Dose Encounters

When, on February 6, New York’s Office of Chief Medical Examiner finally announced that “Mr. Heath Ledger died as the result of acute intoxication by the combined effects of oxycodone, hydrocodone, diazepam, temazepam, alprazolam, and doxylamine . . . [and] that the manner of death is an accident, resulting from the abuse of prescription medi­cations,” the world breathed a collective sigh of relief. Not only the actor’s family and close friends but the public, too, who, despite gobbling up an endless supply of salacious details surrounding the death, had hoped for an explanation that would be less unseemly than circumstances suggested. “Today’s results put an end to speculation,” Ledger’s father wrote in a statement. “While no medi­cations were taken in excess, we learned today the combination of doctor-prescribed drugs proved lethal for our boy.”

Yes, indeed! For what kind of a doctor prescribes this pharmacological Long Island iced tea to any patient, let alone an otherwise healthy man of twenty-eight? One of the many possible scenarios is that Ledger was being treated for insomnia. Even so, the cocktail—which included two sedatives (Valium and Xanax), two sleep aids (Restoril and Unisom), and two potent painkillers (Oxycontin and Vicodin) normally reserved for postoperative cases and cancer treatment—was dangerously excessive. Five of the six drugs are controlled substances. And yet as far as we know, Ledger obtained prescriptions for each of them legally and without complications.

Barely a week later, a twenty-seven-year-old man by the name of Steve Kazmierczak walked silently into a classroom on the suburban Chicago campus of Northern Illinois University and opened fire, killing five students. He wounded sixteen more before putting a gun to his own head. One headline read: “Gunman Stopped Medication.” His psychiatrist had prescribed him the holy trinity of Ambien (sleep aid), Xanax (antianxiety), and Prozac (antidepressant). According to Dr. Nada Stotland, professor of psychiatry at Rush Medical College in Chicago and president elect of the American Psychiatric Association, “It’s not terribly unusual to prescribe all three.” Yet the combination had such a strong effect on Kazmierczak’s psyche that an otherwise “nice,” “caring,” and “responsible” young man went on a killing spree. Apparently, everyone decided to take a break from reading the day in 2002 when author and Brown University psychiatrist Dr. Peter Kramer wrote in the New York Times that “Prozac was no more, and perhaps less, effective in treating major depression than prior medications. . . . I argued that the theories of brain functioning that led to the development of Prozac must be wrong or incomplete.” Tell that to TV and those ads that hypnotize the consumer-patient directly: “You just shouldn’t have to feel this way anymore” (Zoloft); “Lexapro improves symptoms of depression.” And the clincher: “Feeling unusually sad or irritable? Find it hard to concentrate? Lose your appetite? Lack energy? Or having trouble feeling pleasure? . . . To help bring serotonin levels closer to normal, the medicine doctors now prescribe most often is Prozac.” For all we know, like 35 percent of American adults, according to a 2003 survey on the health effects of direct-to-consumer drug advertising, Kazmierczak walked into his doctor’s office on a day he felt a little worse for wear and requested a prescription for the fix-all himself.

Pharmaceutical companies are among the biggest spenders on advertising in the United States. It’s banned nearly everywhere else in the world; only in New Zealand and the US are drugmakers legally permitted to advertise directly to the consumer. Contrary to any expectations one might have about the efficacy and purity of leviathan bureaucratic “regulatory” bodies like the Food and Drug Administration (which, incidentally, controls everything from eyelash dye to nutritional labels, from semen donation to the sanitary requirements of escargot), the agency does not preapprove advertisements, but monitors them instead once they are in print or on air. A stern letter and, in rare cases, a sanction may follow if the information disseminated appears to be inaccurate. By then, millions of dollars have been spent and made, years have gone by, and thousands of prescriptions have been filled. More shocking: The same principle applies to new medications coming on to the market. Although approval is required, the process is not that rigorous and is not strictly enforced. A company must provide studies suggesting the efficacy of its drug, but no one prevents these studies from being manipulated to show favorable results. In most cases, Melody Petersen writes, “a company must show only that its product can outperform a sugar pill to some small degree. That is, it must show that its medicine is better than nothing.”

Usually, it takes lengthy litigation to bring a drugmaker to its knees (and thereby get the offending drug off shelves). For example, in May 2004 Warner Lambert (a division of Pfizer) paid a $430 million fine to resolve criminal and civil charges that it had marketed the epilepsy drug Neurontin for conditions for which it had not been approved. According to Petersen, “the money helped repay taxpayers for part of what they had spent on experimental prescriptions for Neurontin written by doctors for patients in the government’s Medicaid program.” She estimates that while Neurontin was on the market illegally, it made Pfizer ten billion dollars in revenue.

For Petersen, a former New York Times reporter and the author of Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs (Farrar, Straus & Giroux/Sarah Crichton, $26), this has become a common principle of an American medical system that is rapidly failing at the one thing it was designed to do: care for the patient. We are “a grossly over-prescribed nation,” she quotes Dr. Arthur Relman, the former editor of the New England Journal of Medicine and professor emeritus at Harvard Medical School, as saying. Among Petersen’s most startling figures: More than one hundred thousand people die annually as a direct result of their prescriptions. From children on Ritalin, antidepressants, and human growth hormone to seniors on a daily pharmacological regimen two to three times what might be necessary (arthritis begets pain relief begets high blood pressure begets hypertension treatment and a whole new set of adverse effects), the system has derailed.

“The drug companies’ chain of influence is so complete that there are few people left to look objectively at the effects of their products on the nation’s health or at the consequences of their power for society,” Petersen writes. And where is the industry’s power concentrated? Washington, DC. According to a study released by the Center for Public Integrity called “Second to None,” the drug lobby spent more than eight hundred million dollars between 1998 and 2005, making it the largest lobby in the capital. At a certain point, there were as many as two drug lobbyists for every congressperson.

We learn from Our Daily Meds that Big Pharma owns the scientists, the physicians, the medical journals they write in, the medical schools they study in, the celebrities shilling for pills on prime-time TV, parents, and, in some cases, God (Klonopin once came in a quick-dissolving form that pop theologian and best-selling author Dr. Paul Meier likened to the communion wafer).

In its best moments, Our Daily Meds reads like a wild thriller. Petersen’s breathless prose translates well to the devious characters and machinations of Big Pharma. Drugs and their terrifyingly brilliant marketing schemes, rather than the white collars who shepherd them on their long journey out of the labsor, more accurately, corporate conference rooms—and onto our shelves, are the protagonists. A seemingly endless number of oddly evocative names parades before us: There’s Detrol (for the “over­active bladder,” butoops!—it also causes dementia), Advair (the “new” old asthma drug), Ambien (it works “right away” but you’ll sleep-crash your way to a fatal car accident; you’ve got a hundred-pill prescription, but don’t take it for more than ten days!), Adderall (“the trusted solution for ADHD,” but it’ll turn your kids into zombies while stunting their growth), Viagra and Levitra (“Strong. Lasting. When He Wants It”), Crestor (lowers your cholesterol but may also liquefy your muscles), Neurontin (hardly works for epilepsy, so let’s try it for everything else! Neurotin for Everything!), Oxycontin (manage your pain, grow an addiction!) . . .

Where Petersen falls into a trap, it’s one Big Pharma critics have before: exasperation, indignation, and a penchant for the human-interest story. A little too frequently, it seems, she takes a break from the facts and dives into the American heartland for further emotional proof that her bewilderingly detailed 335-page indictment (not counting nearly 70 pages of notes) of the industry hardly requires. But one is willing to overlook the occasionally florid prose in favor of the mind-boggling facts her exhaustive research has turned up.

Jessica Joffe is a writer based in New York.