Show 1443: Rethinking Medications: Uncovering the Truth About Common Drugs

Joe

00:00-00:01

I’m Joe Graedon.

Terry

00:01-00:05

And I’m Terry Graedon. Welcome to this podcast of the People’s Pharmacy.

Joe

00:06-00:27

You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Americans spend more on drugs and have less to show for than people in other countries. Today, rethinking medications. This is the People’s Pharmacy with Terry and Joe Graedon.

Terry

00:34-00:41

The FDA used to be the envy of the world. Has it been captured by the pharmaceutical industry it’s supposed to regulate?

Joe

00:41-00:52

You’ve heard of Ozempic and Wegovy. They both contain semaglutide as the active ingredient. How could they have dramatically different rates of side effects?

Terry

00:52-00:59

Are you fed up with all the prescription drug commercials on TV? What about the high price of many prescriptions?

Joe

00:59-01:15

Coming up on the People’s Pharmacy, uncovering the truth about common drugs.

Terry

01:14-02:31

In the People’s Pharmacy Health Headlines, lowering sodium intake is good for cardiovascular health, but increasing potassium intake may be just as important, if not more so. A Danish study of twelve hundred patients with implanted cardioverter defibrillators, or ICDs, compared usual care to a strategy designed to get potassium levels into the upper end of the normal range. All of these study participants were at high risk of atrial fibrillation and all started with potassium levels at the low end of the normal range. The outcomes of the study were ventricular tachycardia, which is a dangerous heart rhythm, or having the ICD kick in appropriately. In addition, the investigators looked at hospitalization for arrhythmias. The patients assigned to the high-potassium group were prescribed potassium-sparing blood pressure medicines, such as ACE inhibitors. They were encouraged to follow a diet rich in potassium, including foods such as cabbage, beets, white beans, bananas, spinach, nuts, and fish. If those steps were unsuccessful at nudging potassium into the high normal range, the researchers prescribed potassium supplements.

Joe

02:29-03:12

In this vulnerable population, targeting high normal potassium was helpful. They had significantly fewer episodes of ventricular tachycardia or hospitalization for arrhythmia, and their ICDs activated less frequently. A hundred and thirty-six of them experienced such an event, a rate of 7.3 per 100 person-years. In the usual care group, 175 volunteers had one of these dangerous episodes, a rate of 9.6 per 100 person-years. The patients in the high normal potassium group were also less likely to die during the three years of the study.

Terry

03:11-04:10

The VITAL trial is a randomized controlled study of vitamin D and omega-3 fatty acid supplementation. The initial findings were that neither supplement reduced heart attacks or cancer in otherwise healthy middle-aged people. After four years, however, people taking 2,000 international units daily of vitamin D3 had longer telomeres than those taking placebo. Telomere length is a powerful measurement of aging. Telomeres are located at the tips of chromosomes and appear to protect them. As a result, shorter telomeres are associated with chronic diseases such as cancer and cardiovascular disease. Longer telomeres are a biomarker for slower aging. The authors conclude that vitamin D3 supplementation reduced telomere attrition and preserved telomere length, supporting an anti-cellular aging effect of vitamin D.

Joe

04:11-05:17

Scientists have known for years that people with high blood pressure can benefit from drinking beet juice. British scientists have now done a more thorough study of this effect. They compared the reaction of 39 people under 30 to that of 36 volunteers in their 60s or older. Each group took nitrate-rich beet juice every day for two weeks or a placebo juice that had the nitrate removed. After a two-week washout period, they took the other treatment for two weeks. During this time, the researchers monitored participants’ blood pressure and their oral microbiome. In older volunteers, both oral microbiome and blood pressure improved with beet juice. A healthier mix of microbes in the mouth helps metabolize the nitrates in beet juice into nitric oxide that relaxes blood vessels. The investigators point out that beet juice is not a substitute for prescription blood pressure medication, but it can help. People who don’t like beets might consider other nitrate-rich vegetables such as spinach, celery, and kale.

Terry

05:17-06:16

For decades, cardiologists prescribed beta-blocker heart drugs to almost everyone who had a heart attack. A new study published in the New England Journal of Medicine calls that practice into question. The randomized controlled reboot trial assigned over 8,000 patients to receive either a placebo or the beta-blocker bisoprolol. After nearly four years of follow-up, there was no difference in outcomes. The new consensus is that many heart attack patients with good heart function don’t need beta blockers. Those with poor ejection fractions may still benefit. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon.

Joe

06:17-06:29

And I’m Joe Graedon. Americans love pills. We take more medicines, spend far more on them, and see way more prescription drug ads than anyone else in the world.

Terry

06:29-06:43

The Food and Drug Administration was once regarded as the best regulatory agency. Over the past decade, though, standards for drug approval have changed. Are Americans more vulnerable now than they were before?

Joe

06:43-07:19

To help us tackle questions about drug safety and effectiveness, we turn to Dr. Jerry Avorn. He is a professor of medicine at Harvard Medical School and a senior internist in Mass General Brigham Healthcare System. He built a leading research center at Harvard to study medication use, outcomes, costs, and policies. Dr. Avorn is the author of “Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs.” His new book is “Rethinking Medications: Truth, Power, and the Drugs You Take.”

Terry

07:19-07:23

Welcome back to the People’s Pharmacy, Dr. Jerry Avorn.

Dr. Jerry Avorn

07:24-07:25

It’s good to be back.

Joe

07:26-08:00

Dr. Avorn, during your really long and illustrious career at Harvard Medical School, you have focused so much of your research on the benefits and risks of pharmaceuticals. I would have to say you are probably the country’s most respected pharmacoepidemiologist, and we have been tracking your work for decades. We’re honored, honored to have you as a guest today on the People’s Pharmacy. So thank you so much for writing Rethinking Medications and joining us today. It’s a pleasure to be with you.

Terry

08:01-08:11

Dr. Avorn, I’m wondering, how has the pharmaceutical industry changed since you started studying medications that Americans are taking?

Dr. Jerry Avorn

08:11-08:35

Well, it has become even bigger business than it was, which is something we need to all be kind of cognizant of. But also the science has gotten more and more impressive, both within the industry and also within medical schools and academic medical centers where we’re just really discovering things and putting them into practice in ways that would have been unthinkable even 30 years ago.

Joe

08:36-08:46

What about the FDA, Dr. Avorn? I mean, it seems as if the FDA has also changed over the last couple of decades.

Dr. Jerry Avorn

08:46-10:10

Yeah, and that’s I think a less happy story, in the sense that uh a lot of the mischief began with the best of intentions back in the nineties at the height of the AIDS epidemic and there was concern that FDA was being so careful about reviewing drugs that maybe it was taking longer than it should. And the idea came up of let’s have a system of accelerated approval in which even if a drug hasn’t really been shown in a clinical study to benefit patients, if it looks promising, let’s approve it and then have the company do follow up studies so we know what we’re dealing with.

That was a sensible idea back in the early nineties, because we did have no good treatments for AIDS at that point, and we did want to get anything that looked promising out there. But unfortunately, that accelerated approval program has become a loophole that has been widened and widened well beyond what anybody ever intended. And we now have drugs, you know, like for ALS or muscular dystrophy or other conditions, which are approved on the scantiest of evidence. And then the companies don’t quite get around to always doing the follow-up studies that they promised to do. And we have a lot of medications that actually should not have been approved hanging around on the market and costing money and presenting risks and not doing any good for patients.

Joe

10:10-11:31

Well Dr. Avorn, you brought up a really, uh hot topic for us. Because it used to be that the FDA was very clear and it said, we will not approve any medication unless it’s proven safe and effective. And I think the FDA’s definition of safe and effective is obviously quite different from what the average citizen would define as safe and effective. And all you have to do is turn on the television and watch one of the uh commercials for for pharmaceuticals where they say this drug can cause heart attacks and strokes and severe infections and cancer, and even death, and uh uh it’s like, well, how could that medicine be considered safe if those are potential side effects. And then when it comes to the effectiveness side, we have drugs that are barely better than placebo, as you’ve sort of alluded to. And in particular, I’m thinking of the FDA’s approval of the most recent Alzheimer’s drugs that uh don’t actually do very much. So tell me about safe and effective and what that means to you versus what it means to the FDA versus what it means to the average citizen.

Dr. Jerry Avorn

11:31-13:51

Boy, is that a good question? Yes. Let me say something encouraging for starters, and that is all of those adverse effects that we see rattled off on the TV commercials that you can’t possibly avoid if you want to watch the evening news, um, are there because they are required to be there by the FDA. But you know, if you were to look at the adverse effects of, you know, aspirin or Tylenol, uh it would be a pretty scary list as well. What we have relied on the FDA for is to say, in effect, over the years: Every drug can cause side effects, some of which are very scary, but we want some assurance that it’s been looked at carefully. And that the good that the drug does is overwhelmingly better and more common and more useful than the rare side effects that it can cause. Because there is no drug, as you both know so well. that doesn’t have side effects. We just want that balancing to be done by the FDA and then by the prescribing doctor or other healthcare professional. That’s the ideal.

Where things have really gone off the rails is with FDA paying less attention to the real does it help patients question And then frankly, as you mentioned for the Alzheimer’s drug, the worst of which was this drug called Aduhelm that did not benefit patients at all. Was approved kind of over the objection of the outside advisors and the FDA’s own staff, and turns out to actually have some substantial side effects And it was initially priced, uh, as you know, at $56,000 a year for getting an infusion intravenously every other week. to achieve no important clinical benefit. You know, that was really kind of the low point of of FDA’s recent history and it got pulled off the market a couple of years ago because it was such a stupid drug. But so I think where FDA has gone astray is that it has really lost its uh value system or a sense of balance. and has really lowered the standards of, okay, if you can make a lab test look a little better, then we’ll let you have approval. And even if you’ve not been able to show benefit to patients. And that that’s really not what the FDA was designed to do in the modern era

Terry

13:49-13:59

Oh well Dr. Avorn, how did the FDA get to the point where it was willing to lower its standards so much? You do write about that in “Rethinking Medications.”

Dr. Jerry Avorn

13:59-15:02

Well, you know, as as you both know so well, this is a half a trillion dollar a year industry in the US alone, probably more than that by now. And that brings with it an enormous amount of political pressure. And it used to be that the FDA would kind of rise above political pressure and just do what the science said. But over a number of years, the pharmaceutical industry became the most powerful and richest lobbying entity in Washington, and they’ve got more lobbyists than there are people in Congress. And there’s a lot of pressure both on Congress people from both sides of the aisle and on the administration under Democrat and Republican presidents. To, you know, have the FDA kind of go easy on industry and just approve stuff that hasn’t really been shown to pass muster. And the more dollars go into medications and the bigger business it is, the more firepower there is behind that political pressure. And the political pressure has been sort of winning out over the science more and more in recent years.

Joe

15:02-15:39

Dr. Avorn, when you started your career and when we got started, there were no prescription drug ads on TV. You know, there were you know Anacin ads and Alka-Seltzer ads, but there there weren’t ads for Jardiance. And for um oh you go down the list, there’s so many that it’s almost takes your breath away these days and they come on every other every other commercial. Can we get your perspective on the direct-to-consumer prescription drug advertising that’s everywhere?

Dr. Jerry Avorn

15:40-18:03

Yes. As your listeners will know, and as you both know very well, we are the only country on earth that allows drug companies to advertise prescription drugs direct to consumers. And every other country, with the one exception of New Zealand, which is kind of an asterisk, but every other kind of wealthy industrialized country that we often compare ourselves to has said, no, these are too complicated issues. They are not something you can boil down into a 60-second commercial with people dancing around and singing songs and having the adverse effects flash by quickly on the screen. Everybody knew that this is not something you can condense into a quickie commercial and then get the patient to go to their doctor and say, gimme this. And actually the industry was pretty the drug industry was pretty okay with that for many, many years because ads to consumers, especially the kind that are on prime time, are very, very expensive to buy airtime. and they’re expensive to produce. And as long as uh the industry felt it was okay not competing with shampoos or cars or toothpaste or any of the other things you see ads for, they were willing to go along with that ban.

And then in the 90s, with the rise of managed care and health maintenance organizations that said, no, this drug is not on our formulary. It’s way overpriced. It’s not particularly good. We’re not going to cover it. The industry said, hey, wait a minute, we gotta try to get around that prohibition. And they said to themselves, we can make every patient into a potential sales rep. And by, you know, having releasing our our our self-imposed w unwillingness to have drug ads. Let’s have the FDA say it’s okay because we need to get to the patients to make them into agents of sales to go to the doctor and say, I want Ozempic because I saw a commercial for it. And so in 1997, for the first time ever, the FDA said, okay, it’s all right for there to be direct-to-consumer drug ads, again, alone in the entire world. I don’t think we can say that this has somehow benefited the public health or made prescribing of medications better or safer or more effective, but it is something which billions of dollars get spent on. by the companies. And of course those billions of dollars just get added on to the drug price.

Terry

18:04-18:21

You’re listening to Dr. Jerry Avorn. He’s a professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham Healthcare System. Doctor Avorn is the author of Rethinking Medications Truth, Power, and the Drugs You Take.

Joe

18:21-18:28

After the break, has the FDA been captured by the industry it’s supposed to regulate?

Joe

21:03-21:07

Welcome back to the People’s Pharmacy. I’m Joe Graedon.

Terry

21:06-21:08

And I’m Terry Graedon.

Joe

21:08-21:20

Today we are putting the FDA and the pharmaceutical industry under a microscope. Should we be rethinking how our medications are regulated, priced, and advertised?

Terry

21:20-21:52

Our guest is Dr. Jerry Avorn. A professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham Healthcare System, he built a leading research center at Harvard to study medication use, outcomes, costs, and policies. Dr. Avorn is the author of Powerful Medicines, The Benefits, Risks, and Costs of Prescription Drugs. His most recent book is Rethinking Medications: Truth, Power, and the Drugs You Take.

Joe

21:52-23:00

Dr. Avorn, the cost of prescription drugs has skyrocketed, and in particular for something called orphan drugs. Now, I have to be honest with you, I visited Dr. Marion Finkel at the FDA shortly after the Orphan Drug Act was passed, because she had led the Committee on Drugs of what were called limited commercial value. I wonder what happened to those ideas about kind of facilitating the development of medications for rare conditions, because the FDA thought, you know, no drug company is going to make money from medications for these so-called orphan drugs. That is not the way it turned out, and I Fear that Marion is turning over in her grave. Your thoughts on drug prices for orphan drugs and drugs in general.

Dr. Jerry Avorn

22:59-25:52

Well, as you both know, Americans spend twice per capita what citizens of other wealthy countries spend on medications. Whether it’s uh Canada or England or um Japan, Australia, all of Europe, um, they pay literally half of what we do for the same drugs made by the same companies in the same factories. And orphan drugs are one important example, but it really is across the board. Even Ozempic, which we’ve talked about in the last segment, is a drug which in the uh in most of Europe costs half of what it costs Americans. Why is that? It’s because America is the only country on earth that says to the drug companies, set your price at any amount you want, and that’ll be the price. Not only is that weird, it’s also not the way we pay for anything else in our economy. It’s certainly not the way the federal government pays for anything. They don’t um you know, go to a um airplane manufacturer and say, charge whatever you want uh for this new fighter plane and we’ll pay whatever you ask. It’s up to you. That’s a crazy way to do business. For people who are fans of a functioning marketplace, you know, it’s not a marketplace. It’s just this weird arrangement that is only there because we have legislated it into being.

And in fact, when the Medicare program started paying for drugs in the early 2000s, the guy that shepherded the program through Congress. Passed a law that said that no company can be negotiated with over the price of its drugs in the Medicare program. And then he promptly left Congress and took a job at a million bucks a year to head the pharmaceutical lobbying group. So he was well rewarded for that legislation. And we then are left with this crazy system where, you know, there was there was a one drug company CEO when he raised the price of a drug by thousands of percent when he bought the rights to it, and they said. How can you possibly do that? And his answer was, because I can. And sadly, although that was more crude and he ended up doing some jail time for some fraudulent activity in other ways. He was he was ruggedly honest. Yeah, because they can.

So when you have companies that understandably want to please their shareholders and they’re allowed to charge anything they want, why wouldn’t they? And and we’ve in our group at Harvard have talked to folks from other countries where they have a much more thoughtful process for looking at what a medication is worth. Drug companies ought to earn handsome profits on the work that they do. And if they discover a new drug, they ought to be richly rewarded for it. But if they’re just taking a same old, same old little modification and they say it’s a new molecule and we want our own patent and then charge whatever they damn please, that that really shouldn’t be allowed, as it isn’t most everywhere on earth.

Joe

25:53-26:54

Dr. Avorn, I had mentioned orphan drugs and you know there are now designated orphan drugs for cancer, for example. That cost literally hundreds of thousands of dollars a year per patient. And there are some other rare diseases, muscular dystrophy, et cetera, where the cost can be, you know. uh close to a million dollars a year. Uh and these were supposed to be drugs of limited commercial value. Um It’s not unusual for some of these so-called orphan drugs to bring in billions of dollars a year for the manufacturer. I, I’m I’m just wondering what will happen if there is truly an effective drug for Alzheimer disease. The company could easily charge couple hundred thousand dollars a year and say, hey, it’s a bargain keeping people out of nursing homes, and yet that would break the bank on Medicare and break the bank of insurance companies almost overnight.

Dr. Jerry Avorn

26:54-28:52

Absolutely. And of course, Alzheimer’s would not be an orphan condition because it is so appallingly common, but other conditions, and you you mentioned cancer drugs. If a company says this drug is going to attack a particular kind of mutation or a particular kind of receptor or a particular kind of pathway in a particular kind of cancer, they can manage to narrow it down to the point where that condition affects less than 200,000 Americans a year. And that is the legal definition of an orphan drug. But, you know, we think of cancer as a relatively common condition. But if they’re able to structure the application to the FDA for a particular kind of a particular kind of lung cancer. They can say, oh, this is now an orphan drug, so we get to have all the goodies that come with it, which is much uh more generous research and development money and much more freedom to get it approved uh with perhaps lower standards. And so that that’s a particular um anomaly for drugs that are for conditions that are uncommon.

You mentioned muscular dystrophy. That has got to be one of the more egregious examples of companies. There’s one company here in the Boston area called Sarepta that got through on not the orphan drug pathway primarily, but on the accelerated approval pathway. And they said, look, we’re changing the level of a certain protein in muscle. And that’s you know by just a tiny bit, but I bet that’ll help patients It didn’t help patients, but the FDA said, well, you did change that level a little bit. Maybe that might work, even if you didn’t show any benefit. And that company then went on to not just market that drug, but several other drugs of exactly that approach with tiny modifications, none of which have been shown to be very helpful. And the FDA’s excuse was they wanted to bring cash into the company because that will help them to do more research to find a cure.

Terry

28:52-28:53

So wait a second.

Dr. Jerry Avorn

28:53-29:14

That’s not FDA’s job to bring cash into companies. And B you, it actually had the opposite effect. It said to the companies. Hey, you can get by with a drug that has a trivial change in a lab value and you’ll get yourself a drug. So that’s why we now have multiple ones of these drugs, each of which cost hundreds of thousands of dollars per person per year, and none of which work hardly at all.

Terry

29:15-29:55

All right, so Dr. Avorn, this really brings up the issue of the FDA is supposed to be reviewing drugs and the research that has been done on these drugs to make sure that they’re safe and effective. And we we haven’t really talked about how do you tell if a drug is safe enough. We have talked about the fact that every drug that we know of has some side effects for some people some of the time. But has the FDA actually changed its objectives? Has it, in fact, been captured by the industry it’s supposed to be regulating?

Dr. Jerry Avorn

29:53-32:54

I think that’s a great question, and the quick answer is yes, they have. To look separately at effectiveness and safety. The effectiveness, as we’ve discussed, if you are going to be willing as FDA to now accept a tiny change in a lab test as your replacement for this helps patients, then you know the horse is really out of the barn. And we’ve seen that with the accelerated approval of these muscular dystrophy drugs, the Alzheimer’s drugs and so forth. So they’ve lowered the bar so low that you almost, you know, it’s kind of rubbing on the ground. So that’s on that’s on the effectiveness side. And that’s not what the nation had in mind in the 1960s when they said for the first time anywhere, The government can require a company to show that a drug works before you can sell it. That was a revolutionary advance in 1962, and we’ve really bit by bit backed away from that. Safety-wise, I think there’s a somewhat happier story, but it followed a kind of tragedy, and that is the drug that you both know well. which is Vioxx, which was made by Merck as a treatment for arthritis and pain. And it appeared that it was likely to cause heart disease. And we actually did a fair amount of research uh on that question in in our group at Harvard. And it turns out that we found, as did other groups, around the country that yeah, it if you take this drug, it’s going to increase your risk of heart disease. And is that worth it, you know, to get a little bit better pain relief or a little bit gentler on your stomach? And the company said no, no, no. They said we should not publish our research because we would become laughing stocks. And they denied it up until the moment, after five years on the market. That a randomized trial that they themselves at Merck had funded showed that the drug doubled or tripled the risk of heart attack and stroke. And then once that data was available from a randomized trial, they kind of had to take the drug off the market and they ended up spending the next several years paying out five billion dollars or so to patients who had had heart attacks and strokes after taking Vioxx.

So the good news, if you can to come back to your question and How is this leading to good news? Is that there were congressional hearings right after that drug was withdrawn? Because after all, 20 million Americans had had taken the drug. Medicaid spent a billion dollars on just that one drug. And Congress said, essentially, to Merck and to the FDA, how the hell did you let this happen? And that unleashed a program that many of us had been advocating for years. which is FDAs performing more proactive surveillance of side effects for drugs that are in widespread use so that they get claims data. anonymized from people all over the country so they know who took which drug and who had what side effect. And so the the happy outcome of that tragedy is that uh we are now much better able to spot a side effect of a drug while it’s on the market before it’s affected millions of people.

Joe

32:55-34:48

We’ll talk a little bit about the MedWatch program in a moment and how firings at the FDA may have affected that, but I want to go back to the issue of effectiveness first. Because I don’t think the average patient, and maybe even the average physician or prescriber Understands the difference between relative risk reduction and absolute risk reduction. And our favorite example is atorvastatin. And the commercial for the brand name Lipitor. There were ads in magazines that showed Lipitor lowered the risk of MI, myocardial infarction, heart attacks, by 36%. And I think a lot of people thought, oh, that sounds terrific. You know, 100 people take Lipitor. 36 of them out of 100 will avoid a heart attack. Wow, that’s impressive. But there was a little asterisk next to that, and it said three percent of the people on placebo experienced a heart attack after five years. Whereas two percent of the people on Lipitor experienced a heart attack after five years, so the absolute risk reduction was actually one percent, not thirty-six percent. And I I think this idea of absolute versus relative risk gets hidden because drug companies love to talk about relative risk reduction. How does the average physician understand the difference between absolute and relative risk reduction when it comes to, for example, statins?

Dr. Jerry Avorn

34:49-37:23

To answer your question, we often don’t understand it as well as we should. Uh my view of how we train doctors is that while we do fill the heads of our very smart students with a lot of important facts, and we gotta do that, What we do a less good job at is helping them think about data in the way that you just described. And the fact that we are always, whenever we prescribe a medication, not only balancing risks and benefits, but also needing to think about the magnitude of those risks and those benefits. And that’s something which, you know, I’ve often felt that The facts that we cram into students’ heads, um, half of them may turn out to be wrong in ten years, but giving them the ability to think in the way that you were just describing about, you know, it still may well be that a statin is if it’s if it’s as safe as they are, is still, you know, for a high risk patient a good thing. But you want to come to that conclusion or not, based on thinking carefully about that issue of absolute risk reduction and relative risk reduction, and also about the the magnitude of the risks that are involved with taking any drug. And that’s where FDA could do a much better job. And that’s where we doctors, frankly, and we medical educators need to also do a better job.

FDA’s standard has been If you have a drug that works better than placebo, unless it’s unethical to do a placebo-controlled study, like for AIDS or cancers. But if you have a drug that works better, which was the standard for that awful Alzheimer’s drug, Aduhelm, it it changed the level of amyloid in the brain a little bit tiny bit more than a placebo did. That’s not a comparison that I as a prescriber want to hear about. I want to hear how well does it work compared to other alternatives that we might want to offer? And then of course the the big granddaddy question is is whatever change it causes worth the exorbitant amount that we might be asked to pay for it. And that’s a level of analysis that is tricky to do. And you can’t just tell patients, Or doctors for that matter, go do your own research, you know, look up the papers and decide for yourself. We need to say this is a public good kind of question. And just as we don’t ask everybody to build their own section of roadway or make sure that you know, the water in their tap is you know clean and forget about where it’s coming from. These are things societies need to provide to their citizens. And it’s something we need to do a much better job of as a society.

Terry

37:24-37:53

And we certainly have not done that very well for uh prescription medications. Consumer Reports uh offers you evaluations if you’re going to buy a car or a computer. You can take a look at the various categories in which you might rank such a consumer product, there is nothing like that for prescription drugs and they’re more important to our lives than uh a car or a computer, one could argue.

Dr. Jerry Avorn

37:54-38:40

Mm-hmm. Absolutely. And I’ve tried to provide people with lists of reliable websites that you can go to without feeling like you’re being barraged by advertising or or just scammery. And you know those sites do exist and I tried to make that list available to people because While I’m not encouraging people to always just figure out for themselves what they need to take for their diabetes, it does help for to kind of even the playing field so that when a patient does go to the doctor, they at least can come equipped with questions like You know, is this drug just better than a placebo or is it really effective? What about the newer drugs? Is this affordable? Are there generics? And the kinds of things that everybody needs to be able to think about when they’re talking with their doctor about a prescription.

Terry

38:39-39:07

You’re listening to Dr. Jerry Avorn. He’s a professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham Healthcare System. He developed the educational outreach approach known as academic detailing, providing evidence-based information about medications to prescribers. Dr. Avorn’s new book is “Rethinking Medications: Truth, Power, and the Drugs You Take.”

Joe

39:07-39:11

After the break, we’ll talk about side effects.

Terry

39:11-39:16

All medicines have some side effects. How do we learn which ones to watch out for?

Joe

39:16-39:27

Dr. Avorn did a groundbreaking study comparing the side effects of placebos in antidepressant studies. What lessons can we take away?

Terry

39:27-39:33

We’ll also get tips on the questions we should ask before we start taking a medication.

Joe

39:34-39:39

And what should you know about stopping your prescription?

Joe

40:59-41:01

Welcome back to the People’s Pharmacy. I’m Joe Graedon.

Terry

41:02-41:04

And I’m Terry Graedon.

Joe

41:04-41:18

One of the fastest-selling drugs in the pharmacy is semaglutide. You’ve probably seen commercials for its brand names, Wegovy or Ozempic. Why are the side effect rates for the same medicine so different?

Terry

41:18-41:35

Our guest today is Dr. Jerry Avorn. He’s a professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham Healthcare System. His most recent book is Rethinking Medications: Truth, Power, and the Drugs You Take.

Joe

41:36-42:10

Dr. Avorn, we’d like to segue a little bit into the side effect profile of medications. and how drug companies do their data collection. And we were so impressed with a study that you did many, many years ago. comparing placebo rates of an old-fashioned antidepressant category called tricyclics, drugs like amitriptyline. versus the side effects in the placebo group of the so-called SSRI.

Terry

42:10-42:24

So comparing placebo to placebo So first explain please to the listeners why you compared placebo to placebo.

Dr. Jerry Avorn

42:22-44:55

Well, one of the best inventions of all time is not a thing, but is a concept, the randomized control trial. Because it in the old days, um, people you know used to say, like if you were a doctor, in my experience this drug works well, or in my experience this one causes side effects. And it turns out As most of your listeners will know, you can’t figure that out from the perspective of any one doctor or any one patient. You’ve got to look at this systematically. And the beauty of a randomized control trial, which simply means that patients are given a new drug or a dummy pill, a placebo, And they look exactly alike, and they are randomly allocated to who gets the new drug and who gets the placebo. And neither the patient nor the doctor knows who got what. That is a very, very effective way of getting a handle on moving beyond this, in my experience, this drug works, you know, because if it doesn’t come across in a randomized controlled trial, then you got to wonder what in the world is is going on. But then we introduce the other really interesting issue of what some people call the nocebo effect And most listeners will know about the placebo effect, which is you give somebody a dummy pill and they say, thanks, Doc, that made me feel much better.

There is the opposite um effect called the nocebo, which is from the Latin word for noxious, which is you give somebody a dummy pill and I mean I I don’t encourage ever doing this in practice, but in research, and they say, boy, that that pill really made me have side effects. And you know it’s not the pill because the pill just had, you know, some lactose powder in it. And so this has been a real boon to thinking about research studies because it gives you a handle on what is from the pill and what is just the patients. expectation that either they’re going to feel better or that they’re going to sometimes feel worse. And so what what we’re talking about in comparing Well the placebo rate of side effects is there shouldn’t be any difference if you have ideally people getting a dummy pill. in one study or another, if the patients are similar enough, you shouldn’t have it vary based on what the studied drug is that you’re testing. But we do see this, and it uh reminds us that an awful lot of the effects that people report from meds, both for good or for ill, may be not from the med, but may actually just be from the patient’s expectations or or perceptions.

Joe

44:56-46:14

And one of the things that we think we’ve discovered is that drug companies have become ex- Extraordinarily skilled at influencing the reports of side effects. So let’s just compare two identical drugs Semaglutide is the ingredient in ozempic, which is a drug that was approved for diabetes, followed by Wegovy, the same exact drug that was approved for weight loss. In the clinical trials that the drug companies performed, 20% of the people who got Ozempic reported nausea. Forty to forty-four percent of the people who got Wegovy reported nausea, so almost twice as many on the same exact drug, but more interestingly, the people who were given placebo, that is to say, a dummy injection, 6. 1% reported that they experienced nausea on the dummy shot, whereas 16 to 18 percent of those getting the placebo shot complained of nausea. How did the drug company create those kinds of numbers? Twice as many.

Dr. Jerry Avorn

46:12-47:45

Well, I think that they were probably as surprised as you were when they looked at those numbers because in principle, giving somebody a dummy shot should not create nausea or diarrhea or any other side effect. And so the reason it’s so important that we as prescribers and and the FDA have access to well-done randomized placebo-controlled studies is that we can look for things like that, and then we can say, well, gee, maybe there was there is a dose difference in the active drugs in those two examples. But the placebo doesn’t have a dose because it’s basically salt water. Why is this going on? And that makes me think as someone who evaluates drug evidence. Maybe there was a difference in the underlying patient populations, maybe because one was mostly for obesity and one was mostly for diabetes, or maybe there was some difference in the way they elicited the um symptoms. That is, you know, if they said, did you have any queasiness in the last week, as opposed to were you severely nauseated and vomiting? You know, you’re going to get very different answers depending upon how you ask the question. Now, ideally, the randomization should take care of that. And when you see a difference, you know that the difference is from the ingredient and not from any kind of expectation by the patient or the doctor. But it’s it’s a little hard to explain why it would be. And it must come down to either the underlying patient population and or the way they asked about the nausea, the vomiting, the diarrhea that created that.

Joe

47:45-48:30

I am a bit cynical and I do think it has something to do with the way they asked the question because when they asked about diarrhea, the people on placebo had ten times the diarrhea rate if they were in a uh trial for Wegovy compared to a trial with Ozempic. But I I know we’re now in the weeds. And I guess what I’d like to do is segue quickly to the questions that patients should ask their doctor. whether it has to do with benefits or whether it has to risks, so that a patient will really have some substantive data to be able to evaluate whether they should be taking this medicine or not.

Dr. Jerry Avorn

48:31-50:38

Absolutely. And as both of you have advocated for many, many years, patients need to be informed consumers and informed um patients when they go to the doctor. And that’s getting harder and harder every year because doctors are more and more rushed than ever. You know, it’s not their fault, but they’re asked to see more and more and more people. And it makes it hard for them to find time to actually sit down with a patient and talk about meds. But, you know, a as you both know, this is some of the most important conversations that we doctors can possibly have with our patients. And what I used to say was if your doctor doesn’t have time to that to do that, find another doctor. That was before it became impossible to find another doctor because we’ve so depopulated the field of primary care in our healthcare system. But still, I think the patient needs to advocate for him or herself, and come in with a list of questions.

Because I know when I go to my doctor, I forget half the things I wanted to ask him before the visit, unless I write it down. And then I forget half the things he tells me and that’s, you know, and I’m a professor. So um people should go in knowing that you’ve got to advocate for yourself. Uh and in the book I try to give some questions that people should go in and ask their doctor, like, what is this medication for? Do I take it forever or until my symptoms are better? You know, in some drugs we say Take as little of this as you can and stop as soon as you can, like an opioid. Other drugs like drugs for high blood pressure or diabetes, we say you’ll take this probably for the rest of your life. And patients aren’t born knowing the difference between those categories. So how long will I need to take it? Is there a more affordable alternative that will work just as well? What side effects should I be on the lookout for? And what is the goal here? Is it to get my blood pressure down to a certain number? Is it to make me feel better? Is it to get rid of a target symptom? And you know, unless you know what the doctor is is going for, uh you’ll not be able to tell if you’ve gotten there or not. So it’s hard to extract that amount of time from a doctor, but I think patients really do need to use those, that list of questions of that they can ask their doctor.

Terry

50:38-51:11

I think that idea of goal is really important and it’s not one that’s always incorporated into the conversations that we have with our doctors. Um and especially important, how will I know when I have reached the goal? Uh because If if you aren’t clear on the metric, you’re not going to know that, oh, okay, that’s that’s all I needed to do. And now I can look at something else that might be uh getting my attention.

Joe

51:12-51:24

Well you know, Dr. Avorn, there’s another question that is rarely asked, and uh we think it’s really important, and that is how Should I stop this medication?

Terry

51:24-51:25

And when?

Joe

51:25-51:58

Because you know, there are a lot of Americans, literally tens of millions of them, taking antidepressant medications. uh, like Prozac, Paxil, and sertraline and we go down the long list. And you just can’t stop cold turkey Because this quote-unquote sudden discontinuation syndrome can be quite devastating. So finding out how to discontinue a medicine may be almost as important as how to start it

Dr. Jerry Avorn

51:56-53:49

Exactly correct. And there has been an interest in the last number of years in this relatively new term of deprescribing. And seeing all these people that and I’ve I when I was in active practice people would come in with these long lists and I would ask them to please bring me a list or even better, a bag of all the drugs you’re taking. And, you know, things I would say, gee, you know. I thought I stopped that two years ago. Or who gave you that? Or, you know, all sorts of things that your doctor may not No, despite their being diligent because maybe it’s somebody else prescribed it or they thought it had long since gone away. So this issue of deprescribing is useful. However, there was a period where it was almost I would consider kind of a fad that, you know, let’s get everybody off of everything as much as we can. And it turns out there have again been, you know, the the answer for me to everything is rigorous clinical research. Studies where people were randomly assigned to stop a drug, and particularly antidepressants, was one of the drugs studied. Or keep going, but it was done as a placebo-controlled trial where neither the doctor nor the patient knew who was still getting a placebo and who had been switched over uh who’s still getting an antidepressant and who is switched over to placebo.

And the answers are not always what one would expect from one’s armchair. That is, there are some people that um really when you stop their antidepressant, even if you do it carefully, really get worse and really get depressed. And then there’s others who don’t have any problems at all, might even feel a little bit better, but you can’t know that without really having good research data. And that’s not a topic that, you know, the drug industry is keen on funding clinical trials of stopping medications. But we do need more than more information on that because it comes up, you know, like millions of times a day in medical practice.

Terry

53:50-54:20

Dr. Avorn, I’d like to turn a little bit to the topic of uh current events, as it were. I’d I’d like to ask you for your thoughts on what is going on with the FDA currently. Is the agency going to have the personnel it needs to carry out the functions we expect of it? What reforms if the FDA were to be reformed, what reforms would you see as beneficial?

Dr. Jerry Avorn

54:20-57:46

Okay, I’m glad you asked that because I am scared out of my mind at these dramatic cuts that are being made wholesale. Not just at FDA, but at CDC, the Centers for Disease Control, and at the National Institutes of Health, that seem to be getting made without a whole lot of attention to are these cuts a good idea? We know that FDA has been understaffed for many, many years. And a solution that was proposed decades ago was that the drug industry said, gee, Congress doesn’t want to give you enough money to hire the people you need to review our drugs, FDA. Why don’t we just pay you to review our drugs? And the so-called User Fee Act, which was put in place in 1992 and has been renewed every five years ever since, has gotten us to to a situation in which the drug industry is now paying for about half of the salaries that FDA spends on the scientists who review the drug company’s products. Which does not seem like an ideal plan, but FDA was not able to get the money it needed from Congress going back many decades, many administrations, many different parties in power. They just never got the staff they need and they were all too willing to let the FD the uh drug companies pay for fifty percent of their salaries. So we were already starting from a bad place.

And then these draconian cuts that do not seem to be getting made in a thoughtful way. And we know that because they were done so abruptly, have put the whole drug evaluation activity at risk. They’ve also put at risk apparently the people who are trying to figure out how to negotiate lower drug prices, which was a reform put in by the prior administration. Many of them have let have been let go, so the government is kind of down on its staff who are supposed to be negotiating with the drug companies

But what scares me the most is these draconian cuts in the National Institutes of Health funding who are funding the research that, as we all know, leads to the drugs of tomorrow. The drug companies do research themselves, to be sure, but our our group at Harvard has shown that an awful lot of the best drugs we’ve got came from NIH funded research in universities or or academic medical centers. And then when the product is kind of ready for prime time it comes to be owned by a drug company that then charges whatever it wants for the drug. But what nobody is really talking enough about is if we stop that pipeline of discovery of basic biological insights as we are doing now at NIH. And my own institution, Harvard, is being hit with all kinds of billions of dollars of cuts by the administration. It’s not like we are all driving around in limousines and, you know, taking six-month vacations in the Caribbean. You know, most of us earn way less than we would earn in the private sector, and are doing this work because we really believe in it and then to find out that active grants are being just absolutely canceled with stop work orders going out. Is really going to come to a head, not in the next month or two, but in the next couple of years, where all the basic research that led to the development of new drugs will have been shut down or at least crippled. And then so sometime around 2027, people might say, hey, where’s all these new pharmaceutical wonders that we were expecting? You know, they’re not going to be there and that’s going to be a tragedy.

Joe

57:47-58:22

Dr. Avorn, a lot of our medications now come from abroad. It’s been reported that over 90% of our generic medications come from places like China and India. And I do worry about the FDA’s ability to monitor the manufacturing process. D do you have any thoughts about A: the drug manufacturing abroad, and uh and B: the drug shortages that have resulted over the last couple of years.

Dr. Jerry Avorn

58:22-01:00:40

And if I may add a C, which is what is going to happen to drug prices when tariffs kick in, given that so many of our drugs, as you just said, come from India and China. And if there are huge tariffs slapped on any imports from those countries, that is going to make not only make drugs harder to afford. But it also, I think, is gonna make our shortage problem worse, because a lot of generic manufacturers, and we’ll we’ll get back to the inspection thing in a second, a lot of generic manufacturers based in India and China operate on very, very thin margins, because generics are very, very cheap. That’s one of the great things about generics for the consumer.

But if they find that their thin margins are now being essentially erased by these crippling tariffs, They’re just gonna say, hey, I’m gonna lose money with every pill I make. I’m just gonna stop making these pills. And that is gonna, and we’ve seen that before with cancer drugs and and other medicines. That is going to get exponentially worse because of the tariffs if they are handled in as careless a way as many of us worry that they might.

But to come back to your earlier question, which is so important about inspection. Yeah, this is another thing that I referred to before as a public good. You know, it’s it’s the right of every citizen to know that their tax dollars are going to be used by government agencies working on behalf of everyone to make sure that somebody’s inspecting the meat, and that the water in your tap is is pure, and that the drugs that you are getting that come from another country–that those factories are being inspected adequately and are passing muster. And FDA has had a very hard time keeping up with that. And they’ve not had enough budget to do it.

And as a result, uh particularly if the cuts at FDA extend to this part of their mission, we’re not going to be able to be as sure as we want to be that our blood pressure pill, diabetes pill, cholesterol pill, whatever, that may have been made in India or China, leave aside the unaffordability and leave aside the shortage, is that factory being inspected as well as it should be, especially if FDA has gotten staff cuts that it’s getting, and they don’t have the people to do that work. So it’s it’s pretty scary.

Terry

01:00:41-01:01:34

Dr. Avorn, I’d like to ask about primary care. You mentioned during our interview that uh at at one point at least you were doing brown bag reviews with your patients in which They would put everything they’re taking into a brown bag and bring it in so that you could review everything they’re taking, including over-the-counter stuff and dietary supplements. And I think more and more patients are anticipating that they will be seeing specialists. So they’ll see the cardiologist, they’ll see See the podiatrist, they see the ophthalmologist, they don’t see one person who is looking at the whole patient. Can you give us some idea of the difference between the practice and the effect on the patient of primary care versus these very siloed specialist cares?

Dr. Jerry Avorn

01:01:35-01:04:14

That that’s a really important point. I did my residency in in Boston when in in the 70s when we thought this is now the era of primary care. And you know, we’re going to train people particularly to be general internists who will deal with most everything that walks in the door and once in a while you’ll need a specialist to help with particularly complicated problems.

But we’ve really, as a healthcare system, been beating up on primary care doctors mercilessly for the last several decades. They get paid much less than the specialists. The hours are not compatible with having a life. The emotional and intellectual responsibility of taking on whatever walks in the door, which is I think what most of us would like to have as patients as our first stop in the healthcare system really takes stall.

I think primary care doctors ought to be, you know, rewarded the most and made their lives as easy as possible, but that’s quite the opposite has happened. So as a result, as you’re pointing out, somebody might be getting medications from their diabetes doctor and their heart doctor and their arthritis doctor. And it is not always possible for every doctor to be aware of what all the other doctors are prescribing. And uh I’ve written about how somebody may be taking, you know, Advil for headaches, and ibuprofen for their sore knee, and Motrin because they have low back pain, and aspirin because they think it’ll prevent a heart attack, and not ever knowing that those are all basically the same class of drugs, and they’re just multiplying the potential risk for for side effects. That’s where a primary care doctor can really shine.

And, you know, we are an endangered species. It’s imperative. I’ve found some of the most useful time I would spend with patients. would not be listening to their heart or listening to their lungs, but actually saying, next visit, bring in a brown bag and fill it with not just what I’ve prescribed, but what you’re getting from all your other doctors and as you said in the question, whatever dietary supplements you’re taking and whatever herbal remedies you’re taking, whatever over-the-counter meds you’re taking, and dump it out on my desk and we’ll talk about every one.

The reason that’s so useful is that you find stuff that actually is uh you know can kind of chill your blood about, oh my God, who put you on that? And you’re still taking that? I’s a very useful activity, and I urge all patients, if their doctor doesn’t ask to do it because every doctor is just so horribly overloaded with not enough time and too much to do is to offer to bring it in and you know include those supplements and over-the-counters and things from the other doctor and see what happens when you dump them on the doctor’s desk and see what his or her reaction is.

Terry

01:04:14-01:04:59

And they may actually say, oh my God, we got to fix this. Well, one of the examples that you gave in rethinking medications, that is something we have heard from probably hundreds of people. is the idea that um you may have a chronic cough, that it doesn’t go away no matter what cough medicine you take and you’ve been worked up for allergies and you’ve been worked up for this and that, sometimes people get worked up for um acid reflux to see if that’s the cause of the cough. And if you just looked at the blood pressure medicine that the patient is taking. Exactly. If they’re on an ACE inhibitor, the chronic cough might be a reaction to their blood pressure medicine.

Dr. Jerry Avorn

01:05:00-01:05:43

You said it. Right. I think the the figure I know is about 15% of people. And by the way, ACE inhibitors are wonderful drugs. They do a great job of lowering blood pressure. But as as you’re as you’re saying, about 15% of people on ACE inhibitors will develop a cough from them. And there’s ways of fixing that. You know, there’s angiotensin receptor blockers you can switch people to, you can use another category of drugs. But if it doesn’t come up in the conversation with a doctor, you know, they could, as you point out, they could get worked up for lung disease or put on meds for, you know, asthma or things that they don’t really need because it’s their blood pressure med. It may be a great med for most people, but if like one in seven people gets a chronic cough, that’s something that ought to be part of the doctor’s questioning of the patient.

Joe

01:05:43-01:07:16

Uh Dr. Avorn, you’ve mentioned how important it is for patients to bring in all the medications and the dietary supplements and the vitamins and the goodness knows what they’re taking. for the physician, but I’d also suggest that it’s important for pharmacists to also be part of the process And also do these brown bag uh examinations, but there’s a a problem that we hear from pharmacists all the time. A patient comes into the pharmacy and they get a flag on their computer that says, uh, this antibiotic should not be taken at the same time you’re taking one of these blood pressure medications. It, it could cause potassium levels to go through the to the roof and it it could cause cardiac arrest. So this is a dangerous combination and the patient is waiting to g to get their antibiotic And now the pharmacist has to contact the physician. But when the pharmacist calls the doctor’s office, the receptionist says, I’m sorry, doctor is seeing patients now. And as you said, so many doctors are overworked and overwhelmed, it may be hours before that physician can call back to the pharmacist. And we hear from pharmacists who say, I never got a call back. What do I do when I’ve got an interaction and a patient sitting right there in front of me waiting for their prescription to be filled? What what would you recommend in a situation like that?

Dr. Jerry Avorn

01:07:17-01:08:59

Absolutely. And as you both know from what I’ve written over over many years, I think pharmacists are one of the most potentially valuable and underused and abused healthcare professionals that we have. You know, they know so much about medications and yet most pharmacists find themselves working in increasingly in chain drugstores where the entire premium is on throughput and fill them and send them home and get, you know, make sure they pay.

And the idea that a smart enlightened pharmacists can be part of the healthcare team just has not caught on as much as I had hoped because it could deal with a lot of these issues that that come up. It’s and then of course it puts the pharmacist in a rough spot. And sometimes, as you both know, some of these alerts are really not very sensible. But it you know the computer flashes a red light and then the pharmacist says, oh my God, I can’t do this. And then you can’t reach the doctor.

I mean my vision, which is very naive and and probably unrealistic, is that practices would increasingly have pharmacists embedded in the practice who are part of the whole healthcare team. And that when the question comes up, first of all, they might even be involved in the dispensing of the drug. But if not, uh the outside pharmacy could call and they talk to the inside pharmacist, then he or she would be able to look at the patient’s records. They may even be able to snag the doctor as he or she walks by. Or they would have their own expertise and say, yeah, it’s okay. That’s one of those automatic computer flashes. Or they might say, holy cow, don’t fill the prescription But leaving everyone holding the bag because everyone is too busy to be able to just get their work done is not a good solution for anyone.

Terry

01:08:59-01:09:05

Dr. Jerry Avorn, thank you so much for talking with us on the People’s Pharmacy today.

Dr. Jerry Avorn

01:09:06-01:09:09

I’ve really enjoyed talking with you both again. Thanks for having me.

Terry

01:09:10-01:09:44

You’ve been listening to Dr. Jerry Avorn, a professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham Healthcare System. He built a leading research center at Harvard to study medication use, outcomes, costs, and policies, and he developed the educational outreach approach known as academic detailing Providing evidence-based information about medications to prescribers. Dr. Avorn is the author of Rethinking Medications: Truth, Power, and the Drugs You Take.

Joe

01:09:44-01:09:46

Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music.

Terry

01:09:52-01:10:00

This show is a co-production of North Carolina Public Radio WUNC with the People’s Pharmacy.

Joe

01:10:00-01:10:14

Today’s show is number 1443. You can find it online at peoplespharmacy.com. That’s where you can share your comments about today’s interview. You can also reach us through email, radio at peoplespharmacy.com.

Terry

01:10:15-01:10:38

Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In the podcast this week, we discuss sourcing medications from abroad. How does that affect drug shortages? How will tariffs affect costs? In addition, you’ll get the details on a brown bag review.

Joe

01:10:38-01:11:13

At peoplespharmacy.com, you can sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We are pleased to announce we are now launching transcripts for selected interviews, including our conversation with Dr. Jerry Avorn. We would be grateful if you would consider writing a review of the People’s Pharmacy and posting it to the podcast platform you prefer. In Durham, North Carolina, I’m Joe Graedon.

Terry

01:11:13-01:11:48

And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money.

Joe

01:11:48-01:11:58

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Terry

01:11:58-01:12:03

All you have to do is go to peoplespharmacy.com/donate.

Joe

01:12:03-01:12:19

Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.