Is Trustworthiness Too Much to Ask?

By SAM URETSKY

Some stuff just feels wrong. Some people are ethical, honest, trustworthy, and others not so much. According to a Gallop survey (2019), nurses are the most trustworthy people, and members of Congress the least. Automobile salespeople rank just above members of Congress for trustworthiness, and business executives just a notch or two higher than telemarketers. Even so, it just feels as if members of the clergy should rank higher than accountants – but they don’t, and business executives should sort of depend on the nature of of their business. The most trusted occupations all deal with health and medicine, so that a medical researcher, or corporate executive at a major pharma corporation should be fairly honest. Should be. Aren’t, at least not always.

One of the reports from Kaiser Health News is headlined “County By County, Researchers Link Opioid Deaths To Drugmakers’ Marketing.” The review found an association between expense account lunches, opioid prescriptions written, and deaths due to drug overdoses. These were casual lunches at local restaurants, but they were enough to influence the prescribing habits of completely ethical prescribers, with tragic consequences. Another technique used to influence prescribing practices was to tweak the published studies of drug efficacy. This technique relies on the way most professionals read published studies.

A 2012 review in the Journal of Research in Medical Sciences titled “Fraud and deceit in medical research” discussed why and how researchers might distort the results of their studies. In theory, medical progress is based on well controlled studies, carefully written and reviewed by experts (peer review), then published in carefully edited medical journals. The plan doesn’t always work that way. Even the best journals let some low quality studies slip in. Other journals can be fairly careless.

Medical research papers normally follow a standard format. As described by the University of Minnesota Libraries, the parts of a study are:

1. Title Page – what’s in the paper, and who wrote it

2. Abstract: a synopsis of the paper

3. Introduction: Gives some history of the subject

4. Methods: “how did you do the study.”

5. Results: “what did you find” —

6. Discussion: Place for interpreting the results

7. Conclusions: What do you think the study showed

8. Acknowledgments: who helped

9. References: books and papers that were used

There are a lot of different reasons for publishing a false or misleading study, and a lot of ways to do it. In some cases, researchers may take shortcuts because the phrase “publish or perish” has real consequences. In other cases though, studies may have been designed to improve sales of the sponsor’s product, either by designing a protocol to guarantee that the sponsor’s product will be favored, or by leaving out important information from the final report. In some cases, drugs are compared with inequivalent doses – for example a twice a day drug might be compared with a once a day drug – but they’re both given only once daily. Then, the once-a-day drug will be more effective. In other cases, vital information can be omitted – some of the studies of oxycodone simply said “rate of addiction was low”.

And what matters is that hardly anybody really reads the published study. Most professionals will read the abstract and then jump to the conclusion, and assume that they’ve learned the results of the study. Even well intentioned professionals will skim over the materials and methods section, making it easy to get fooled.

Given time these fakes and lies will be uncovered and the article will be retracted. This is about as effective as a judge telling a jury to ignore something they just heard. The retraction will be noted in the web site retracionwatch.com, but by the time it’s noted, physicians may have changed the way they practice, and forgotten why.

There are a number of companies and publications that do careful reviews of published studies and would guard against being fooled by dishonest publications. Wider distribution of some of these publications and services might have reduced the misprescribing of opioids and moderated the current crisis. There are several services of this type, including The Medical Letter and Up to Date. What’s notable is that Canada supports the Therapeutics Initiative, which describes itself, “The TI aims to reduce bias as much as possible and operates as an independent organization, separate from government, pharmaceutical industry and other vested interest groups. Many groups who assess the benefits and harms of drugs accept the presence of financial or professional conflicts of interest. We believe that high quality independent assessments of evidence on drug therapy must be free from conflicts of interest and those assessments should provide balance to the many sponsored information sources clinicians are exposed to..”

The TI is free, although donations are requested,

Although Canada has its own review service it also provides access to the Cochrane Library, an extensive multinational collection of intensive literature reviews. These are national licenses that include most European nations, as well as African, Australia, New Zealand and South America. What’s missing is the United States,

Having access to accurate clinical information wouldn’t have caused a major reduction in the pattern of misprescribing of opiates, or any other class of drugs – but it would help, and just knowing that somebody is reading a study as it should be read might even encourage honesty.

Sam Uretsky is a writer and pharmacist living in Louisville, Ky. Email sdu01@outlook.com.

From The Progressive Populist, October 15, 2019

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