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Hired_Sellout
Aug 16, 2010
Did you ever want to know if your organic, fair trade, free-range, CBD oil will really cure your cat's depression? Curious how someone can sleep at night making a living raising healthcare costs for hard-working Americans? Are you curious to know why drugs cost so much, or why exactly your insurance company sucks? I've spent about 8 years now in the drug industry. I do not have a PhD, nor am i involved in doing chemistry, but I am nonetheless in the best position to explain why our system is the way it is. My job is to build the business case for each new drug that could potentially end your sniffles and put your rear end-cancer into remission. Ask me about Pharmaceuticals!

Hired_Sellout fucked around with this message at 03:48 on Jul 28, 2019

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I. M. Gei
Jun 26, 2005

CHIEFS

BITCH



How close are we to curing ADHD or autism?

Or at least treating them better?

Hired_Sellout
Aug 16, 2010

I. M. Gei posted:

How close are we to curing ADHD or autism?

Or at least treating them better?

Obligatory "not a doctor, not your doctor, not medical advice".

ADHD is pretty well controlled for most folks, honestly. Stimulants like mixed amphetamine salts (Adderall & Vyvanse) and methlylpenidate (Ritalin) work really well to get norepinephrine and serotonin levels back to where they should be. Non-stimulants like guanfacine, clonidine, and atomoxetine are a decent option but take some time (several weeks) to show an effect. People mix and match these to the tune of 55-60 million prescriptions per year in the US.

I don't think that anybody has done enough work to identify whether there are genetic or epigenetic markers for ADHD that you could correct with something like CRISPR, but I haven't read up on it that much.

Autism is more tricky. It's got a mix of epigenetic and environmental causes, and a wide spectrum of symptoms; from patients who are high-functioning (Asperger's) to completely mute, with a uniformly flat affect, and in need of lifetime care. There are a couple things in development for the "core symptoms" of autism, but they're still in early days. It'll be another 4-5 years before we have anything we know really works.

If we look at the currently active phase 3 clinical trials for autism spectrum disorders, there are a few old drugs being tried (aripiprazole, acamprosate) and a newer compound from Roche called Balovaptan, which is a a vasopressin 1a (V1a) receptor antagonist. In phase 2 studies, Balovaptan had sufficiently compelling data to be granted "breakthrough" designation by the FDA, which gives Roche some goodies like a faster review (6-ish months instead of 10-12) and significantly more collaborative help in things like clinical trial design.

If you're curious, here is a listing of all the things currently being studied in Phase 3 for ASD.

https://clinicaltrials.gov/ct2/results?cond=Autism&recrs=a&recrs=f&recrs=d&age_v=&gndr=&type=Intr&rslt=&phase=2&Search=Apply

Hired_Sellout fucked around with this message at 03:47 on Jul 28, 2019

Canine Blues Arooo
Jan 7, 2008

when you think about it...i'm the first girl you ever spent the night with

Grimey Drawer
Pharmaceuticals gets a super bad rap among the public. Does it deserve it?

Hired_Sellout
Aug 16, 2010

Canine Blues Arooo posted:

Pharmaceuticals gets a super bad rap among the public. Does it deserve it?

As you might expect, it's complicated. I'm rather proud of the work I do. I think it's useful to society, I find it intellectually stimulating, and... yeah it pays pretty good too. I've worked a company that was quite patient focused, and one that was...not so much. The former is a way better work environment. I think the industry as a whole probably gets the right amount of credit for the treatments it provides. It's in the ball-park anyway.

The US is responsible for something like 70% of innovative new therapies. A lot of credit is due to the NIH for this. There are thousands of postdocs doing yeoman's work in the labs there every day. Their output is tremendous. Occasionally the Germans, the Brits, or the Dutch will come up with something, or a researcher in Africa or S.E. Asia will find a treatment for some horrible tropical disease that is specific to their locale, but by and large innovative therapies are developed in the US. It's not because we're that much more clever, though we are clever, but this is where the funding is. We can afford way more shots on goal. This state of affairs is likely to persist because about 4 trillion dollars of GDP isn't about to jump up and go do something else.

Pharma hasn't done really basic science since the 1960's. The UK's Wellcome was a company that actually did what people think of as basic drug research; walking around some sweaty-rear end jungle and collecting plants to test for medicinal value. Nowadays all the really basic research is done in a beaker (in vitro) or on a computer (in silico), and it's nearly all taxpayer funded at the NIH (90%) or philanthropically funded at the big teaching hospitals (9%) with very little basic research being funded by industry or solo inventors with startups (1%).
What the US drug industry does is take these early inventions, about which very little may be known at the time they're acquired, and do the last $100-1,000 million or so in testing and validation to make sure they're safe, and will do what it says on the box. This work is useful, necessary, and would not be accomplished nearly as well by a government body or university research department.

As for the criticism, well, some is overblown, and some is very well deserved. Take the opiate crisis:

I have not seen it anywhere I have worked, but I have zero doubt that there people in my industry who do illegal things and completely screw over the patients. What the Sackler family / Purdue Pharmaceutical did with opiates was beyond the pale, and I fully expect some of their executives to go to jail before it's all over. Keep in mind that they didn't act alone though. Purdue's drug reps may have over-sold the benefits and downplayed the addictive nature of their opiate medicines, but thousands of doctors needed to Rx billions of tablets of OxyContin over the past decade, and thousands of pharmacists at hundreds of pharmacies had to dispense them. Everyone was a little complicit, and everyone got paid, oftentimes including the patients, who sell their extra pills for cash. My industry needs to do more to find non-addictive, effective treatments for pain. Part of the problem with opiates is they really do work for their intended purpose.

Drug manufacturers can buy data from a company called IQVIA that projects how much of what is Rx'ed in a given place, and I remember looking at data for some pain doctors in West Virginia that would have had to be writing a Rx for opiates every twelve minutes, 10 hours per day, 350 days per year, in order to hit some of the totals attributed to their practices. These doctors, mind you, are supposed to sign up for a special risk mitigation program and keep no more than a couple hundred patients on their "access to opiates" roster at a time. it's not just OxyContin either. Johnson City, TN is the Suboxone capital of America. A handful of physicians there write tens of thousands of Rx for Suboxone (made by Indivior) per year. This is all in the open. They get paid to fill out a survey estimating what they prescribed which IQVIA collects and makes projections from, or their practice management software (EMR / electronic medical records) vendor will sometimes aggregate and sell the data for what Rx they enter there. It's all tracked pretty closely by the DEA and FDA. One assumes they have some excuse for being such promiscuous prescribers for when the fuzz checks in.

Hired_Sellout fucked around with this message at 03:50 on Jul 30, 2019

CountFosco
Jan 9, 2012

Welcome back to the Liturgigoon thread, friend.
Do you read slatestarcodex and, if so, what do you think of his appraisal of pharmaceutical drugs/the industry?

Hired_Sellout
Aug 16, 2010

CountFosco posted:

Do you read slatestarcodex and, if so, what do you think of his appraisal of pharmaceutical drugs/the industry?

I do not. Even though this is the internet, I'm not really keen to give my opinion about someone else's opinion. Does he have a specific thesis you'd like an alternate take on?

lllllllllllllllllll
Feb 28, 2010

Now the scene's lighting is perfect!
340$ for insulin seems a little high. Are you in favour of regulating prices? Drug corps usually justify them rising prices by telling the public some of the earning are going to "research". How much of that is true?

CountFosco
Jan 9, 2012

Welcome back to the Liturgigoon thread, friend.

Hired_Sellout posted:

I do not. Even though this is the internet, I'm not really keen to give my opinion about someone else's opinion. Does he have a specific thesis you'd like an alternate take on?

Nah, I was just curious because many of his blog entries are his analysis of the various effectiveness of pharmaceuticals on mental illness. It's nbd.

I would blow Dane Cook
Dec 26, 2008
Why does everyone like Xanax so much lately? Its patent expired long ago so it's not like an Opioid/Purdue situation with the manufacturers pushing it hard.

Why are antidepressants considered "non-addictive" when the withdrawal symptoms are so terrible? Why isn't this a huge scandal?

Do you think direct advertising of prescription drugs to consumers should be banned?

vuk83
Oct 9, 2012

I would blow Dane Cook posted:

Why does everyone like Xanax so much lately? Its patent expired long ago so it's not like an Opioid/Purdue situation with the manufacturers pushing it hard.

Why are antidepressants considered "non-addictive" when the withdrawal symptoms are so terrible? Why isn't this a huge scandal?

Do you think direct advertising of prescription drugs to consumers should be banned?

Addiction requires you want more. Has nothing to do with withdrawal.
It's not a huge scandal because it's the best possible. Do you think psych patients want drugs? It's a pain but the everyday of a person with for example anxiety is hell in our modern rat race of a society. It's sometimes the best possible solution.

silence_kit
Jul 14, 2011

by the sex ghost

Hired_Sellout posted:

What the US drug industry does is take these early inventions, about which very little may be known at the time they're acquired, and do the last $100-1,000 million or so in testing and validation to make sure they're safe, and will do what it says on the box. This work is useful, necessary, and would not be accomplished nearly as well by a government body or university research department.

Could you explain why you think your last statement is true? I've gotten into an argument in a thread on Debate & Discussion on this subject. This is in the context of orphan drugs.

The person I've argued against, who I think conflates basic research and product development, made the statement that we could just ban private drug companies and expand the government to take on that task. Being a typical poster in the D&D forum, where 'nationalize industry X!' is a mantra and government organizations cannot fail, they can only be failed, he maintains that the government would be so good at that function, he says, that they'd be way more efficient at drug development than private drug companies.

My argument is that basic research, which is what government and universities are best at, and product development are two totally different skills. Being good at one doesn't mean that you are good at the other. It is totally not clear to me why the government would be better at product development. Furthermore, in the case of orphan drugs, the government might even be worse at developing them than private companies, since the government is more motivated by the following utilitarian thinking: we should invest in the R&D that provides the most benefit for our citizens. It is thus better than to work on common illnesses like cancer and heart disease, instead of spending that money on trying to work on the myriad obscure illnesses that exist.

You are making a much stronger claim than me, which is that academia and government would definitely be worse at the drug development function. Why do you think this?

mystes
May 31, 2006

I would also like to see Hired_Sellout's explanation, because I honestly don't see why it would make much difference. The government already has enormous control over drug research and development by determining what clinical testing is needed and deciding orphan drug designation, etc. As far as I know the FDA also has complete control over whether it even wants to consider things like obesity diseases and approve drugs for them in the first place.

If drug research was nationalized, it would still presumably be the exact same people who were doing the same work (either hired directly or contracted by the government) so why would it matter?

Chernobyl Princess
Jul 31, 2009

It has long been an axiom of mine that the little things are infinitely the most important.

:siren:thunderdome winner:siren:

I would blow Dane Cook posted:

Why does everyone like Xanax so much lately? Its patent expired long ago so it's not like an Opioid/Purdue situation with the manufacturers pushing it hard.

I kind of know this one...There's a complicated answer and a simple answer, and they're both true. The complicated answer is that there are fads in the mental health community just like in any other community, only for us it's prescriptions or diagnoses that go in and out of style. It's basically just what's in the cultural consciousness of the region at the moment, if you're thinking more about anxiety disorders you're more likely to interpret client symptoms as an anxiety disorder instead of ADHD or depression. This can be linked to pharmaceutical marketing, but it can ALSO be linked to what CEUs are on offer in the area, what clients are being presented by other clinicians in the prescriber's supervision groups, and what studies recently got published in big name journals in the prescriber's field. So if you're a prescriber and you saw a study earlier indicating that people with PTSD who took xanax daily saw a decrease in rumination and avoidance symptoms, and a colleague presents a case that day showing a client with previously treatment resistant depression showed improvement by combining xanax and another medication, and you just took a seminar last month about the treatment protocols for anxiety disorders.... the next patient who walks in the door describing anxious symptoms is more likely to walk away with a prescription for xanax than for another drug.

The simple answer is that clients tend to self-diagnose and walk in with medications already in mind. Everyone has heard of Xanax. Its popularity as a drug of abuse has actually helped to reduce stigma for taking it for prescribed reasons. So clients ask for it and they're likely to get it unless there's an obvious reason to say "no, you'd be better off with drug y instead."

...this is of course assuming that the medical professionals in question are actually operating at the top of their game with no graft, laziness, or corruption involved, which is quite an assumption. Doctors also prescribe drugs sometimes 'cause they get a kickback from the people selling them on the street. Sometimes they prescribe drugs 'cause it's just easy. The fact is that 50% of psychiatrists in America are over the age of 50 and facing down retirement, and in my professional experience tend to either be huge assholes or really lazy and noncommittal.

Dr. Red Ranger
Nov 9, 2011

Nap Ghost
You may also have doctors who've had bad experiences or learned defensive attitudes, or disagree with direct-to-layman marketing, so for good or ill a doctor may decide to refuse to prescribe something you ask for directly.

As for antidepressants, the issue isn't keeping patients from abusing them, but keeping them on the medications at all. Psychiatric treatment usually begins with choices made by protocol or practitioner experience, and then may end up in the weeds months down the line because 1) the drug action is decently well understood but everyone can respond differently and 2) due to the side effects and very nature of mental illness symptoms, psych patients are notorious for stopping their medication whenever. The desired result of psych meds isn't euphoria, or a positive outlook, or basic happiness; it's whatever gets you to a a functional baseline where your lows aren't so low or highs so unmanageably high. So, you often have people get to a workable, functional daily mental state and just stop taking their meds only for the original condition to creep back up. Then they have to go back through the startup side effects again, and deal with whatever daily effects it might have like preventing arousal or weight gain and the cycle begins again. I'm not a psych specialist but IIRC one of the primary metrics of psych medication efficacy is how long patients can tolerate being on them.

Of course, that's all before insurance gets to step in and make clinical decisions for your doctor by denying coverage.

nankeen
Mar 20, 2019

by Cyrano4747
describe the most sociopathic person you've ever worked with

Dr. Red Ranger
Nov 9, 2011

Nap Ghost
Hired_Sellout might have cooler answers, but in the retail pharmacy world it's usually the people managing your district or market or whatever your big box calls it. One of my classmates the next city over was made to work a 9a-9p shift as the sole pharmacist for her store and then scheduled to teach a 6 hour training class 4.5 hours across the state the next morning at 8am. I helped another floater retire because she had a TIA at work and was regularly showing a systolic blood pressure of 185+ while on the job ( that's immediately go to the ER level) and they tried to bully her into finding her own coverage for her next two months of scheduled shifts or they "wouldn't accept her two weeks notice".

EDIT: Almost forgot, my best tech who made it into pharmacy school was scheduled for a drug test by our employer during her mandatory pharmacy school boot camp week. She tried to explain that it was mandatory, she absolutely could not skip it, could they just wait a week for her to have a free afternoon, but of course they refused. So she went to her mandatory event to not get booted from the hyper competitive school that doesn't care about your grandfathered prereqs, and she was "failed" for her drug test. Had this happened later after her intern license showed up she could have been barred from school and pharmacy entirely.

And a friend of mine who became pregnant during school so they tried to pressure her to quit halfway through. Or the classmate who's mother died the morning of a test and they told her she'd have to sit for the test or be failed. I'm going to stop because the more I think about this the angrier it makes me.

Dr. Red Ranger fucked around with this message at 20:22 on Aug 9, 2019

Pryor on Fire
May 14, 2013

they don't know all alien abduction experiences can be explained by people thinking saving private ryan was a documentary

Xanax is huge in hip hop right now, everyone's talking about how great it is.

Given how we have invented a system where the TV tells you to go to the doctor and ask for the meds that are on the TV it's not really a stretch to imagine that hip hop is the primary factor in it's popularity.

Dr. Red Ranger
Nov 9, 2011

Nap Ghost
I'm not much aware of the hip hop scene but I had coworkers in food service showing off their bars and what they were planning to do with them ten years ago, and well to do northside women with oh so stressfull lives demanding their xanax have been an obnoxious phenomenon for longer than that. Maybe it just has a new surge in popularity?

Shooting Blanks
Jun 6, 2007

Real bullets mess up how cool this thing looks.

-Blade



Chernobyl Princess basically answered it. It's among the best known medicines for anxiety, it can be abused, side effects tend to be less, and since it's available as a generic it's relatively inexpensive. A lot of people are also exposed to it via recreational use, which helps increase its popularity since, as CP said - patients will straight up ask for it rather than let their doctor prescribe something else.

Hired_Sellout
Aug 16, 2010

lllllllllllllllllll posted:

340$ for insulin seems a little high. Are you in favour of regulating prices? Drug corps usually justify them rising prices by telling the public some of the earning are going to "research". How much of that is true?

I'm not in favor of regulating prices, because there is some truth to the statement that profits feed innovation, however it's not as direct a path as many people think. It depends on the company, and on what you mean by investing in research. Big pharmaceutical companies rarely do basic science. Generic drug companies never. The government does basic science, primarily via thousands of scientists at the national institutes of health (NIH). The total NIH budget for FY 2019 is $39 billion. NIH research gets cited by university researchers, who take the findings from the and use the ideas to cause a great deal of discomfort to mice and rats in the course of testing various theories, most of which will be wrong.

Once they find an idea that is not wrong, they will disclose the innovation to their institution's technology transfer office, who patent it at a cost of a few tens of thousands to a million dollars, depending on how many countries you want to cover, and how much intellectual ground a given invention covers. The university's cost to patent stuff needs to be recouped, so they will find a company to license the patent. This can either be a new company the inventor founds, or one that is looking for new stuff. If the discovery is particularly groundbreaking, it could be a Big Pharma like Pfizer or Bayer that acquires the patent rights. More often than not there will be a new company formed; backed with venture capital, and tasked with taking the pre-clinical therapeutic agent to an IND (investigational new drug) filing, which is what the FDA makes you do to test a drug in people. It costs about $10-20 million to get a small molecule to this stage.

There are certainly companies that do groundbreaking research, and take enormous risks with sums of money that could buy you a medium-sized Pacific island nation. There are also companies that have a lot more sizzle than steak, and two or three outright criminal enterprises. For an incremental innovator, taking a big chalky tablet and making a small, easier-to-swallow capsule with the same drug in it, or making a pediatric friendly dosage form like a liquid suspension might be incremental innovation, but it ain't curing hepatitis. I think that the insurance companies have done a pretty good job of curbing "me too" drugs through reimbursement management, but it's not perfect. It's also not as easy to identify "me too"s as you might think. Sometimes taking a cheap, immediate-release generic tablet that you take 3x/day and making an extended-release once-a-day formulation can dramatically improve side effects, so we don't want a blanket policy of one formulation per molecule.

Hired_Sellout fucked around with this message at 04:35 on Aug 14, 2019

Hired_Sellout
Aug 16, 2010

vuk83 posted:

Addiction requires you want more. Has nothing to do with withdrawal.
It's not a huge scandal because it's the best possible. Do you think psych patients want drugs? It's a pain but the everyday of a person with for example anxiety is hell in our modern rat race of a society. It's sometimes the best possible solution.

I'll just add that the withdrawal symptoms are highly variable. Not every bored teen who downs a couple bars to pass the time is going to have withdrawal seizures, and the psychiatric patient who is trying to manage anxiety is probably on a couple different things, in addition to a very high dose of Alprazolam. Psychiatry is the least-exact branch of medicine we've got unfortunately and a "pure" diagnosis of anxiety, or depression, or whatever is essentially unheard of.

Hired_Sellout
Aug 16, 2010

silence_kit posted:

Could you explain why you think your last statement is true? I've gotten into an argument in a thread on Debate & Discussion on this subject. This is in the context of orphan drugs.

The person I've argued against, who I think conflates basic research and product development, made the statement that we could just ban private drug companies and expand the government to take on that task. Being a typical poster in the D&D forum, where 'nationalize industry X!' is a mantra and government organizations cannot fail, they can only be failed, he maintains that the government would be so good at that function, he says, that they'd be way more efficient at drug development than private drug companies.

My argument is that basic research, which is what government and universities are best at, and product development are two totally different skills. Being good at one doesn't mean that you are good at the other. It is totally not clear to me why the government would be better at product development. Furthermore, in the case of orphan drugs, the government might even be worse at developing them than private companies, since the government is more motivated by the following utilitarian thinking: we should invest in the R&D that provides the most benefit for our citizens. It is thus better than to work on common illnesses like cancer and heart disease, instead of spending that money on trying to work on the myriad obscure illnesses that exist.

You are making a much stronger claim than me, which is that academia and government would definitely be worse at the drug development function. Why do you think this?

1. The Government is good at doing big, expensive, long-term research projects that don't produce a thing people will buy at the end. Nuclear weapons. The space race. Wildlife management and lands conservation. All government successes. Health research; not so much. There really isn't a thing called "the Government" that's capable of making a decision as small as "how can we create a new therapeutic modality to reduce migraine headaches?". The CDC says one thing. The NIH another. The Surgeon General makes a recommendation, and the DEA tries to quash it. There are too many cooks in the kitchen and nobody to enforce focus. The NIH is essentially a big $39 billion sandbox. They are still spending time studying mechanisms that are well understood, like the role of cholesterol in cardiovascular disease, and well known dead ends, like misfolded beta-amyloid plaque deposits in Alzheimer's. Bureaucracies don't know when to declare victory and down tools, or when to give up on a dud idea. Besides, the Tuskegee experiment is not that far in the past, the shameful stonewalling by the DEA with respect to psychedelics over the past thirty years is just beginning to turn, and the War on Drugs continues, despite the fact that Drugs won handily some time in the early 1980's. The government is for answering policy questions, and "what is the best thing to treat this disease?" is not a question that will result in a policy.

2. Having said that, in the case of ultra-orphan diseases with fewer than 500-1,000 patients nationwide, I think it probably should fall to the taxpayer, or to some kind of philanthropy anyway, to fund experimental treatments. The economics of developing a drug for something like Hashimoto's Encephalopathy (60 cases in the literature) is not realistic. I would have to price the treatment at several million dollars per patient, and be assured of capturing 100% of the market in order to make back the investment to develop something safe and effective, and whatever that was would only address some peripheral symptoms (nothing has really borne out in cognition enhancement yet). Nobody would accept such a price for what would likely be minimal benefit to 60 people, and the way the research would need to be done, all the patients in the world would end up on the drug (at the company's expense) in the clinical trial before I ever got it to market anyway. I suspect that unless you hit the right combination of independently wealthy people whose family members suffer from a rare disease, (See the wonderfully bizarre Martine Rothblatt and Pulmonary Arterial Hypertension for a success story along these lines), you won't see much headway made in ultra-orphan indications. "Regular" orphan diseases like cystic fibrosis, ALS, etc. are addressable by industry.

3. As to your counterpart's claim that the government would be better at drug development, I say the onus is on him to make a case why that might be. Elucidating theoretical new mechanisms of action is a far cry from doing the pharmacology, toxicology, carcinogenicity, drug-drug interaction, and formulation work necessary to produce a viable candidate compound to test in a first-in-man trial, let alone allowing for scale-up in synthesizing the active ingredient, and honing the formulation to find the right benefits to side-effects ratio so you can do a pair of pivotal trials in a thousand + patients to establish efficacy and safety, all in a timeline that might allow you to reach the market in a few years. It takes hundreds of people in two dozen disciplines coordinating across at-minimum, six years of work. The profit motive is the best thing we've come up with to make that all happen.

Here's the facts: North American consumers spend about 3.5 times the cash per dose of medicine, including generics, compared to their European counterparts, even though their income is only 60%higher. Most of this gap is due to increased per-capita use of newer and more potent medicines in America. The remainder can be attributed to prices set artificially lower by government health ministries overseas. The bulk of pharmaceutical profits are made in the US. This figure is somewhere around $130-$290 billion. A sizable chunk, though not a majority, of this profit is earned by foreign companies like Germany's Bayer, Glaxo-Smith-Kline in the UK, Israel's Teva, and Takeda in Japan. These profits -earned from US patients- subsidize the impossibly low drug prices in Europe and elsewhere. By way of example, a counterpart recently told me that in South Korea, a prosperous country of 50 million people, a certain large psychiatry indication with a multi-billion dollar market in the US is valued at $12 million or whatever that is in Won. You couldn't afford to run a single phase 3 study for that amount. It's absurdly cheap. Do US drug prices need to come down; yes, but prices in the rest of the world need to come up if we want to continue producing new therapies at the rate we have been.

Hired_Sellout fucked around with this message at 04:47 on Aug 14, 2019

Canine Blues Arooo
Jan 7, 2008

when you think about it...i'm the first girl you ever spent the night with

Grimey Drawer
This is a really interesting read. Pharma is not exactly seen in the best of light, especially in the last few decades, but I do appreciate you sharing the perspective.

mystes
May 31, 2006

It's not impossible that the US will end up adopting a single payer system within the next decade, and if so it will presumably set prices in the same way that other countries do. In this case I think it will be very hard to convince Americans that the US should continue to spend the same total amount on drugs it does now.

Bioshuffle
Feb 10, 2011

No good deed goes unpunished

I read somewhere that no one knows the exact mechanism of action for SSRIs, that psychiatrists pretty much keep guessing and changing up the prescription and dosage until they get it dialed in.

Is there any truth to that?

Dr. Red Ranger
Nov 9, 2011

Nap Ghost

Bioshuffle posted:

I read somewhere that no one knows the exact mechanism of action for SSRIs, that psychiatrists pretty much keep guessing and changing up the prescription and dosage until they get it dialed in.

Is there any truth to that?

Eh, close? We know what the literal function of Selective Serotonin Reuptake Inhibitors are, and we've got a significant body of evidence over the years built up of their side effects and so on look like. But mental conditions, by their very nature, can be very subjective to diagnose and treat because of the doctor's experience and knowledge, how the patient presents or even understands their symptoms, the patient's personal pharmacokinetic response to the drug, and so on.

Imagine, as a doctor, that you have a patient with a broken arm. You would likely agree that such a situation would be a fairly objective diagnosis. The treatment would be relatively straightforward and your medication concerns would be limited to: antibiotics yes/no(and what kind), patient pain tolerance, and allergies.

For mental illness, your patient may not be able to accurately describe what they are feeling, or if they are ill at all. What's a bad attitude vs abiding major depression? Are they experiencing a manic episode or are they in a period of personal upheaval that would provoke a similar response? Are they trying to get a particular drug or are they denying they have symptoms at all? Do they even know what a good, functional baseline mood feels like and could they even tell you if they experienced it through learned coping mechanisms?
What about ADME, the pharmacokinetics of the drug? Does their absorption/distribution/metabolism/excretion of the drug have any hiccups anywhere due to a genetic enzyme condition that would lead them to experience less or too much of the effect? Beyond obvious issues like weight gain, sexual repression and such that we know these drugs carry, how will the patient know what should be happening and what shouldn't? Should you switch from SSRI's to Wellbutrin, an norepinephrine/dopamine reuptake inhibitor or just change the dose, or go to another in-class drug? You can start someone on something easy like Lexapro, and after 3 uneventful weeks they tell you they felt a strange "pop" sensation go off in their head and they experienced a three day vertigo spell. Heck, I know I'm a slow metabolizer because I once took a single, low dose of an antihistamine and proceeded to feel like I had been dunked in a barrel of lidocaine the whole day.

These things get dialed in because treatment for mental illness is like a collaborative effort between you and your doctor to find what "normal" is.

Dr. Red Ranger fucked around with this message at 19:44 on Aug 15, 2019

Bastard Tetris
Apr 27, 2005

L-Shaped


Nap Ghost

mystes posted:

It's not impossible that the US will end up adopting a single payer system within the next decade, and if so it will presumably set prices in the same way that other countries do. In this case I think it will be very hard to convince Americans that the US should continue to spend the same total amount on drugs it does now.

I work in “big pharma” and asked a VP in charge of pricing at a happy hour what happens when they sell to countries with single-payer. They get a price from the country, and sell at that price because the market is too big to pass up. They still make money.

I’m pretty convinced at this point that the only thing UHC in America will dent is my bonus, but since I wouldn’t have a $6500/yr deductible I’m totally willing to roll those dice. We spend like 4.2 trillion a year on healthcare. US Pharma R&D spend is like $60B/year.

mystes
May 31, 2006

Bastard Tetris posted:

I work in “big pharma” and asked a VP in charge of pricing at a happy hour what happens when they sell to countries with single-payer. They get a price from the country, and sell at that price because the market is too big to pass up. They still make money.

I’m pretty convinced at this point that the only thing UHC in America will dent is my bonus, but since I wouldn’t have a $6500/yr deductible I’m totally willing to roll those dice. We spend like 4.2 trillion a year on healthcare. US Pharma R&D spend is like $60B/year.
The fact that it's still profitable to sell to countries with single-payer is basically irrelevant to the issue of America effectively subsidizing pharma research with its current drug prices. Once the drug has been developed, it's going to be profitable to sell to a given country as long as the price the government sets is higher than the (negligible) marginal cost of producing the drug, but this is completely separate from R&D cost. The R&D cost has no effect on the cost of producing the drug once it has already been developed.

That said I didn't realize it was only $60B/year. Considering how much we spend on healthcare and the military it seems like it would be pretty easy to just subsidize pharma research if necessary, but I wonder if that will happen politically considering that there seems to be a lot of hate for pharma companies right now. A single payer system should eliminate that hate anyway, though.

mystes fucked around with this message at 12:25 on Aug 16, 2019

silence_kit
Jul 14, 2011

by the sex ghost

Bastard Tetris posted:

I work in “big pharma” and asked a VP in charge of pricing at a happy hour what happens when they sell to countries with single-payer. They get a price from the country, and sell at that price because the market is too big to pass up. They still make money.

I’m pretty convinced at this point that the only thing UHC in America will dent is my bonus, but since I wouldn’t have a $6500/yr deductible I’m totally willing to roll those dice. We spend like 4.2 trillion a year on healthcare. US Pharma R&D spend is like $60B/year.

Well, R&D is ~20% of drug company revenues ($4 trillion isn't only drug costs). This is one of the highest R&D spends by industrial sector. It makes sense to me that the US switching to a single-payer system could lead to a lower rate of new drug development. Maybe this is ok! I and I think many Americans would gladly live in this world with cheaper healthcare and prescription drugs, but fewer new prescription drugs and treatments.

Would the US switching to a single-payer system, causing drug company revenues to drop, greatly lower drug company R&D spending? If so, do you think that this drop in R&D spending would lead to a) a lower rate of new useful prescription drugs and therapies (this is the D&D poster model of government-funded technological development, where output is always proportional to investment), or b) a similar rate of useful new products coming out, because drug companies would spend their R&D money more judiciously?

I suspect that the answer is closer to a), since I have heard that the theory of medicine isn't really that great, drug development consists of doing a billion trial and error experiments, and so it is hard to spend R&D money judiciously because it is hard to predict the outcomes of experiments, but I'd be interested in other opinions.

Sk8ers4Christ
Mar 10, 2008

Lord, I ask you to watch over me as I pop an ollie off this 50-foot ramp. If I fail, I'll be seeing you.
Here's something that happened to me I've been wondering about:

A doctor writes a prescription for some medication, but tells the patient that they will not send it to the patient's pharmacy. Instead, the doctor knows a pharmacy that can get this medication at a huge discount. They tell the patient they will send the prescription to that pharmacy, and the patient should receive a phone call from the pharmacy the next day to confirm payment and shipping details (pharmacy is in the same state, hours away).

The pharmacy calls the patient the next day. They never ask for insurance information. The patient pays the pharmacy directly. The cost of the medication is much, much cheaper than what it normally retails for. It's even much cheaper than what the co-pay would be. Medication arrives. It's not a generic version, and everything seems correct.

The benefit to me is obvious. Something that would have cost me a $200 co-pay ended up being less than $40. I'm just wondering what kind of deal the doctor and pharmacy have going on where they're able to pull this off and profit from it.

Shooting Blanks
Jun 6, 2007

Real bullets mess up how cool this thing looks.

-Blade



Sk8ers4Christ posted:

Here's something that happened to me I've been wondering about :

A doctor writes a prescription for some medication, but tells the patient that they will not send it to the patient's pharmacy. Instead, the doctor knows a pharmacy that can get this medication at a huge discount. They tell the patient they will send the prescription to that pharmacy, and the patient should receive a phone call from the pharmacy the next day to confirm payment and shipping details (pharmacy is in the same state, hours away).

The pharmacy calls the patient the next day. They never ask for insurance information. The patient pays the pharmacy directly. The cost of the medication is much, much cheaper than what it normally retails for. It's even much cheaper than what the co-pay would be. Medication arrives. It's not a generic version, and everything seems correct.

The benefit to me is obvious. Something that would have cost me a $200 co-pay ended up being less than $40. I'm just wondering what kind of deal the doctor and pharmacy have going on where they're able to pull this off and profit from it.

Online-only pharmacy maybe? Or did you pick it up in person?

Sk8ers4Christ
Mar 10, 2008

Lord, I ask you to watch over me as I pop an ollie off this 50-foot ramp. If I fail, I'll be seeing you.

Shooting Blanks posted:

Online-only pharmacy maybe? Or did you pick it up in person?

Not sure if they're online-only, but they mailed it to me.

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jbusbysack
Sep 6, 2002
i heart syd
Welcome to the absurdly-profitable PBM (Pharmacy Benefits Management) business model.

It's about as late-stage-capitalism as one can envision.

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