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Prescription drug use has reached record levels in Rhode Island and will keep rising for years. Having already transformed the face of health care, the trend will continue to affect patients, providers and insurers, experts agree.
"It's a mega-influence on the health-care system," says Dan Curran, pharmacy manager for Blue Cross & Blue Shield of Rhode Island, the state's largest health insurer. "It's going to be a dominant influence in the health-care debate for the foreseeable future."
Rhode Island is in step with a national trend that has seen prescription drug use rise dramatically for well over a decade.
Americans bought 3.4 billion prescriptions last year, according to IMS, a Connecticut-based consulting firm that processes data from drug manufacturers. That was nearly double the number of prescriptions purchased a decade ago -- and represented an average of about 11.8 prescriptions per person per year, an all-time high.
Never in history have so many people taken so many legal substances. Prescription spending last year in the United States, according to IMS, totaled $216 billion (wholesale) -- an increase of almost 12 percent in just 12 months. And there is no end in sight to the increase in use and cost.
"There has been a biomedical revolution," says Dr. Kathleen W. Wilson, author and internist at Ochsner Clinic Foundation in New Orleans.
Several factors are driving the trend.
Americans live longer than ever, and as they grow old they become increasingly susceptible to disease -- more and more of which can now be treated with medications. Aging baby boomers create demand for "lifestyle" drugs such as Viagra. Better and safer drugs are available for many disorders -- and new drugs are successful for ailments that were once untreatable. For certain conditions, pharmaceuticals have replaced surgery and other interventions as the treatment of choice.
And after investing hundreds of millions of dollars in developing a major new drug, manufacturers spend heavily to market it. Doctors offer copious free samples, courtesy of the drug makers. Major drugs have their own Web sites and even nicknames -- heartburn-reliever Nexium, for instance, is "the purple pill," and is featured at www.purplepill.com. And one can barely turn on the TV today or attend a professional sports event without seeing a drug ad.
"Pharmaceutical firms are in the business of maximizing profits," says John A. Vernon, a professor with the Center for Healthcare and Insurance at the University of Connecticut's School of Business. "Like any business, you market your products."
ALTHOUGH MEDICAID and other government programs track their subscribers' medications, no agency monitors all prescription drug use in Rhode Island, and private insurers do not release detailed numbers.
But data collected by NDCHealth, an Atlanta healthcare information services firm that tracks pharmacy sales, provide insights into prescription drug use in the state.
According to the firm, Rhode Islanders bought 14.7 million prescriptions in 2002, the last year for which complete data were available. That was an increase of 1.7 million prescriptions since 1999.
The per-person average in 2002 was 13.7 prescriptions purchased -- somewhat higher than the national average, but about the same as Pennsylvania and Massachusetts, which have high concentrations of elderly residents like Rhode Island. In 1999, the per-person average in Rhode Island was 13.1 prescriptions.
Rhode Islanders and their insurers in 2002 spent $937 million (retail) on prescription medications -- almost double the 1999 expenditure, an increase attributable in part to the higher costs of many new drugs. The average cost of a prescription in 2002 was $63.75, up from $39.28 in 1999. Consumers would not necessarily see such figures, since insurers pick up some or all of the cost.
At the Journal's request, NDC ranked the 100 best-selling drugs in Rhode Island last year.
With 478,921 prescriptions, Lipitor was the most-prescribed (nationally, it was number two). The drug lowers cholesterol, a factor in heart disease, the leading cause of death in Rhode Island and the nation. Lipitor sales in Rhode Island last year surpassed $40 million (wholesale), cost-wise more than double any other drug.
Second in Rhode Island, with 367,804 prescriptions, was the painkiller hydrocodone with acetaminophen -- sold as Vicodin, among other brand names. Hydrocodone was the most-prescribed drug in the United States last year, with almost 86 million prescriptions.
Third and fourth in Rhode Island were lisinopril and atenelol, both of which are prescribed for high blood pressure, a factor in strokes, the state's and nation's third-leading killer.
Fifth in Rhode Island was amoxicillin, an antibiotic.
The remainder of Rhode Island's top 20 included drugs for heartburn and ulcers (Nexium); for depression, anxiety, panic and related disorders (Zoloft, Xanax, Prozac); asthma (albuterol); and thyroid ailments (Synthroid).
AN AMERICAN born in 1900 could expect to live to 47; today, a typical newborn will live past 77, and every year life expectancy increases. This change has been particularly evident in Rhode Island, where 14.5 percent of all residents in the 2000 census were 65 or older -- making the state the sixth oldest, by percentage, in the nation.
"We've got an aging and a graying population and with that comes increased health issues. And the majority of those issues require some combination of drug therapy," says Charles Mahoney, administrative director of pharmacy services for Rhode Island, Miriam, and Bradley hospitals.
In many instances, says Kate L. Lapane, an associate professor at Brown Medical School who specializes in drug use by the elderly, patients suffer from more than one disorder. It is not uncommon to find a patient with heart disease, diabetes and cancer.
"Each of these conditions can require multiple medications," Lapane says. "And as you live longer with the diseases, it may require [even] more complicated drug regimens to control and manage."
The inevitable result, as Lapane witnessed with her grandmother, who took at least ten medications for heart disease and diabetes: greater drug use.
And that use will intensify as the baby boom generation advances toward retirement, swelling the ranks of America's elderly population. According to Census Bureau projections, 39.7 million Americans will be 65 or older in 2010 -- about 4 million more than today. By 2025, that number will soar to 63 million Americans -- and of those, more than 7 million will be 85 or older.
EVEN WITH YOUNGER patients, the trend is toward earlier drug treatment of certain disorders. Dr. Yul D. Ejnes, associate professor at Brown and past president of the Rhode Island Medical Society, cites high blood pressure as an example.
When Ejnes began practice as an internal medicine specialist in the late 1980s, doctors believed that blood pressure was acceptable as long as the systolic reading (the first number in the reading) was below age plus 100. Now, Ejnes says, 140/90 is the benchmark for everyone -- with specialists debating whether 130/80 would be a healthier marker.
"We're getting more aggressive in the treatment of high blood pressure," Ejnes says. "Treatment thresholds are going down."
With the introduction of new drugs, doctors have more effective ways of lowering blood pressure than ever before. It is no coincidence that lisinopril, sold under the brand names Zestril and Prinivil, is the third most-prescribed drug in Rhode Island (and sixth in the nation), with nearly a quarter-million prescriptions filled last year.
New drugs are also replacing surgery as the treatment of choice for certain disorders. Ejnes cites ulcers as an example.
Decades ago, doctors treated ulcers with milk and cream, and when that failed, they resorted to surgery. Antacids replaced dairy products -- but surgery remained an option. With the recent advent of a class of drugs called proton pump inhibitors -- including Nexium, the 16th most prescribed drug in Rhode Island -- surgical treatment has virtually disappeared.
"I don't have a patient who has ever undergone that kind of surgery in recent years," says Ejnes. In terms of overall health-care costs, this is an instance when drug treatment can be cheaper.
AND THEN THERE is the profit motive.
Drug manufacturing is big business: led by Pfizer, with $45 billion of sales, the top 10 pharmaceutical firms alone sold more than $200 billion in drugs last year. Among Pfizer's best-selling products are Lipitor, Zoloft, and Viagra.
With an annual return of 17 percent on revenues, drug-making is the country's most profitable business, according to the Kaiser Foundation. Pfizer's last year returned almost $4 billion in profit to its shareholders.
A study cited by the University of Connecticut's Vernon found that it costs a drug maker an average of $802 million to bring a major new drug to market. But when a drug hits, that investment pays off -- big time. A highly successful drug like cholesterol-lowering Lipitor rang up more than $9 billion in sales last year.
To make money, a drug first must work, of course.
But most drugs have competition. Lipitor, for instance, is up against cholesterol-lowering drugs made by Novartis (Lescol), Merck (Zocor), and Bristol-Myers Squibb (Pravachol). Each of these companies rings up more than $20 billion a year in sales.
Like any other business, drug firms aggressively market their products. The firms field sales forces that call on doctors. They sponsor conferences and pay for health-care professionals to attend. They provide free samples.
According to a November 2001 study by California's Kaiser Family Foundation, pharmaceutical manufacturers in 2000 provided nearly $8 billion (retail) in free drug samples to U.S. doctors -- $3 billion more than in 1996.
Meanwhile, encouraged by the growth of the Internet and by a government ruling in the 1990s that allowed drugs to be advertised on TV, companies now pitch their products directly to consumers. During the 1996-2000 period studied by Kaiser, spending for direct-to-consumer advertising rose almost 33 percent -- from $791 million to nearly $2.5 billion, and indications are that spending keeps climbing. Pfizer alone last year spent $664 million on ads directed at consumers, according to Pharmaceutical Executive magazine.
According to Blue Cross & Blue Shield's Curran, many patients go to their doctor's office with a diagnosis and a request for a drug -- which they get. "People say, 'I saw the purple pill on TV -- I think I have those symptoms, can you give me that?' And doctors want their patients to be healthy and they want their patients to be happy with them," Curran says.
Direct-to-consumer advertising has led to a measure of abuse, says Stephen J. Kogut, assistant professor in the University of Rhode Island's Department of Applied Pharmaceutical Sciences. "Patients who may or may not need a medication may demand it anyway," he says.
But direct-to-consumer advertising has also helped to create a more knowledgeable consumer -- and that can be a good thing, he maintains.
"Some would say that it interferes with the patient-provider relationship," Kogut says, "but in this country there's a right to disseminate information that is not inaccurate or misleading."
WITH DOZENS of new drugs set to enter the market, projections show prescription drug use continuing to climb. Medco, a New Jersey-based pharmacy benefits manager, anticipates annual increases of three to six percent in numbers of prescriptions written through 2006 in the United States.
Costs are projected to soar, too.
The Federal Centers for Medicare and Medicaid Services, which analyzes all prescription drug use in the United States, predicts that the total cost of prescription drugs will rise at an annual rate of 11 percent through 2013.
Rhode Island, experts say, will stay firmly inside the trend.
And sooner or later, experts predict, that will force a public debate on a multitude of issues, including: the cost of drugs; who pays for drugs; access to new drugs; drug imports; drug safety; and better communication among patients, doctors, insurers, and pharmacists.
"It's a train that's coming down the track," says Curran. "There's a crying need for public policy."
G. Wayne Miller is compiling stories of people's experiences with prescription drugs. If you would like to share your story -- good or bad -- please send it, with as much detail as you prefer, to Miller at gwayneproject [at] yahoo.com. Users of over-the-counter drugs, herbals, and nutritional supplements are also welcome to submit.
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