Comment by bayesianhorse | Hacker News Reader

Comment by bayesianhorse | Hacker News Reader

On the issue of efficiency of Prozac or similar drugs, sometimes the explanation is that they simply work and you know it if you have taken them. I found the effects of SSRIs very noticeable, and every doctor prescribing them knows of patients who suddenly were able to leave the bed, or deeply depressive patients switching into a manic episode. The latter might not sound like an improvement, but for the patients, quality of life improves immensely. This can explain why doctors and regulators look favourably on drugs with a long history of clinical use.

I'd also criticize the conclusion that there's nothing better than Aspirin on the market. Which hasn't been known since ancient times by the way. The original salicylic acid was much worse on the stomach. Both Ibuprofene and Diclofenac have better analgesic properties, again very noticeable, and metamizole has different properties, again much more useful than asparin. There's really nothing to argue with that, except some hand-waving "placebo" talk, which often isn't so scientific either.

I'm more familiar with the veterinary side of things, and there the situation is that there are both independant trials, and a sort of "grapevine" where veterinarians compare notes on different drugs.

You can't really argue with anesthesia drugs. Either they work or they don't. Either they have a high incidence of accidents in a particular species, or they don't. Antibiotics much the same, especially when performing individual lab tests. Sure there is a lot of hyperbole or bad advertising, but it's not just "bad pharma".

> On the issue of efficiency of Prozac or similar drugs, sometimes the explanation is that they simply work and you know it if you have taken them.

This is what people who take homeopathy say. It's what doctors and patients said about knee arthroscopy for rheumatoid arthritus until they did a trial involving sham operations.

When Prozac was introduced in the UK we were told that it made people "better than well", and that everyone should have it and that the UK prescription laws were seriously flawed because this drug was restricted to people who had a diagnosed illness and was not available to everyone.

It's that kind of behaviour which is sleazy. The deliberate hyping of medications.

The brutal cynicism of using dying cancer patients to campaign for your ineffective very expensive cancer medication is really disgusting.

I'm not sure whether you're critiquing the book or what you've read in the review.

>It's what doctors and patients said about knee arthroscopy for rheumatoid arthritus until they did a trial involving sham operations.

small correction; The NEJM studies (below), to which your comment was probably referring, were actually for arthroscopic surgery in osteoarthritis patients, not rheumatoid.

It's quite common to think these conditions are similar, but are really rather different, with diverse etiologies. RA is considered an autoimmune disease, whereas OA is not.

update: included subsequent years

(2002) http://www.nejm.org/doi/full/10.1056/NEJMoa013259

(2008) http://www.nejm.org/doi/full/10.1056/NEJMoa0708333

(2013) http://www.nejm.org/doi/full/10.1056/NEJMoa1301408

Pain medication does work for quite a large number of conditions. Much of this has been demonstrated against a placebo or different treatments. If you give these drugs to animals in pain, they cease showing pain behavior.

Just defining all effects of pain medication as placebo just isn't scientific at all. Placebos often don't work reliably and repeatable either...

You still haven't said whether you are responding to the book or this review of the book. This review is, as several people have said, lousy. It's pointless for us to discuss this review because I disagree with the review. I do agree with a lot of the book.

When Goldacre talks about placebo he tends to talk about the pricing differences between differently packaged but identical medication. Thus, a brand name paracetamol is the same as an own-brand paracetamol and they're the same as a budget paracetamol. Yet one can be five or six times more expensive than the other. (Personally I don't see this as particularly bad behaviour.) I agree that he tends to place too much emphasis on placebo, but then I haven't read the studies. There are strong psychological aspects to pain; pain in cancer patients can be helped with cognitive behaviour therapy; some people (40% in one (not very good) report) with long term pain reported relief when they took a placebo.

But also look at coproxamol. This is an old med. we used to think that mixing meds meant you could use smaller quanties of active ingredients. Coproxamol is a sub-therapeutic dose of paracetamol and a dangerous toxic opiod (opiate?) dextropropoxyphene. (Paracetamol in acute overdose is very dangerous so for the dextropropoxyphene to be the more worrying ingredient tells us something). We've known since at least the 1980s that this med is not particularly effective and is very risky, yet it has only just been withdrawn from general use in the UK. We knew that it was less effective than paracetamol alone (because you'd take that at an effective dose) but that it was far more dangerous and that evidence got stronger through the 1990s and 2000s. (An overdose of paracetamol is treatable if caught in time, although paracetamol overdose does kill many people each year. An overdose of coproxamol is usually fatal before help arrives. For a time coproxamol was the leading medication in fatal overdoses.) Removal of this med was fiercely fought for years by pharmaceutical companies and by patient advocacy groups (sometimes funded by those same companies).

That is sleazy behaviour.

The parent never said anything about pain medication.

He talked about Prozac and about homeopathy.

The argument that painkillers haven't progressed in efficacy since Aspirin seems like it'd be thwarted simply by comparing Advil, Aspirin, and Tylenol, which seem to have noticeably different anti-inflammatory properties (acetaminophen being better for headaches and ibuprofen better for toothaches, for instance).

A zeroth-order argument for the utility of modern painkillers: you can take acetaminophen and ibuprofen at the same time for "twice" the effect, without either risking deadly liver poisoning from acetaminophen overdose, or stressing out the stomach lining from high-dosage ibuprofen or aspirin.

Those of us who occasionally get migraines know all about this, as do people in palliative care.

> On the issue of efficiency of Prozac or similar drugs, sometimes the explanation is that they simply work and you know it if you have taken them.

This can often be down to the placebo effect. Chris Kresser talks about this [1], saying that even when given a placebo people will report feeling better.

[1] http://chriskresser.com/placebos-as-effective-as-antidepress...

Of course, the mention of painkillers is a throwaway line in the review, not from the book.

>On the issue of efficiency of Prozac or similar drugs, sometimes the explanation is that they simply work and you know it if you have taken them.

I hear the same thing about the power of prayer and Reiki.

If your disease is something that's subjective in the first place, that's not as much of a problem.

Turns out, medication tends to work with much more people than prayer or Reiki...

Drugs seem to work much more reliably.

But the reason we know whether a medication works or not is by well conducted trials, not by giving it to a few people and asking how they feel.

It is exactly this kind of thinking that pharmaceutical companies are exploiting when they hide results from trials.

I wasn't referring to any comment about "medication" or "drugs" in general, but to a comment about Prozac and similar drugs. When you study them, they absolutely don't work better than the pre-SSRI antidepressants, and neither of them work much better than placebo. When you don't study them and just know that they work because you have taken them, they work just as well as prayer and Reiki.

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