Tuesday, August 5, 2008

Consumer Reports Sept 08: Meds versus Machine

September 2008 Consumer Reports finds those sound machines are a great alternative to sleep medication.

Big Pharma has been making plenty of money by pushing pills for sleep. Partly this is because we (in general) have gotten into the habit of thinking that we need to run to the physician every time we have some problem. People describe this as the “medicalization” of problems. Take a problem, figure out how it could be a medical problem. Define it that way for others. Provide the medical-style solution (typically pills or surgery). Problem Solved.

So, we all start believing that a problem like insomnia is somehow fundamentally the same as cystic fibrosis. Give it a diagnosis. Give it a diagnosis code. Allow a physician to be “reimbursed” for providing “diagnosis” and “treatment.”

People, let’s get real. If you have sleep problems, you know you have sleep problems. You don’t need a “diagnosis.” Does it make you feel better if a physician tells you that you can’t sleep?”
So, you come home and tell your family:
“Oh, now I know what my problem is. The doctor said I have insomnia 780.52.”
“What is 780.52.”
“It’s the number for my medical condition. It also coincidentally is the cost of getting diagnosed and starting treatment. Thank goodness I have that nice, fat health insurance package.”

[Now, we are all starting to see how we spend so much and get so little for our health care dollar.]

So, Consumer Reports decides to ask a group of everyday people about sleep problems. Things don’t look so good for Big Pharma, because unlike academic researchers, the universities, psychiatrists, other physicians, medical organizations, advocacy organizations, the prominent peer-reviewed journals who accept advertising, the FDA, and other entities, Consumer Reports cannot be “supported” through loads of cash. No conflict of interest.

For those who don’t know, Consumer Reports is the main publication from Consumer’s Union, a magazine-subscription-supported group who evaluate everyday products and services that everyday people are concerned with. Such as sleeping pills, since many of us have problems with sleep. To stay independent, when they test something, they usually go out and buy their own. If they test five different models of toasters, they just send staff out to the store and buy these. Then they run the toasters through tests to see how well the toasters perform. Their criteria are usually the things we everyday people are concerned about: does it burn the toast? Is an inexpensive model as good as an expensive model?

Increasingly, Consumer Reports has branched out from evaluating toasters and lawn mowers. They have gotten more into health care. I think this is awesome.

In April, they conducted a phone interview of almost 1,500 everyday adults in the U.S. to ask about sleep problems, and what people do to address sleep problems, and how well that attempt worked. One weakness of the Consumer Reports strategy is that I can’t readily find details, so I cannot evaluate various potential limits and biases of this study.

Nonetheless, they found that 20% of us are taking these sleeping pills, prescription or OTC, at least once a week to sleep better.

Wow. One in five of us.

The U.S. has 300 million people. One-fourth are under 18. That leaves a guesstimate of 225 million adults. Let’s say the survey failed to be representative of half of that, and that none of that half of us take sleeping pills. That leaves 20% of 110 million people. So, conservatively, well over 20 million people each week are taking at least one pill for sleep. Now, some of them are only paying a nickel for a Benadryl. But some are paying a lot more – for prescription pills. So, there is a lot of money to be made from 20 million or more people per week. A million dollar industry? It sounds like a million dollars-per-week industry.

But, seriously, folks. We know why we can’t sleep. We watch TV too late. We don’t take time to calm down and relax. We are over-committed. We don’t manage our time well. We drink something with caffeine too late in the day. We get allured into surfing the internet, or talking on the phone, too late into the night. We never get active enough in the daytime to be tired enough to really fall asleep at night. We worry a lot – we worry about money problems, job problems, aches and pains, the leaky roof, the noise in our car, about someone breaking into our home, etc.

“Therapy” for sleep involves assessing and addressing these various problems. Look at that list. You are probably on there. Therapy for sleep is obviously going to be individualized, not one-size-fits-all. For me to address my worries, I will need a different conversation to help me discover these, and address these, than you will need for your worries.

[Oh, excuse me – let’s just re-label the worries as “racing thoughts,” and diagnose ourselves with the bipolar 296.80. Then we can simply be cured with Zyprexa.]

You might need to switch to decaf. Or find a non-caffeinated tea. Sure, it will not be as satisfying, but it is the trade-off for solving the sleep problem. Oh, excuse me – I meant to say “curing” your “insomnia 780.52.”

Any of these methods will take work and effort. The pill companies are gonna try to convince you that it is all much easier – just take a pill and you are done.

The advertisements are sooo peaceful!

You might be able to get it covered by your insurance, since you have a legitimate medical disorder: “insomnia 780.52.”

What worked for the people surveyed by Consumer Reports?
For those using prescription medication, 75% said the pills worked “most nights.”
Listen to this: what was in second place?

A sound machine. 70% said this worked “most nights.”

What else worked? OTC meds (57%), making the sleep schedule more routine (50%), and also practicing “muscle relaxation (40%).”

So, why not go with the pill? It is the clear winner. Meds versus therapy, and meds won.

Well, what are the trade-offs?

This problem is so big, I can’t begin to get through it all at once. Sleep-driving. Drug dependence. Rebound insomnia. Tolerance. Oh, don’t worry about these – as Big Pharma says- only use these pills OCCASIONALLY. In other words, people, you are still left with the problem.

The problems with sleep pills rose to a level that the FDA broadcast a special warning last year about them:

The Consumer Reports survey said that for people using pills, half were using strong pills not meant for sleep but meant for other problems: Xanax (anxiety), Darvocet (pain), Neurontin (seizures). Wow. Fifty percent paying big bucks and facing big side effects.

Not to mention the fact that with the pill, you are moving one more step down the path to believing that all of our problems are actually “medical disorders” that need to be treated by a physician, and by a pill or surgery. You are losing the belief that you can use your own abilities, and help from others, to figure out your own problems and solve them. To determine when some are and some are not medical problems.

Insomnia due to some thyroid problem = medical problem. Insomnia because you are wondering if checks are gonna bounce = you need financial therapy. See the difference?

Your physician may or may not. What we do know is that your physician does not have time to diagnose the root cause of your insomnia, and is probably not very good at providing counseling to help you manage your money, and ALSO we know the physician was just visited by his or her best friend, the drug rep. The drug rep just provided a free-lunch talk on the epidemiology, diagnosis, treatment, and third-party reimbursement of insomnia 780.52. Plus, the drug rep left some samples. Mmmm.

Now – how easy is it for the physician to provide you a solution? They just hand you a sample and send you on your way. Oh, and the side-effects issue? Well, uh, that’s up to the pharmacist. Besides, you weren’t gonna use alcohol at the same time, anyway, right?

If you live in a dangerous neighborhood, and can’t sleep because you worry about someone breaking in, the pills will not make the bad guys stay away!! Have you made your home relatively safe? Yes or no. If not, do it, to the best you can. Once it is reasonably safe, then “rest-assured.” We can never be safe. But you can do only what you can do. How safe is it to be intoxicated into somnolence when that burglar or rapist does break in?

So, in Consumer Reports, meds barely squeaked out a victory over behavioral strategies. There is a great body of literature, more “scientific” – ruling out more alternative hypotheses, etc. – defining behavioral interventions as the first choice for most sleep problems. And these are very effective. Plus, with GOOD side effects versus BAD side effects. For example, if you learn Jacobian progressive muscle relaxation (Gurgle that to learn more) to help you sleep, you can then use it to help you with test anxiety, stage fright, etc.

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