatments?

~~~
burkaman
It's not illegal to take them, but yes I doubt insurance will cover unapproved
treatments. Also, while it's not directly illegal for a doctor to prescribe an
unapproved drug, I think it would open them up to malpractice lawsuits, and it
just seems like a bad idea in general. Here's a doctor's blog post about this
issue: [http://thehealthcareblog.com/blog/2013/08/26/should-a-
doctor...](http://thehealthcareblog.com/blog/2013/08/26/should-a-doctor-
prescribe-drugs-that-are-unapproved-by-the-fda/)

~~~
darkerside
Thanks for sharing the article. Layman's perspective, but it seems like the
problem in the USA is not the FDA regulation process, but the drug
prescription process. If I, a functional adult, have done the research and
weighed the risks and decided I want to purchase a specific drug or treatment,
why should I need a doctor to "co-sign the loan" for me? We're coupling
doctors' financial risks to patients' health risks when the decision making
factors are significantly different.

~~~
burkaman
If prescriptions were not necessary, drug advertising would be even more
heavily targeted at average consumers, addiction problems would be more
widespread, and anyone could operate a doctor's office without a license or
proper education. You should have the right to put whatever you want into your
body, but drug companies and pharmacies should not have the right to sell
whatever they want to you.

Fundamentally, you have not "done the research and weighed the risks" unless
you went to medical school.

~~~
darkerside
I disagree that medical school makes anyone more of an expert on my body than
me. Not to discount years of experience and training physicians have, but it's
just one leg of the stool. By over-weighting it, you become just another
patient who is not staying informed and involved with their own treatment.
Doctors know a lot, but you can ask any doctor if they know everything about
the human body, and they'll sure tell you they don't.

I think sensible people can choose to procure FDA approved treatments through
conventional providers. It's a jump to assume that, just because alternative
treatments are available, everybody will be lining up to purchase them.

~~~
burkaman
I'm not talking about alternative treatments. If prescriptions are not
necessary, anyone can buy opiates without understanding the risks of
addiction. Anyone can open a doctor's office, charge half as much as a real
doctor, and recommend whatever drugs they feel like. Anyone can buy some heart
medication they saw on TV because they've been having chest pains.

Doctors absolutely know more about your body than you do. Obviously they don't
know everything, and patients should be active and involved, but that doesn't
mean you can cut out the doctor because you read a few papers. Letting drug
companies sell anything to anybody would be immensely damaging to society.

~~~
darkerside
I agree doctors know a lot, but they are human. Most specialize in a narrow
subset, and that is the lens through which they will treat you. That's not
always a bad thing, but I will respectfully disagree and say that I know more
about my own body than a doctor I'm meeting for the first time (i.e. most
specialists).

Legalization of drugs, including opiates, has been successful (or at least not
disastrous) in many societies. What makes you think it would be a disaster
here?

Also, it's a straw man to argue that random people would be opening up
doctor's offices. I'm not advocating that we remove the MD from anybody's
name.

~~~
burkaman
Legalization of drugs is "successful" in that it's a lot better than jailing
people, but addiction is still a huge problem for society. If someone really
wants to get high, there's not much we can do to stop them, and that's an
acceptable consequence of drug legalization. But what we can stop is someone
in a lot of pain who buys way too much Oxycodone and gets addicted because
they didn't understand the risks. Right now, they'd have to go see a doctor
first, who could prescribe an appropriate amount and/or recommend less
dangerous treatment options.

When I talk about unlicensed doctor's offices, I don't mean someone posing as
an MD, I mean a well-meaning individual opening a cheap clinic and offering
medical advice for non-emergency issues. Or maybe more likely, WebMD adding
links to order drugs on their results pages. Why go to the doctor if you can
just look up your symptoms in 5 minutes and have pills arrive at your door the
next day?

~~~
stagbeetle
> but addiction is still a huge problem for society. If someone really wants
> to get high, there's not much we can do to stop them, and that's an
> acceptable consequence of drug legalization. But what we can stop is someone
> in a lot of pain who buys way too much Oxycodone and gets addicted because
> they didn't understand the risks.

But what part of the pain management patients actively abuse their meds. It's
a real issue, but is it a commonplace issue where we absolutely have to devout
resources to solving it?

~~~
burkaman
Yes, there's a reason it's called an epidemic:
[https://www.hhs.gov/sites/default/files/Factsheet-
opioids-06...](https://www.hhs.gov/sites/default/files/Factsheet-
opioids-061516.pdf)

Imagine the numbers if patients didn't need a prescription and didn't need to
talk to a doctor about safe usage.

~~~
darkerside
Doctors over prescribing this is exactly the problem.

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WalterBright
> Steven Galson [...] has called the strengthened approval process created in
> 1962 the FDA’s “biggest contribution to health.” Before that, he said, “many
> marketed drugs were ineffective for their labeled uses.”

Sam Peltzman in "Regulation of Pharmaceutical Innovation" provides statistical
evidence that the "safe and effective" 1962 Amendments reduced the development
of new effective treatments as well as new ineffective ones, for a net
decrease in positive results.

------
woodandsteel
This is an excellent and disturbing article. However, something very important
was missed.

Let me start by saying that I think that whenever we have a problem in this
country, one of the things we should do is look at how other countries handle
it to see if there is anything useful we could learn.

That being the case, we need to know how other countries handle the over-
treatment problem. Are there studies on this? Perhaps the authors could write
a follow-up article.

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happy-go-lucky
Speaking from my personal experience…

My way of life dictates adequate exercise, healthy diet and normal sleep
patterns.

I come from a family of strict vegans. No, I’m not here to promote either
veganism or non-veganism. I’m in my early 40’s and have been exercising since
I was a teenager. My routine includes running, cycling, strengthening
exercises, lifting light weights, and I do one or two of these a couple times
a week. IMO, any and all physical activity is a form of exercise. Usually, my
day starts in the early hours. And, as I’m getting older, my endurance levels
have been getting significantly better now than during my schooldays, 20’s, or
30’s and with regard to my work I’m getting more productive, too.

I also think that those who are not predisposed to any genetic conditions are
in a league of their own. Even those who inherit a predisposition can benefit
from delayed onset of a condition by practicing a healthy lifestyle. I’m not a
medical professional, so my assumptions may or may not carry any weight.

All I’m trying to do is keep such treatments as are being discussed here at
bay and I will keep at it as long as I possibly can :)

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fsloth
Is this a correlating effect with the fact that a large number of published
scientific results are botched? If researchers are not allowed to do good
science they are no more progressive than the augur reading from the entrails
of a fish.

~~~
maxerickson
It isn't just poorly done research. In many cases it is simply difficult to
design a study that can reasonably evaluate a treatment. The article discusses
a cancer vaccine at length, pointing out that the ethics of providing known
effective treatment basically obliterate the ability to evaluate the vaccine.

It's concerning that the vaccine was approved despite the problems with the
study, but they also can't have people agreeing to die in order to increase
the statistical power of their results.

