http://www.nytimes.com/2005/09/30/books ... nted=printSeptember 30, 2005
Tense? Lonely? There's Promise in a Pill
By MICHIKO KAKUTANI
In his hilarious stand-up routine, Chris Rock talks about the ubiquitous television drug commercials that "keep naming symptoms till they get one that" the viewer's got. Sometimes, he says, the ads don't even tell you what the pill does: "You see a lady on a horse or a man in a tub, and they just keep naming symptoms: 'Are you depressed?' 'Are you lonely?' 'Do your teeth
hurt?' " He adds that one commercial he saw went, "Do you go to bed at night and wake up in the morning?"
"They got that one!" he says. "I got that. I'm sick. I need that pill!"
Mr. Rock's observations are almost too close to the actual truth to be considered satire, as Greg Critser's provocative new book, "Generation RX,"
makes clear. Indeed, baby boomers and their offspring have become the most medicated generation ever, devoted consumers from cradle to grave of every manner of pharmaceutical imaginable - pills that not only cure real
diseases, but that also promise, in Mr. Critser's words, to "do everything from guarding us against our excesses of drink, food and tobacco, to
increasing our children's performance at school, to jump-starting our own productivity at work, to extending our very time on this mortal coil."
Boomers, who grew up using drugs recreationally, have become a generation that lives almost full time in the Valley of the Dolls: bombarded by
direct-to-consumer ads, they are happy to self-medicate, and their cost-conscious H.M.O.'s are happy to substitute antidepressants for expensive talk therapy, prescriptions! for repeated doctor visits.
Little wonder, then, that drug use - of the legal sort - has soared. Americans routinely take pills for high cholesterol and high blood pressure,
and they also routinely take pills to sleep, pills to focus, pills to chill and pills to perk up, pills for more sex and pills for less stress. Mr. Critser notes that "the average number of prescriptions per person, annually, in 1993 was seven," but had risen to 11 by 2000, and 12 in 2004.
"The total number of annual prescriptions in the United States now stands at about three billion," he writes. "The cost per year? About $180 billion,
headed to an estimated $414 billion by 2011." He adds that spending on all forms of drugs to treat childhood and adolescent behavioral disorders rose
by 77 percent between 2000 and 2003, "with 65 percent of all children on such drugs taking at least one antidepressant." On college campuses, the portion of students who went to health centers and "who were already taking psych meds went from 7 percent in 1992 to 18 percent in 2000." There is little in "Generation RX" that hasn't been reported before - in the flurry of articles about the pharmaceutical business, which appeared in the wake of the Vioxx recall last fall, or in the slew of recent books by experts like Marcia Angell ("The Truth About the Drug Companies"), Jerry Avorn ("Powerful Medicines") and John ! Abramson ("Overdosed America").
What Mr. Critser has done in these pages is synthesize a lot of information and reserve it to the reader in an accessible, easily digested form - much as he did with information about obesity in his 2003 book, "Fat Land." While
his prose sometimes buckles from his efforts to be chatty and conversational - at one point, he describes the liver, which can regenerate
itself, as "a kind of Donald Trump of the human body" - he does a lucid job conveying the dramatic ways in which the development and marketing of pharmaceuticals have changed over the last two decades and the equally dramatic and often disturbing consequences of this phenomenon.
Like Ms. Angell in "The Truth About the Drug Companies," Mr. Critser traces the big changes in the drug business back to what he calls "newly loosened and speeded-up regulatory processes" that began with the Bayh-Dole Act of 1980, which "made it easier for the industry to use research discoveries that originated in publicly funded laboratories," and the Hatch-Waxman Act
of 1984, which made it easier for cheaper generics to find their way to the market but also made it easier for drug companies to get extensions on their monopolies. As for the Prescription Drug User Fee Act, passed in 1992, Mr. Critser says it in effect resulted in "a clientized" Food and Drug Administration, by allowing companies to pay "user fees" to expedite the reviews of new drugs.
In recent years, Mr. Critser goes on, the two great buffers between Big Pharma and the public have grown increasingly porous. The government,
besieged by pharmaceutical lobbyists, has grown more and more accommodating toward drug companies, while doctors - coping with growing workloads, demanding patients and the strictures of managed care - have started to change their prescription-writing habits. Needless to say, Big Pharma has done everything it can to promote its own interests: Mr. Critser estimates that the business spends "between $8,000 and $15,000 annually per physician to sell its wares," adding that it also pays for some 90 percent of all
continuing medical education classes.
At the same time, drug companies have employed a host of other strategies to maximize sales and profits: focusing on the development of drugs for chronic conditions and drugs with large patient populations; enlarging the patient base for existing drugs by selling them as cures for related disorders (Paxil, for instance, eventually won approval for treating depression, panic disorder, obsessive-compulsive disorder and social anxiety disorder); and promoting drugs like Viagra as "quality of life" products that patients would ask their doctors to prescribe.
Although Mr. Critser skims a little too briefly over the stories of specific drugs like Vioxx and Seldane that have been recalled for serious safety
reasons, he does an effective job of showing why the F.D.A.'s speeded-up review process, combined with Big Pharma's aggressive pushing of its drugs,
has led to such tragic cases. He also raises important questions about the possible damage that the long-term use of pharmaceuticals may cause - from liver damage to cascading drug interactions to the more intangible psychological effects of young people relying on antidepressants and attention-deficit-disorder drugs to cope with the stresses of life.
"The principal forces that have so deeply pharmaceuticalized American life are hardly likely to abate anytime soon," he writes. "Managed care over the next decades will continue to depend heavily upon pills as a proxy for physician care. Cost-conscious employers and insurers will make sure of that. As will Wall Street - particularly as baby boomers begin to cash in their retirement funds, which have been floating on that nice, easy cushion of double-digit pharmaceutical company returns for two decades. The average pharma C.E.O. will feel the heat and continue to do what he has been doing,
only faster."
