Overdosed America Paperback Edition Available

"Some of the nation's worst drug dealers aren't peddling on the street corners, they're occupying corporate suites. Overdosed America reveals the greed and corruption that drive health care costs skyward and now threatens the public health. Before you see a doctor, you should read this book." - Eric Schlosser, author of Fast Food Nation

Buy on Amazon | Buy on Barnes & Noble

Excerpts: Introduction | Chapter 13 | Chapter 14

Is Evidence-Based Medicine Evidence Based?

According to the U.S. Centers for Disease Control and Prevention, of the 2.4 million U.S. deaths in 2000, 400,000 were associated with unhealthy diet and lack of physical activity. These are deaths related to the particular way in which civilization has "progressed" upon this planet: high-fat, high-carbohydrate fast foods devoid of fruits and vegetables; a vast multitude of automobiles that make self-propulsion (walking) obsolete as a standard life routine; and couch-potato-creating television sets that not only replace the neighborhood kickball game and hide-and-seek activities that amused me when I was a kid, but also badger us to purchase those same automobiles and eat those same fast foods.


How has the trillion-dollar-plus enterprise we call the health care system responded to this pervasive undermining of our health? By offering more inventions, which—like those cars, fast-food chains, and TV sets—are capable of making money for a small stratum of society. Instead of approaching the health effects of modern civilization through community-wide and public health interventions—banning cars and creating greenbelts within cities, spending more dollars on health education than the food industry spends on advertising, and creating more neighborhood physical activity programs than the auto industry creates cars—we have chosen to address those 400,000 deaths with a few rushed minutes in a sterile exam room populated by a highly trained physician, a passive patient, and a prescription pad.

John Abramson is a physician who spent more than twenty years in those exam rooms, filling out thousands of those prescription pads. But something happened to him that, sadly, happens to few physicians. He began to study epidemiology and research methodology, expanding his viewpoint from a close-up focus on the individual patient to a panorama of the entire population. Carefully reviewing the research literature, he found that spin doctors had been doctoring the evidence. The conclusions he reached from his careful literature review differed from the conclusions published by the authors of the universally accepted clinical practice guidelines—the "evidence-based medicine"—that are the yardsticks against which physicians’ quality of care is measured.

Abramson’s book, Overdosed America, provides detailed arguments on the false conclusions reached from research on such topics as the prevention of coronary heart disease and hip fractures. He explains why those conclusions are distorted: the web of interlocking monetary relationships among the pharmaceutical industry, academic research physicians, the Food and Drug Administration, leaders within the National Institutes of Health, and some of the hallowed organizations that promulgate evidence-based medicine—with the nation’s prestigious medical journals often serving as unwitting collaborators in the distortions.

Overdosed America presents a strong indictment of the evidence that dictates medical practice, a challenge that is credible only because Abramson backs up his statements with detailed analyses of the prevailing evidence. It is beyond the purview of this review to judge whether each of Abramson’s conclusions are scientifically and statistically valid. What can be said, however, is that the seriousness with which he explores clinical issues merits a major debate on those issues within the world’s leading medical journals—untainted by the almost ubiquitous monetary distortions. To give a sense of Abramson’s approach, it is worth summarizing his treatment of an important clinical problem: osteoporosis.

Twenty percent of women over age fifty have osteoporosis, and another 40 percent have osteopenia, thinning of the bones that puts women at risk for osteoporosis. Osteoporosis increases the risk of a serious medical event—hip fracture. Osteoporosis is diagnosed with a bone mineral density (BMD) test. About half of all American women who have a BMD test will be diagnosed with osteoporosis by age seventy-two. The market for pharmaceutical products to manage this condition is enormous. Accordingly, based in part on the work of an expert panel funded by drug companies, current practice guidelines recommend that all women have a BMD test at age sixty-five, or earlier if at greater risk for osteoporosis. The drug Fosamax (alendronate), which improves BMD, was found to reduce the risk of hip fractures for postmenopausal women with osteoporosis by 56 percent. Here, Abramson does what every journal article, newpaper report, and TV airing of a medical advance should do: report the absolute risk instead of trumpeting the relative risk. If, in a hypothetical example, 2 of every 10,000 women with osteoporosis sustained a hip fracture in a year, a relative risk reduction of 50 percent would mean that 1 of every 10,000 women would be spared a hip fracture—a very small improvement. If four of every ten women with osteoporosis sustained a hip fracture in a year, then a relative risk reduction of 50 percent would mean that two of every ten women would be spared a hip fracture—a very large improvement. Relative risk by itself can be highly misleading. Abramson reports the more illuminating facts: 81 women would have to take Fosamax for 4.2 years to prevent one hip fracture, and for women ages 70–79, Actonel (risedronate), a medication similar to Fosamax, had no effect on the number of hip fractures.

What is going on? Why do drugs that improve bone mineral density have little effect on hip fractures? It turns out, according to Overdosed America, that BMD is not a good test to predict hip fractures. BMD mainly measures the outer layer of bone (cortical bone), whereas much of the strength of bone lies in the inner structures of trabecular bone. Drugs such as Fosamax primarily strengthen cortical rather than trabecular bone, which improves the BMD score but may not contribute as much to fracture prevention.

Finally, women age sixty-five and older who engage in regular exercise enjoy twice the reduction in hip fractures achieved with Fosamax. Exercise not only increases bone density but improves muscle strength and balance, thereby preventing falls, the proximate cause of hip fractures. Yet physicians who prescribe drugs such as Fosamax for at-risk women, while ignoring or downplaying the greater importance of exercise, are viewed as "evidence-based" physicians.

Why this lengthy exposition of a clinical issue in a health policy book review? Because readers who might be inclined to view Overdosed America as simply another in the growing number of diatribes against drug companies should be aware that this book makes its arguments in a detailed, well-referenced manner. Moreover, responsibility for the overdosing of America goes far beyond the drug industry, resting equally with the nation’s physicians. I beg all of my physician colleagues to read this book and to think deeply about how we are practicing our chosen profession.