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Comment: Researchers’ focus on drugs over other treatments ignores doctors’ and patients’ views
Xiulu Ruan, MD, Adjunct Clinical Associate Professor of Anesthesia (corresponding author)
Dept. of Anesthesiology, Louisiana State University Health Science Center
1542 Tulane Ave. New Orleans, LA 70112
Alan David Kaye, MD, Ph.D., Professor and Chairman of Anesthesia
Dept. of Anesthesiology, Louisiana State University Health Science Center
1542 Tulane Ave. New Orleans, LA 70112
We read with interest the article by Zosia Kmietowicz, “Researchers’ focus on drugs over other treatments ignores doctors’ and patients’ views” published on June 25, 2015 in BMJ (1). The author’s news report is based on a research study by Crowe and colleagues (2), published in “Research Involvement and Engagement”, where they found researchers choose to investigate the effect of drugs on a range of common conditions despite evidence that patients and clinicians would like to see a greater focus on non-drug treatment options, such as psychological therapies and educational interventions. Crowe et al. suggest that incentives may be needed in the research selection process to ensure that the concerns of patients and clinicians are not ignored.
Obviously, clinical research cannot be conducted without adequate monetary support. Funding for science has changed with the times. Historically, science has been largely supported through private patronage (e.g., the backing of a prominent person or family), church sponsorship, or simply paying for the research yourself (3). Nowadays, researchers are likely to be funded by a mix of grants from various government agencies, institutions, and foundations. Medical research however, is increasingly sponsored by private pharmaceutical companies. By 2000, almost 75% of U.S. clinical trials in medicine were paid for by private companies (3). By 2013, that number went up to 85- 90% (4). It is really not surprising that majority of clinical trials are therefore drug trials.
However, we believe there are other factors that may have played significant roles in contributing to this discrepancy, i.e., insurance company, healthcare policy makers, availability of resources, etc. For example, patients with uncontrolled chronic pain should have access to a full range of diagnostic and therapeutic modalities appropriate to their particular case, which may include pharmacological therapy, physiotherapy, clinical psychology, surgery, invasive techniques, occupational therapy and rehabilitation medicine (5). Current data suggests that access to integrated interdisciplinary pain management varies across Europe. In Norway, for example, patients now have a legal right to receive prioritized healthcare in multidisciplinary pain clinics, if their health-related quality of life is severely affected by the pain condition with efficacious and cost-effective treatment available. In Italy, a law passed in 2010 defined patients’ rights to access to multidisciplinary pain centers and promoted the development of regional and national networks of centers and care pathways (6). In contrast, patients in many countries have limited access to these services, and even where multidisciplinary pain centers do exist, there can be prolonged waiting times. In the US, many insurance policies provide limited coverage to physical therapies; however, most insurance carriers do not cover psychological services for patients with chronic pain. Despite the large and growing body of research supporting both the clinical effectiveness and cost-effectiveness of interdisciplinary care, there continues to be reluctance among third-party payers to cover the costs of all components of such care (7).
In an recent article by Milloy and Wood, titled “Withdrawal from methadone in US prisons: cruel and unusual?, published in May 2015 issue of “the Lancet”, they described, “In the USA, the so-called war on drugs has contributed to an era of mass incarceration…, The USA not only has the world’s highest rate of incarceration, but treats opioid-addicted prisoners very differently from those in prisons in other countries. Individuals with opioid dependence will often have their medically effective treatment such as methadone, the standard treatment for opioid dependence, discontinued on incarceration in most US correctional institutions. In a nationally representative survey of 500 US prisons, only 12% reported that individuals who enter custody on a methadone treatment program are maintained in this program during their time of incarceration. Furthermore, in the prisons that do not provide methadone, most institutions reported that they have no standard protocol to taper individuals off methadone. Therefore, the first days of their detention are spent in the pain and discomfort of physical withdrawal.”
Methadone maintenance is a highly effective treatment for opioid addiction and has been included in WHO’s Model List of Essential Medicines since 2005. Eleven randomized controlled trials have assessed the efficacy of methadone maintenance in treating opioid dependence as compared with placebo or non-pharmacological therapy and showed the effectiveness of methadone maintenance therapy in reducing illicit opioid use and increasing retention in treatment (8). In prisons, where many individuals are addicted to opioids, WHO recommends the provision of buprenorphine or methadone maintenance as a best practice for opioid agonist therapy and opioid withdrawal. Accordingly, many nations, including Iran, Australia, Canada, and most of the European Union, have made methadone maintenance therapy available in correctional facilities (8).
By contrast, in most of the USA, the standard procedure is to discontinue methadone treatment for prisoners. Further, this is in the context of a plethora of literature indicating so, including reduced recidivism (9). This underscores how challenged the concept of continued methadone for incarcerated prisoners remains to this date, despite an abundance of literature supporting it in this population.
To conclude, while leadership and incentives may be important to facilitate research to reflect the priorities of patients and clinicians, healthcare policy makers are the final and most significant dictating factors in allowing the translation and implementation of solid research evidence into better patient care. Cooperation of all stakeholders will best serve the public as we move forward in these ever changing and most challenging times.
References:
1. Kmietowicz Z. Researchers’ focus on drugs over other treatments ignores doctors’ and patients’ views. 2015.
2. Crowe S, Fenton M, Hall M, Cowan K, Chalmers I. Patients’, clinicians’ and the research communities’ priorities for treatment research: there is an important mismatch. Research Involvement and Engagement. 2015;1(1):2.
3. Paleontology UoCMo. Understanding Science 2015 [cited 2015 July 9, 2015]. Available from: http://undsci.berkeley.edu/article/0_0_0/who_pays.
4. LaMattina J. Pharma Controls Clinical Trials Of Their Drugs. Is This Hazardous To Your Health? Forbes2013 [cited 2015 July 9, 2015]. Available from: http://www.forbes.com/sites/johnlamattina/2013/10/02/pharma-controls-cli....
5. Breivik H, Eisenberg E, O’Brien T. The individual and societal burden of chronic pain in Europe: the case for strategic prioritisation and action to improve knowledge and availability of appropriate care. BMC Public Health. 2013;13(1):1229.
6. Cevoli S, Cortelli P. Italian Law “measures to guarantee the access to palliative and pain treatments”: rebound on headaches’ management. Neurological Sciences. 2011;32(1):77-9.
7. Turk DC, Stanos SP, Palermo TM, Paice JA, Jamison RN, Gordon DB, et al. Interdisciplinary pain management. Glenview, IL: American Pain Society. 2010.
8. Rich JD, McKenzie M, Larney S, Wong JB, Tran L, Clarke J, et al. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. The Lancet. 2015.
9. Kouyoumdjian FG, McIsaac KE, Liauw J, Green S, Karachiwalla F, Siu W, et al. A systematic review of randomized controlled trials of interventions to improve the health of persons during imprisonment and in the year after release. American journal of public health. 2015;105(4).
Competing interests:
No competing interests
10 July 2015
Xiulu Ruan
Adjunct Clinical Associate Professor, Dept. of Anesthesiology
Alan D. Kaye, MD, PhD, Professor and Chairman, Dept. of Anesthesiology, LSU HSC, USA
Comment on: Researchers’ focus on drugs over other treatments ignores doctors’ and patients’ views
Comment: Researchers’ focus on drugs over other treatments ignores doctors’ and patients’ views
Xiulu Ruan, MD, Adjunct Clinical Associate Professor of Anesthesia (corresponding author)
Dept. of Anesthesiology, Louisiana State University Health Science Center
1542 Tulane Ave. New Orleans, LA 70112
Alan David Kaye, MD, Ph.D., Professor and Chairman of Anesthesia
Dept. of Anesthesiology, Louisiana State University Health Science Center
1542 Tulane Ave. New Orleans, LA 70112
We read with interest the article by Zosia Kmietowicz, “Researchers’ focus on drugs over other treatments ignores doctors’ and patients’ views” published on June 25, 2015 in BMJ (1). The author’s news report is based on a research study by Crowe and colleagues (2), published in “Research Involvement and Engagement”, where they found researchers choose to investigate the effect of drugs on a range of common conditions despite evidence that patients and clinicians would like to see a greater focus on non-drug treatment options, such as psychological therapies and educational interventions. Crowe et al. suggest that incentives may be needed in the research selection process to ensure that the concerns of patients and clinicians are not ignored.
Obviously, clinical research cannot be conducted without adequate monetary support. Funding for science has changed with the times. Historically, science has been largely supported through private patronage (e.g., the backing of a prominent person or family), church sponsorship, or simply paying for the research yourself (3). Nowadays, researchers are likely to be funded by a mix of grants from various government agencies, institutions, and foundations. Medical research however, is increasingly sponsored by private pharmaceutical companies. By 2000, almost 75% of U.S. clinical trials in medicine were paid for by private companies (3). By 2013, that number went up to 85- 90% (4). It is really not surprising that majority of clinical trials are therefore drug trials.
However, we believe there are other factors that may have played significant roles in contributing to this discrepancy, i.e., insurance company, healthcare policy makers, availability of resources, etc. For example, patients with uncontrolled chronic pain should have access to a full range of diagnostic and therapeutic modalities appropriate to their particular case, which may include pharmacological therapy, physiotherapy, clinical psychology, surgery, invasive techniques, occupational therapy and rehabilitation medicine (5). Current data suggests that access to integrated interdisciplinary pain management varies across Europe. In Norway, for example, patients now have a legal right to receive prioritized healthcare in multidisciplinary pain clinics, if their health-related quality of life is severely affected by the pain condition with efficacious and cost-effective treatment available. In Italy, a law passed in 2010 defined patients’ rights to access to multidisciplinary pain centers and promoted the development of regional and national networks of centers and care pathways (6). In contrast, patients in many countries have limited access to these services, and even where multidisciplinary pain centers do exist, there can be prolonged waiting times. In the US, many insurance policies provide limited coverage to physical therapies; however, most insurance carriers do not cover psychological services for patients with chronic pain. Despite the large and growing body of research supporting both the clinical effectiveness and cost-effectiveness of interdisciplinary care, there continues to be reluctance among third-party payers to cover the costs of all components of such care (7).
In an recent article by Milloy and Wood, titled “Withdrawal from methadone in US prisons: cruel and unusual?, published in May 2015 issue of “the Lancet”, they described, “In the USA, the so-called war on drugs has contributed to an era of mass incarceration…, The USA not only has the world’s highest rate of incarceration, but treats opioid-addicted prisoners very differently from those in prisons in other countries. Individuals with opioid dependence will often have their medically effective treatment such as methadone, the standard treatment for opioid dependence, discontinued on incarceration in most US correctional institutions. In a nationally representative survey of 500 US prisons, only 12% reported that individuals who enter custody on a methadone treatment program are maintained in this program during their time of incarceration. Furthermore, in the prisons that do not provide methadone, most institutions reported that they have no standard protocol to taper individuals off methadone. Therefore, the first days of their detention are spent in the pain and discomfort of physical withdrawal.”
Methadone maintenance is a highly effective treatment for opioid addiction and has been included in WHO’s Model List of Essential Medicines since 2005. Eleven randomized controlled trials have assessed the efficacy of methadone maintenance in treating opioid dependence as compared with placebo or non-pharmacological therapy and showed the effectiveness of methadone maintenance therapy in reducing illicit opioid use and increasing retention in treatment (8). In prisons, where many individuals are addicted to opioids, WHO recommends the provision of buprenorphine or methadone maintenance as a best practice for opioid agonist therapy and opioid withdrawal. Accordingly, many nations, including Iran, Australia, Canada, and most of the European Union, have made methadone maintenance therapy available in correctional facilities (8).
By contrast, in most of the USA, the standard procedure is to discontinue methadone treatment for prisoners. Further, this is in the context of a plethora of literature indicating so, including reduced recidivism (9). This underscores how challenged the concept of continued methadone for incarcerated prisoners remains to this date, despite an abundance of literature supporting it in this population.
To conclude, while leadership and incentives may be important to facilitate research to reflect the priorities of patients and clinicians, healthcare policy makers are the final and most significant dictating factors in allowing the translation and implementation of solid research evidence into better patient care. Cooperation of all stakeholders will best serve the public as we move forward in these ever changing and most challenging times.
References:
1. Kmietowicz Z. Researchers’ focus on drugs over other treatments ignores doctors’ and patients’ views. 2015.
2. Crowe S, Fenton M, Hall M, Cowan K, Chalmers I. Patients’, clinicians’ and the research communities’ priorities for treatment research: there is an important mismatch. Research Involvement and Engagement. 2015;1(1):2.
3. Paleontology UoCMo. Understanding Science 2015 [cited 2015 July 9, 2015]. Available from: http://undsci.berkeley.edu/article/0_0_0/who_pays.
4. LaMattina J. Pharma Controls Clinical Trials Of Their Drugs. Is This Hazardous To Your Health? Forbes2013 [cited 2015 July 9, 2015]. Available from: http://www.forbes.com/sites/johnlamattina/2013/10/02/pharma-controls-cli....
5. Breivik H, Eisenberg E, O’Brien T. The individual and societal burden of chronic pain in Europe: the case for strategic prioritisation and action to improve knowledge and availability of appropriate care. BMC Public Health. 2013;13(1):1229.
6. Cevoli S, Cortelli P. Italian Law “measures to guarantee the access to palliative and pain treatments”: rebound on headaches’ management. Neurological Sciences. 2011;32(1):77-9.
7. Turk DC, Stanos SP, Palermo TM, Paice JA, Jamison RN, Gordon DB, et al. Interdisciplinary pain management. Glenview, IL: American Pain Society. 2010.
8. Rich JD, McKenzie M, Larney S, Wong JB, Tran L, Clarke J, et al. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. The Lancet. 2015.
9. Kouyoumdjian FG, McIsaac KE, Liauw J, Green S, Karachiwalla F, Siu W, et al. A systematic review of randomized controlled trials of interventions to improve the health of persons during imprisonment and in the year after release. American journal of public health. 2015;105(4).
Competing interests: No competing interests