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Home Publications Blogs Beat the Press Patent Monopolies Lead to Corruption #54,123

Patent Monopolies Lead to Corruption #54,123

Sunday, 15 December 2013 09:05

The NYT has an excellent piece on how drug companies have hyped "attention deficit disorder" so that millions of children and a rapidly growing number of adults are now taking drugs to treat the disease. The piece presents the views of several doctors, including one who first identified the syndrome, who complain that the vast majority of these people are not benefiting from taking drugs.

This is yet another example of drug companies pursuing harmful practices in pursuit of patent rents. This is a predictable result of government monopolies that allow drug companies to charge prices that can be over a thousand percent above the free market price.

Comments (13)Add Comment
written by Chris Engel, December 15, 2013 8:33
These drugs are often really dangerous too. Essentially the pill-form of meth in some cases. And doctors are trying to throw them at kids (many of whom feel so out of it form the medication they end up selling them to other kids who get a totally different high from them).

So Big Pharma, through incompetent/corrupt doctors, is pushing hard drugs (but in pill form) on kids seeking help which ends up being diverted into the general population of kids. It's more insidious than any street dope operation and it's happening right in front of our faces.
Village Explainer
written by Jim Henley, December 15, 2013 8:41
Anecdotes are not data. But my ADHD diagnosis at age 49 and four years of drug-based therapy since then have immeasurably improved my life. I wish it had happened decades ago.

This is not to defend patent policy. IMHO the problem is that the prices of the best ADHD meds - the long-acting versions - put them out of reach of enormous numbers of people in lower SES strata who could benefit from them. But I have a personal grudge against ADHD denialism because I used to buy into it, to my own detriment.
@Jim Henley you are making the point actually
written by Jennifer, December 15, 2013 10:08
The fundamental issue is the enormous profit motive behind prescription medications. This is always an issue but in pharma the profit margin becomes SO big in large part due to patent protection. Along with patents, what is even less reported, is pharma's ability to manipulate aspects of patents in ways the average person would never think of.
It was made clear in that piece that nobody doubted the existence of ADHD in children and it stands to follow that adult ADHD is a real thing as well. (Especially considering adults today probably weren't screened for it when they were kids as aggressively as kids are today, if at all). But time and time again pharma takes a small diagnosis and goes about dramatically expanding the market by giving it to everyone, this is a particular issue with psych diagnoses as they often have more "flexible" criteria.
written by Alex Bollinger, December 15, 2013 10:40
I won't discuss the article, which, like Jim, just makes me think it's easily misinterpretable by people with shallow knowledge of ADHD and will probably just contribute to denialism instead of better mental health or an attack on the patent system.

Anyway, I just wanted to point out a few things:

1. Keith Conners wasn't the first to identify the condition, which was first described in the early 20th century by George Still and Ritalin got FDA approval in 1955, before Conners was even practicing, probably.

2. No one quoted in the piece says either that the "vast majority" of diagnoses are false or that, as Prof. Baker says, the "vast majority" of people taking the drugs don't get benefits. Instead, it mentions a few people who didn't like the drugs and stopped taking them with no long-term side effects, except for one who complained that her feelings were hurt because she was told she had a mental handicap (I guess people who actually are handicapped should just go jump off a bridge). These anecdotes do not prove: a) that the "vast majority" of diagnoses are improper, b) that the "vast majority" people taking the medications don't get benefits (why oh why would they take a daily pill that doesn't benefit them? How stupid are these consumers?), and c)that they aren't getting a benefit even if they don't have ADHD.

3. There are now generics of all the common doses and formulations of amphetamine salts and methylphenidate. Some of the bad behavior mentioned in the article occurred when some formulations had patent protections, but, then, we'd expect that to be over and done with now that all but a few of the less effective, less-prescribed non-stimulant treatments lost their patent monopolies. If the soaring diagnoses were entirely the result of patent monopolies, then ADHD diagnoses should be tapering off.

4. It's worth a mention that there are two other economic issues that come into play here: overburdened educators who are supposed to "raise standards" and teach more facts to kids than ever before (ADHD's biggest symptom is that it wastes everyone's time) and insurers who don't want to pay for costly diagnoses of ADHD. I'd also add psychiatrists, who charge way too much for these diagnoses (a 1 hour interview + 2 hours of IQ and computer tests with an intern or a nurse + a typed report = $2300, for me, at least, but my insurer was willing to pay for it because they owned a hospital with a psychiatry wing), are part of the problem.

5. Alan Schwartz is a sports writer with a known bias against ADHD treatment, a bias lots of Americans share with him. Look up his article about a young man who was pretty obviously in the early stages of paranoid schizophrenia when he committed suicide, which Scwartz blamed entirely on Adderall (which Scwartz misspelled in the article... the NYT is so smrt). Because, you know, no one ever develops schizonphrenia in their 20's. Nope, had to have been the Adderall.
How about MOTU?
written by ifthethunderdontgetya™³²®©, December 15, 2013 10:57
Our Masters Of The Universe demand huge salaries (and bonuses, stock options, etc.) for forking everything up.

Shirley we could find people willing to destroy Hewlett Packard for less than a $100 million (for example)?
Synergy of Two Market Failures
written by Last Mover, December 15, 2013 11:28

There are two kinds of market failure going on here.

One is the asymmetric info between doctor and patient. Two is the market power of the drug provider which creates huge incentives to oversell an overpriced drug.

As Dean Baker points out repeatedly, number two is far more controllable than number one, and number two also ends up dominating number one to consistently err on the false positive side of a Type I/TypeII error outcome.

In earlier times before widespread patent abuse became the norm, more doctors could be trusted by more patients to "do the right thing" as a matter of good faith effort, even though both knew the doctor always had the upper hand in making decisions.

No more. The influence of Big Health and Big Pharma through sheer overwhelming market power has undermined decisions at the level of doctor and patient, to the point of driving both into situations which have only one all-or-nothing choice by design.

Either do without the drug in light of a likely false positive diagnosis in this case, pushed onto the doctor anyway, or pay an exorbitant price not only for something that may not be necessary, but something that can do harm against the Hippocratic Oath.

Getting the right drugs to the right patients for the right treatment to get the right results ... was never supposed to be about carpet bombing so many wrong patients just to service the right ones.

America should be so happy to return to the days when the first market failure ruled but in a tame way, when the doctor made all the decisions in the interest of the patient - without adding the second market failure of overselling and overpricing that now depends on and abuses the first market failure more than ever.
written by watermelonpunch, December 15, 2013 6:01

I've often wondered if the common diagnosis isn't being "assisted" by the financial insecurity many more & more people face.
Looking at the list of symptoms for ADHD... it sounds like exactly the sort of behaviours & problems that happen when people are struggling, and not knowing how they'll get through the month.
written by ricksersherpa, December 15, 2013 8:22
Dean points out that the economic incentive that a patent monopoly creates in the holder, particularly in something like drug where the consumer has little choice (he or she is following a professionals' direction) is immense in that sales generate massive profits with little risk of personal accountability.
ADHD is the wrong example for *patent* issues
written by JimJ, December 15, 2013 9:40
As Alex Bollinger pointed out, the most important ADHD-related patents have expired. Pharma continues to extract excessive prices because production quotas mean that generics are not consistently available in practice; branded versions (particularly those which are not quite equivalent) continue to be available throughout the year.
written by Alex Bollinger, December 16, 2013 6:47
@ricksersherpa: Actually, no. Patients can evaluate for themselves pretty well how stimulants manage their ADHD. Doctors who know what they're doing will ask a patient how the meds are going right off the bat - the patient has the best knowledge on this subject.

Unlike other meds, stimulants have an effect almost immediately, are out of your system in 4-12 hours depending on the preparation, and affect outward behavior while leaving the patients' thoughts in tact instead of affecting an internal organ people can't monitor or changing people's thoughts so that they're no longer objective.

That's the big issue here with the NYT article: it never explains why people who don't benefit from these meds would take them. They require a monthly, signed prescription, have to be taken 1 to 3 times a day, and cost money (even generics have a nominal copay). Addiction is not possible at the doses these meds are prescribed at, and if the issue is people obtaining them illegally and snorting 2 weeks worth of them to get high (are there more illegal cocaine dealers or illegal adderall dealers?), then we're discussing another topic entirely. Moreover, people without ADHD notice that they do work a little faster with these meds, but that they feel dizzy and out of control and make lots of mistakes. Other than pulling all-nighters, there's really no point in taking them unless you do have ADHD.

The first day I was put on methylphenidate I noticed the effect right away. I took a shower that lasted 5 minutes instead of the usual 30 (no more daydreaming). I picked up my clothes before going to work (instead of thinking about doing it, wanting to do it, but not doing it, then feeling guilty about not doing it). I noticed I listened to a colleague the first time she explained something instead of listening to the beginning and the end, trying to piece together the middle myself, then sheepishly going back 2 or 3 times for her to re-explain everything. This was all in the first few hours.

I was doing what I wanted and acting like the person I was in my head instead of having this enormous fog and lethargy floating around. If I didn't feel that, I would have given up on these meds a long time ago. I mean, really, there's a large cost to taking them, so why would I pay that cost if there's no benefit? In fact, the 2 people the NYT found that didn't benefit from the drugs just stopped taking them.

I'm saying this as an adult. Children are a different issue.
why take ADD medication?
written by J, December 16, 2013 9:30
>That's the big issue here with the NYT article: it never explains why people who don't benefit from these meds would take them.

I'll tell you, then. Because they're told to take them during a crisis, and when that crisis gradually improves (which they all do, unless you die) they are easily convinced (or convince themselves) that the drug saved their lives, and is saving their lives every day.

There is no evidence of this being true, but evidence has never stopped the born-again. Everybody "knows" that it works for them, and that their subjective experience trumps any evidence. Drug companies feed this by suppressing all bad evidence, overstating neutral evidence, and funding/creating patient groups as proxies to both make completely unreasonable statements that the drug companies would be sued for and to frame access to the drug as a civil rights issue.

If somebody tells me you're going to die if you stop taking a pill, and you have had an experience in your life where you felt like you were going to die, and got better after having been given a pill, and you trust authority figures more than the science that they generate, you'll take that pill.

Anyway, the assumption that if a lot of people do something that it must be necessary - that even if the behavior seems to be irrational, it is just because we haven't been able to understand the good reason for the behavior yet - that's just not good reasoning.

>Patients can evaluate for themselves pretty well how stimulants manage their ADHD.

Then why should doctors be dispensing this stuff? Every teacher and every boss should be given a supply to hand out like the unbelievably safe life-saving candy it is.
Placebo effect concerns
written by JimJ, December 16, 2013 4:46
>> That's the big issue here with the NYT article:
>> it never explains why people who don't benefit
>> from these meds would take them.

More precisely -- why are these medications so tightly controlled? How often/easily are they abused, and what are the consequences? Should we treat these stimulants as though they were vitamins, aspirin, tobacco, alcohol, antibiotics, blood thinners, morphine, or heroin? Why?

Today, we treat most ADHD medications like morphine, where a legitimate medical use is recognized, but regular take-a-prescription-to-the-pharmacy controls are considered insufficient.

> Because they're told to take them during a crisis,
> and when that crisis gradually improves (which they
> all do, unless you die) they are easily convinced
> (or convince themselves) that the drug saved their
> lives, and is saving their lives every day.

Expressed that dramatically, you're talking about anti-psychotics and maybe anti-depressants. Yet (for slightly different reasons) patient compliance is a huge problem in both cases. So clearly continuing to take useless medication isn't the only possible outcome of a crisis.

Expressed with a bit less drama, that concern applies to any medication. Do you believe that antibiotics and blood pressure medication are effective mostly through a placebo effect? If that were much of the mechanism, would that justify not using them when they do work?

Things that tend to lower the risk of falling for a placebo effect include a treatment effect that kicks in (and out) very quickly, symptoms that are otherwise (relatively) steady over the long term, symptoms which are fairly easy to recognize (for both the patient and his or her family).

It would also help if the diagnostic criteria were clear, and there weren't other things that could cause similar symptoms without responding to the same treatment -- but life isn't perfect.

> Anyway, the assumption that if a lot of people do
> something that it must be necessary - that even if
> the behavior seems to be irrational, it is just
> because we haven't been able to understand the good
> reason for the behavior yet - that's just not good
> reasoning.

Spoken like a theorist.

In real life, many Doctors often start treatment long before being even remotely sure of a diagnosis; treatment protocols will often specify "and did not respond to X" as a pre-condition. If we know why something works, great. If it works consistently, better. If we have no idea why it works, and it only helps one person in three -- that is still better than helping nobody. (And with ADHD medications, it is *relatively* easy to tell whether the patient is among those helped, and to discontinue otherwise. The biggest barriers to discontinuing are not medical.)
written by Alex Bollinger, December 17, 2013 5:56
@J: What life-saving experience are you talking about? Who ever said I would die if I stopped taking Ritalin? I don't know if you understand the nature of these meds.

The assumption that behavior that lots of people engage in has a reason (I never said "necessary") is pretty good reasoning, actually. The alternative, that all these folks just randomly go to the doctor every month, then go to a pharmacy, and pay a copay, all because of pure random chance sounds pretty improbable to me.

Your alternative hypothesis, that it's just because of the authority of doctors, also doesn't seem that probable, especially when we're talking about people with ADHD who generally have issues with authority and difficulty when it comes to follow-through if there isn't an immediate, tangible reward. Even non-ADHD people may like what an authority figure says, but to go through all that trouble and inconvenience just because they saw an ad, I don't know, it's just not people as I know them.

Again, maybe I'm wrong and all these people (me included) are really just so stupid that we can't discern the immediate and observable affect a drug on our own bodies. OK, then, but what would then make me think that you'd know better than I do what's going on?

And why have doctors dispense them? Lots of reasons: 1) they can monitor side effects (like heart conditions) better than teachers or candy shops; and 2) there is a black market for these drugs, mentioned above, because if you get 1 or 2 week's worth, crush them, and snort them, they can get you high.

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About Beat the Press

Dean Baker is co-director of the Center for Economic and Policy Research in Washington, D.C. He is the author of several books, his latest being The End of Loser Liberalism: Making Markets Progressive. Read more about Dean.