Making medicines safer for all of us

Adverse drug events are now the fourth leading cause of death in hospitals.

It’s a reasonable bet they are an even greater cause of death in non-hospital settings where there is no one to monitor things going wrong and no one to intervene to save a life. In mental health, for instance, drug-induced problems are the leading cause of death — and these deaths happen in community rather than hospital settings.

There is also another drug crisis — we are failing to discover new drugs. [Read more...]

Archive for AbbVie

What to do about Suicide

These words are from David Foster Wallace.  I don’t know if he was speaking about the depression he had or the akathisia that antidepressants can cause.  Maybe he didn’t know and this contributed to his suicide.

This post needs to be read in conjunction with What to do about Sex on RxISK.  This post is about structural aspects to the problems not just of sexual dysfunction and suicidality caused by drugs but all other adverse events also.   The RxISK post is about the specific things people can do about a specific sexual dysfunction or adverse event such as suicide.

Structurally Speaking

Here’s the easy bit.

Raising Awareness

Its impossible to argue with the proposals after the last post by Heather, Tim and others to try to raise awareness about akathisia.  The word is confusing and it’s difficult not to think as Sally does that its obscurity, almost meaninglessness, has been a godsend to industry

Something like Drug Induced Emotional Turmoil (DIE.T) might have got the message over more effectively twenty years ago but MISSD and others have produced such good material on akathisia already that its not clear that going back is an option.

The tee-shirt ideas are great. I’ve been in touch with Bill James who has produced all of the really striking images we have had on RxISK.  It takes a while for images to come to Bill – and this time will likely take longer as the outlines of a song is what has turned up first.  There is no reason to wait around till more comes from Bill – quite the contrary the fact something else is happening should encourage more diverse effort.  As the message on RxISK and below puts it don’t be put off by experts – even expert artists.

FDA, MHRA, EMA, Health Canada etc

There is no point looking to a regulator to solve problems with any adverse effect on a drug.  Their brief is to supervise the wording of drug labels and adverts by drug companies primarily before a drug comes on the market.  It is not to ensure that patients or doctors are properly warned before they take a drug.

Being bureaucrats their job is to make sure they have a good reason for doing nothing.  This means for instance that there needs to be a hint from an RCT that a drug does something they can point to if politicians ask questions.  If a politician asks about akathisia, the regulator can say – ah but if we warn about that we will deter people from seeking treatment and lives will be lost.

This is why they are so vulnerable on the issue of SSRIs for children.  There is no benefit they can point to – not even for fluoxetine (Prozac).

Why did RxISK submit a petition to FDA, EMA and MHRA about PSSD?  You have to be seen to cover all the bases but there is no expectation that things will change.


Government will never do anything companies don’t want. Even if you were to go on hunger-strike outside Congress or Parliament, it would count for nothing.

In the case of AIDS activists their protests got somewhere with Government and Regulators – primarily because they were asking for politicians to ease the regulations on companies.  ACT-UP wanted things made easy for Pharma.  This resulted in them getting early access to thalidomide and a host of other drugs that may have killed as many people as the virus did.

Guideline Bodies

Bodies like NICE and others who write guidelines base their recommendations on ghost written articles.  They have no access to the data.  They invariably recommend the latest high cost drug over superior lower cost but off-patent drugs because if they don’t pharma will threaten to pull out of a small country like Britain – and there are presumably other threats in the US.

The guideline makers are unwilling to share a platform with anyone who might raise the issue of access to data or what they do about ghost-written articles.

The SSRIs and children story is supremely inconvenient for NICE and other Guideline bodies but they don’t have to share a platform with anyone or answer questions from a journalist on the issues so don’t hold your breath.


Through till 1991, journals carried case reports of adverse events – Evident Based Medicine.  These reports contributed more to the progress of medicine than Evidence Based Medicine has done. But following the publication of the Beasley et al  1991 meta-analysis of Prozac trials in BMJ (which showed an increased suicide risks that BMJ reviewers and editor missed) – the which are you going to believe the anecdotes or the data article – journals like BMJ are now scared to publish case reports or anything about adverse events.  Besides which reprints of RCT and meta-analyses are so much more lucrative.

See Vampire Medicine and related posts – A Call to Harms.

It takes a brave journal to provide a forum for adverse events – see Villains and Heroes.


These are largely marketing companies these days.  The research, clinical trials, medical writing, public relations (SAS and SMC) and increasingly pharmaco-vigilance has all been outsourced.  There is no-one at home who will understand the question being asked.

Some of the major breakthroughs though have come from people within pharma sending documents to people in the media or others.  Or taking the high risk route of filing a legal action against their own company.  They may get lucky and get money from it but there are more likely to just lose a job.  In general, people working in pharma have done vastly more than politicians, bureaucrats or clinicians to bring problems to light.

For every Schindler though, there are thousands of ordinary folk who by doing a good job (keeping to the rules and following orders) are at least as ethical as anyone injured by their drugs from thalidomide to Zyklon B and on.


There are a large number of people who read these blogs and comment and are desperate to find a way forward who have been injured by treatments or lost loved ones to treatment.

There is also a large number of people, perhaps an even larger number who have been injured by treatment and in particular who have lost loved ones to treatment who have become advocates for more treatment – who will front up programs to pick up schizophrenia or depression or osteoporosis or cancer at the earliest possible stage.  If only we’d picked things up in time, everything would have been okay.

This is the side Prince Harry or Camilla Parker-Bowles or Ivanka Trump are always going to end up on – they will all want to spread the good news of salvation through baptism and treatment.


This is where Americans have an advantage.  They can take a lawsuit – although its incredibly difficult to do so. Europeans can’t. Winning a lawsuit can make a difference – 20 years later.  Tim Tobin won his case against GSK in 2001.  The benefits of that win are still making a difference.   But for the most part companies have become adept at shutting down any publicity that might stem from a legal loss.  Pretty well no doctors have heard that GSK lost the Tobin case or cases against them for dependence on paroxetine or birth defects on paroxetine or even the Dolin case.


NGOs from the ACLU to Medecin sans Frontieres (MSF) to Open Society and others are committed to your rights.  This is great but in practice they are committed to your rights to treatment so drug companies actually rather like them.

The coin hasn’t dropped for any of NGOs that access to medicines should mean full access to all the information that transforms a chemical into a medicine. When it comes to harms, NGOs at the moment are part of the problem not part of the solution.


ACT-UP put activism on the map.  Its fizzled out. Its not clear that AIDS type activism can play a useful part in terms of raising the profile of adverse events.  It hasn’t so far.

RxISK put a much older form of Irish activism on the map – the Reverse Boycott.  We called this an AbbVie – Lets Do the AbbVie Again – which may be why it didn’t catch on. Basically this involves getting people to stop writing to companies or regulators asking them to be reasonable and bombarding them instead with reports of adverse events on drugs.  Only 1% of the serious adverse events on drugs are reported.

The ideal form of this would involve getting your doctor to submit a report also – this was the idea behind RxISK reporting.  The courts cannot ignore reports that have people’s names on them and is very unlikely to be able to ignore reports from both you and your doctor.

Companies dismiss your reports with the phrase – The plural of Anecdote is not Data.  Maybe we need a catchy slogan – Corroborates are Compelling.  Corroborates are Conclusive. Please suggest

But people seem scared to do this. This is an important discovery – people are scared silly.  Their doctors are even more scared.  We are facing a Structural Violence that almost no-one is talking about.

APA, RCP, Psych Central

The people who are failing everyone the most are doctors and their professional associations.  If the American President of their Psychiatric Association or Medical Association were to make it clear they thought some drug caused a problem, the pharmaceutical companies and regulators would have to act.  They’d be trumped.

Why would the President do this?  At the time of the 1962 regulations, FDA and other regulators were viewed as small beer – regulating advertisements.  The real people regulating medicine and keeping their patients safe were doctors.  Who for the most part had a good track record in putting conditions like tardive dyskinesia (1959) or dependence or drugs (1961) on the suicide that antidepressants can cause (1959) on the map.

For those with the time to let the dish go cold, the revenge will be that this ignoring of adverse events is going to put doctors out of business.  Just as salt that loses its flavour is useless, there is no point spending money on high cost prescribers if they can’t deliver anything that lower cost prescribers would and perhaps even less than robots soon will.

Social Media

You can’t depend on it.  The Spectre of Dissent post fell foul of Facebook.  It was removed.  If a post threatening to raise the profile of adverse events, even an effort to save children from suicide, ever looks like it might get anywhere, the chances are Facebook or other outlets will find some way to block it.  Facebook has 23 community standards – they’re worth a look at.  It will always be possible using one of them to limit the spread of unwelcome information.

RxISK has an Akathisia page.  In 2016 when it was put up it featured near the top of Google searches.  MISSD have produced a great video on akathisia but it has begun to slip down the rankings also.  We are being replaced by articles and sites like WebMD and related that focus only on the visible motor restlessness this condition involves.  Rather than outright block something – which feels like a Facebook own goal – this is a more subtle way to control the conversation.


There is a thing called the ZPD – Zone of Proximal Development – that mothers know about.  Its means knowing what A to encourage your child to do next to help him get to B and C and then D rather than trying to force him to get straight to D (the way his sister did).

We sometimes think that being reasonable – arranging meetings to talk to the regulators, or those other people we need to keep onside  – is taking the A step, after which B and C and then D will follow.  They won’t follow.  The regulators, and professionals may smile nicely but landing on A makes you an enemy of the people.  You will never be let get to B or C, never mind D.  We will hang on to the carriages being used to transport you to Auschwitz even when the Army are asking for them to try and shore up the Eastern front against the Russians.

This has led RxISK to Taper MD.  It may take 10 years for Taper to begin to make a difference but the trick is to go with the flow.  If  everyone wants to hear drugs work, and no-one wants to hear they might cause problems, then this is what we talk about.

Let’s get you maximal efficacy – this it turns out means 5 or ideally less than 5 drugs at any one time.  Clinicians and patients working together are going to have to perm from among the thousands of possible drugs a winning combination.  What the patient wants will be key to this.  This is what’s going to get people to D.

What to do about…

Meanwhile, for those trying to get a son rather than a daughter somewhere, you need a bunch of Anne-Maries – See What to do about Sex.  People with motivation can move mountains if they don’t sit around waiting for experts or other authority figures to do it for them.





The Spectre of Dissent

The last post The Greatest Failure of What Used to be called Medicine provoked a lot of comment – or at least the photographic images in it did.  There was little discussion about the content of the post and what to do about the spectre of bureaucrats in the guideline and the regulatory apparatus hanging together when it comes to something like children hanging after antidepressants.

Gillian Anderson and others asked if its valid to use images like this?  Will it do “the cause” more harm than good – put off the people who need to listen?

In 1963 Thích Quảng Đức, a Buddhist monk, set himself on fire in Vietnam in protest against the South Vietnamese Government, soon to be supported in spades by the US Government.  JFK said “no news picture in history has generated as much emotion around the world as that one”.

The Americans didn’t listen.  It took over a decade to sort things out.

In 1969, Jan Palach set himself on fire in Prague in protest against the Soviet occupation.

Ireland, the home of Lynching, is also the home of the Hunger Strike, and the Boycott – non-violent ways to bring about change – Gandhi, Martin Luther King and others came later.  These moves often expose the violence in the system – hunger strikers are let die, the boycotters were shipped off to Australia,  Gandhi and King were assassinated.

There is unquestionably something honorable about dying or suffering yourself for a cause.

The people of Prague turned out en masse for Palach’s funeral and his death played a part in the later formation of Charter 77.  There is unquestionably something honorable – but does it work.


Gillian and Maria Bradshaw raise points about re-traumatization.  Showing a photograph of a hanging child or a lynching will disturb people and this is an injury inflicted on them by the person showing the photograph – me in this case.

I don’t buy this.  The violence, trauma, disturbance is real but it comes from the system.  There is nothing more that the system would like but for everyone who has lost a loved one to a medical treatment to shut up.  They would love nothing more than to help generate the impression that someone who tries to raise concerns is an enemy of the people.

If a photograph of a hanging child traumatises some, well we probably should ensure we don’t talk about these things either.  Perhaps there should be trigger warnings on blog posts.  This is reverse Stockholm syndrome.  In Stockholm syndrome, people held captive by their hostage taker come out singing their sympathy for him.

In Saigon syndrome (we need a good name for this), anyone who tries to rescue people from a prison gets seen as an enemy of the people.  The doctors and clinical psychologists who come along to shelter you from something disturbing get seen as the White Knights.

These posts will disturb, unsettle and anger some?   Should they not happen?


I and others have gone down and will continue to go down a non-violent route.  This is what RxISK is all about.

One of RxISK’s main goals was to tackle the violence of the system by getting people not just to file RxISK reports but to take them to their doctors .  Among the most astonishing things this has shown is that people are too plain scared to do so.  They sense their doctors will get nasty.  And many doctors probably will get nasty, because doctors sense the system will get nasty with them if they don’t squash out dissent.

It is clear that pretty well everyone is being traumatised the whole time.  The momentary disturbance triggered by seeing a photograph hints at the pressure everyone is under.

This pressure is not going to go away unless we tackle it. Part of the difficulty in tackling it is alerting people to the fact that their problems don’t come from rogue doctors who make mistakes but from good doctors who keep to guidelines – based on junk.  There are few better symbols of the violence of the system than the craven attitude of bodies like NICE to the refusal of pharma to hand over the data.

Its not just NICE who are part of the problem – its non-governmental bodies (NGOs) like Medicins sans Frontiers (MSF), (Doctors without Borders), George Soros’ Open Society, Health Action International (HAI), the American  Civil Liberties Union (ACLU) and others involved in Access to Medicines campaigns who will fight the easy fight about the cost of drugs and not the fight about access to the data that turns a chemical into a medicine.

Its not just regulators, and guideline bodies and NGOs who are part of the problem, its everyone who turns to complementary medicine or antipsychiatry or who rejects the medical model one way or the other.

Its professional bodies like clinical psychologists who scream blue murder about trauma but never help a patient disabled by the side effects of drugs to stand up to the doctor who has put them on the drugs.

The system depends on everyone to quietly get on the trains that turn up to take us East.  This is a hazard of bureaucracy that was put on our radar by Max Weber a century ago.  There was a “there there now Max” response at the time and later outrage at the suggestion he might have been predicting the Holocaust.  We are nowhere nearer getting to grips with this than we were a century ago.


Following the death of Jan Palach, Vaclav Havel and others set up Charter 77 to respond as they saw it to the bureaucratic dictatorship in which people in Eastern Europe found themselves.  Previous dictatorships had involved a minority and were temporary but the Soviet system ruled in the name of the majority and looked pretty permanent.  Havel didn’t want a turn to the West which he saw as pretty capable of going just the same way.

As Havel put it:

“A specter is haunting Eastern Europe, the specter of dissent…

You do not become a ‘dissident’ just because you decide one day to take up this most unusual career. You are thrown into it by your personal sense of responsibility, combined with a complex set of external circumstances. You are cast out of the existing structures and placed in a position of conflict with them. It begins as an attempt to do your work well and ends with being branded an enemy of society. … The dissident does not operate in the realm of genuine power. He is not seeking power. He has no desire for office and does not gather votes. He does not attempt to charm the public. He offers nothing and promises nothing. He can offer, if anything, only his own skin—and he offers it solely because he has no other way of affirming the truth he stands for. His actions simply articulate his dignity as a citizen, regardless of the cost.

It’s easy to resonate to these nice words now that we know Havel won – largely by accident.  It took a shipworker in Poland to galvanise things.

Feeling a warm glow in response to these words is rather like the warm glow that half the population of Dublin had when later claiming they were in the General Post Office (a small building) at the time of the Easter Rising when in fact most Dubliners were hostile to the revolutionaries at the time.  The Easter Rising was a curious mix of violence and self-sacrifice – almost like committing suicide by aiming what appears to be a gun at the police.

We need more than the stirring words in Havel’s quote.  Written before he won, the key insight is that you become an enemy of the people – even the people who have lost loved ones and been traumatised by the system.  Even for the Jews in 1942 or 43, those who took to the woods rather than getting on the trains were enemies putting everyone else’s life at risk.

If you win, the stone the builders rejected becomes the cornerstone.  If you don’t, the people call for crucifixion – pretty well force the powers that be down this route.

Generalists and Partialists

An issue that crops up in comments on both this and the RxISK blog is the question of whether treatment would be safer if given by specialists (partialists) rather than general practitioners (generalists). We wouldn’t have the problems with antidepressants and antipsychotics for instance many people seem to think if prescribing was done by psychiatrists rather than GPs.

This could not be more wrong. There might at one point have been ways in which some partialists were better at making diagnoses than generalists – in dermatology for instance where clinical practice involves looking and touching and comparing this case to the last one. But in most other areas of medicine, nobody looks or listens anymore, least of all in psychiatry. People increasingly ask the questions on a rating scale or that present on an Electronic Medical Record (EMR), so much so that doctors are being replaced by nurses or pharmacists and all could soon be replaced by robots, and your problem on treatment likely doesn’t feature among the questions on the rating scale or programmed into the EMR.

Patient and doctor

Of if it does feature, perhaps you mention homicidal ideation, ticking the box is likely to lead to you being detained rather than any questioning of whether the management in the health service, or wherever you work is vindictive and bullying, as a BBC program on whistle blowing in the NHS recently suggested, in which case it might be more appropriate to detain the management. Ticking, in this case, and pretty well all cases, literally puts you in a box.

But even if dermatologists look at you and perhaps touch you, they rarely listen to you and when it comes to treatment they are as much boxologists as any other partialists. They put you on Ro-Accutane and doxycycline, and have begun to use Otezla and other new PDE-4 antagonists, and simply don’t hear you when you tell them you’ve become agitated or suicidal or you can no longer function sexually.

The only hope for medicine lies with generalists. They are still much more likely to see you when you walk into their office and notice differences from one visit to the next. Faced with the consequences of a bunch of partialists piling drug on top of drug so that people end up on 10 or 20 drugs per day, generalists are leading the push to de-prescribe. They have been the first doctors to rebel against guidelines, rating scales and EMRs.

So what goes wrong when a generalist gives drugs like antidepressants, Ro-Accutane or asthma drugs like Singulair and Accolate. The problem is they are likely to have been “educated” by a partialist who you might expect to know the truth about a new drug but who in fact is speaking from a text prepared for them by some pharmaceutical company, or have their names on an article written for them by pharma.

The image above is of a goat leading sheep. This is a recognized ph/farming maneuver. The sheep dutifully follow – to the slaughter house. If you google under the term Judas Goat, you can see many more images, some of them distressing. The Judas Goat gets his reward afterward.

The Judas idea applies well in this case, except those who end up slaughtered are those of us with skin or other problems – not the generalists who may have ended up doing the prescribing on the recommendations of a boxologist.

Campaigning to have us all seen by the right partialist, such as a shrink, in the case of an antidepressant, hoping this will lead to a better outcome is exactly the wrong answer to the problems we now have. If there was a choice between getting rid of partialists or generalists, at the very least the Goats would have to go, and if that didn’t solve the problem the partialists should be taken out, sparing only those who show some evidence of realizing their role is a semi-robotic one delegated to them by the generalist looking after the patient’s overall management.

Go Figure: Where Does All the Pain Come From?


Editorial Note: This anonymous comment featured toward the end of the Murder or Accident post. It seemed worth transforming into a post in its own right. In the week of the US vote, a key question facing voters is where does all the pain come from.

A colleague and I gave a talk to family docs this year and we discussed the opioid epidemic, including the 1% risk of addiction myth in Letters to the Editor at NEJM. One Key Opinion Leader (KOL) is now acknowledging that he may have overstated the safety of opioids but maintains that they still have a role in chronic pain, see Dr Russell Portenoy here:

He strikes a controversial chord with others involved in treating the outcomes of chronic pain killer addictions, like Dr A. Kolodny, see here:

Other KOLs like Dr Jane Ballantyne, have made 180 degree turns regarding opioid use in chronic pain, this article is well worth the read:

Challenging myths that have so much resources poured into them to maintain is very difficult. We were all taught that pain was the “fifth vital sign” by the American Pain Society (around the same time OxyContin approval occurred). You can see the sordid history, including how patient satisfaction scores may have a role in this epidemic, here:

The US Docs probably had some scare put into them by the successful legal case brought against a doctor (Dr Chin) in 1998 who was charged for not treating pain adequately. Incidentally, this was the same time as the heavy marketing machine was revving up for Purdue.

The appalling story about Purdue/Abbott’s role in this public health disaster is outlined nicely here:

There has been very vocal opposition from pain advocacy groups and physicians when British Columbia adopted the March 2016 CDC pain guidelines that discuss opioids and state they are not effective and should not be used for chronic pain and that doses should not exceed 50 mg equivalents of morphine.

Pain BC is encouraging patients who have been affected by these new regulations to complain to the College! Nothing strikes fear into physicians quite like a good old College complaint!

Although the evidence of harm is abundantly clearly (lack of efficacy in chronic pain, massive overdose deaths, lives in ruin, 80% of heroin users report starting drug use with physician prescriptions), both people and doctors choose to ignore this and some doctors fear College investigators. Sounds a lot like Dr Chin all over again…

Big Pharma’s influence in Canada continues. See here for Purdue’s lobbying of the Federal Government: A coalition of chronic pain and addiction specialists signed a letter earlier this year, requesting that Federal Health Minister Philpott consider making oxycodone only available as a tamper resistant formulation (of which Purdue holds the patent). Sixty percent of the signatories have ties to industry.

Dr David Juurlink may have said it best in the Globe and Mail piece referenced above:

“It’s time we stopped listening to pain specialists. Their messages, which were wrong, got us into this mess in the first place,” “Many of these physicians are deeply in the pockets of the companies that make opioids and that stand to profit immensely from the sale of these new products.”

Ontario released a new “Strategy to Prevent Opioid Addiction and Overdose” on October 12, 2016. This milquetoast framework to our public health crisis makes several vague recommendations, one of which is to make more substitution therapy available, specifically access to buprenorphine/naloxone (Suboxone). The document fails to provide suggestions for how to carry this out nor does it make mention of the potential public health risks. Studies have shown that Suboxone is ten times more likely to be diverted than methadone (i.e. not taken by the intended person and diverted to illicit market). We may want to ask Finland for some advice (buprenorphine, has been at the top of drugs misused in that country):

The provision of methadone (the other substitution treatment available) in the province received well-deserved criticism from the “Methadone Treatment and Services Advisory Committee”. Page 11 details some of the most egregious concerns:

 Lack of access to comprehensive care in stand-alone fee for service clinics: Many of these clinics provide little more than urine drug screening and methadone prescribing and dispensing, leaving patients without access to primary care, mental health and addiction screening, brief intervention or counselling, and management of acute and chronic illnesses. Variation in the quality of clinical services: Some clinics require frequent attendance for urine drug screening and a brief office visit regardless of the state of recovery demonstrated by the patient. This is wasteful and can be harmful to patients’ recovery as attendance can be inconvenient and at times very challenging, particularly for those in rural and geographically isolated areas.”

Profit driven care has clearly moved the patient far way from being in the centre.
Some are sounding the clarion call of “another epidemic” happening where over 50,000 patients in Ontario are now on methadone

Perhaps the most astonishing elephant in the room is “why are so many people in pain?” As a society we must look at the root drivers of this epidemic and that must also focus on prevention. We need to do some serious soul searching as a nation, as a community of peoples. We will need to address poverty, hopelessness, dislocation, safe housing, disintegration of community, lack of meaningful employment, adverse childhood experiences, resiliency, etc. if we have any hope of bringing this epidemic under control.


The links above are chilling. The video clip of Russell Pourtenoy is beyond belief.

It raises the question as to whether there is a growing amount of pain in the world as this US election suggests. The alternative is that doctors been adding to whatever pain and anxiety there is and to other dis-ease. While opioids and other pain-killers can give wonderful relief when given short term, as can benzodiazepines for anxiety, there is good evidence that given chronically opioids and benzos increase the amount of pain and anxiety we have – by altering physiological thresholds in the wrong direction.

Old style doctors, professionals, knew this. New style technocrats – we have the technology to fix your pain and anxiety – don’t know it.

It was and is an important part of caring for you to know the limits to what we can offer. But we now live in a world where choices like opioids are put on plate in front of you and your doctor and you are invited to choose. The right choice will supposedly deliver the jackpot – this is what marketing promises.

But somehow wisdom is never on the list of options – it can’t be – it’s not evidence based. It would be irrational to let you choose something that is not evidence based – like less medication or vaccines. That’s not a free choice.

Go Figure: Murder or Accident?

Harold Shipman

Harold Shipman was a doctor in Britain, who was arrested for murder in 1998. He turned out to be a true Angel of Death, the most prolific known serial killer, who killed it is thought between two and three hundred of his patients by prescribing opioids in large doses.

After his trial and conviction and jailing, he committed suicide in jail with no-one any the wiser as to why he had behaved the way he did.

His killing spree led to a change in medicine’s regulatory apparatus, ostensibly to ensure this couldn’t happen again. Boxes were put in place, and mandatory courses on a range of issues from consent to continuing education. All of this takes time away from seeing people. But if Shipman’s case held any lesson it is that he was assiduous at ticking the boxes that registration bodies like the General Medical Council in Britain put in place. The system probably makes a future Shipman more rather than less likely.

Short of doctors who have been struck off for proven cases of negligent care or abuse of patients, we might all on average be safer with doctors the regulator is having problems with, who for the most part are more keen on seeing patients than spending time ticking boxes, rather than with the doctors who are in good standing with the regulator. But what can the system do? We, the public, won’t let it do nothing.


While Shipman’s killing spree with opiods was unfolding, North America was sinking into a prescribed opioid epidemic that now accounts for 100 deaths per day, over 30,000 per year, over half a million since the epidemic began, perhaps the single greatest cause of death in America today.

The way in to the epidemic was laid during the 1980s with the marketing of Oxycontin by Purdue Pharma, supported by Abbott, and later Janssen pushing Fentanyl. There was an astute marketing of an idea – that people with real pain do not become addicted to opioids – a myth equivalent to the myth of lowered serotonin in depression. This was allied to new standards of care for pain management which hinged on RCTs, all of which demonstrated that opioids were effective – again exactly the same dynamic exploited by companies marketing SSRIs. The result was mass prescription of opioids by doctors, many whom felt trapped between clinical wisdom and the risk of being sued. But clinical wisdom never makes it into guidelines or standards of care, and since standards of care emerged in the 1980s managers sack doctors who don’t stick to the guidelines – or refer them to their registration body.

Prescription-only status is another part of the regulatory apparatus. It was introduced in America in 1914 in response to escalating concerns about one of the first opioids – heroin.

Purdue’s marketing of Oxycontin exploited this deftly. Companies and doctors were in the clear provided all prescriptions were for physical conditions causing pain. Patients and doctors on cue, to a background tune being piped by Purdue and Janssen, engaged in a dance about the management of pain. There were no problems for doctors prescribing for pain but if they had been prescribing the same drugs for addiction they would have been struck off.

Faced with the horrific consequences of this dance, FDA intervened in extraordinary fashion two years ago. In 2014, a century after the introduction of prescription-only status, FDA made a potent opioid, naloxone, available over the counter in US States who were willing to endorse this option. Given intravenously or nasally, naloxone can save lives by reversing the effects of an overdose by other opioids.

To murder is human. To mass murder needs a regulatory apparatus. We have no problem viewing Shipman as a murderer. But what about Purdue or Janssen? And what about the role of regulators from FDA to the GMC?

Go Figure: A Geek Tragedy


In 1939, in the laboratories of Geigy pharmaceuticals, Paul Mueller discovered that DichloroDiphenylTrichlorethane DDT killed insects more effectively that anything else then available.

Robert Domenjoz, the later creator of imipramine, had the job of evaluating it. He did the testing on lice that was to make DDT one of the best-selling pharmaceuticals in the world. He asked the Salvation Army to bring him two of the paupers who slept there and he bought their shirts – for their lice. He put the lice in small boxes which could be sealed with a sieve so that the lice could breathe. He attached the boxes to his arms so that they could live off his blood. Over weeks, they multiplied. When he had enough, they started testing DDT on them. It worked a treat.

Lice carried typhus, which killed more people in wars since Napoleon than the actual wars had killed. Domenjoz headed straight to the Swiss army who started using it and then presented the results at the American embassy in Bern. When the Americans invaded Italy soon after, the troops were all sprayed with DDT and pretty soon everyone who was liberated from the Germans was liberated from lice also.

After the war was over


After the War it became common to spray the public in cinema queues and at football games across Europe and America for instance as the photo shows. Mueller won the Nobel Prize in 1948. Domenjoz might have thought at the time he should have shared it.

As almost every ghostwritten article about all of the drugs in current use now says, DDT was very clearly safe and effective.

The use of DDT spread. The images most of us have now is of planes dusting crops with plumes trailing behind them.

Then in the early 1960s the wheels came off the bandwagon. By the time Rachel Carson’s Silent Spring was published, DDT was on the road to oblivion, with most of us thankful we had been saved from oblivion. DDT it became clear accumulated in the food chain, with small doses in some insects and crops, ending up as larger doses in the predators living on them,and larger and lethal doses in the birds, fish and other mammals living on them, or in their eggs or milk. And larger doses in us.

We had learnt that the acute effects of a drug given in a particular way might be dramatically different to the effect that came with chronic exposures or from unexpected routes of administration.

Wasn’t this what we learnt?

Geek tragedy

Controlled trials (RCTs) are all about establishing the acute effects of a drug given in a standardized way by drug companies who hope the verdict will be their chemical is safe and effective so that they can head out and put it in the drinking water (metaphorically). People will end up on these chemicals chronically and they will be mixed with lots of other chemicals in ways never imagined when the drug was first tested.

The result is biphosphonate drugs marketed to reduce the risk of fractures which increase the risk of serious fractures. Antidepressants marketed to reduce suicide risk, alcoholism, substance misuse, marriage breakdown etc which increase the risk of all these things, as well as causing Autistic Spectrum Disorder and birth defects. Statins marketed to reduce risks linked to diabetes which increase rates of diabetes, and to reduce the cognitive problems stemming from strokes but causing cognitive problems in their own right. RCTs miss all of these things – and when they don’t miss them as in the case of the antidepressants and suicide the data is fudged, sometimes fraudulently.

Far from recognizing the role of RCTs in producing a new Silent Sprint, RCT enthusiasts are spreading the word that we need more of them. No-one should be on a treatment who isn’t in an RCT. This is the script for a Geek Tragedy.

RCTs do more than miss the long term injuries a drug might do us. They get used to build standards of care to which doctors are obliged to adhere. Anyone who figures it might not be wise to add a sixth drug into the mix a person is on, or that thinks that maybe adolescent crises are not something that need medicating, will find themselves up against these standards of care facing managers who ask Who are you to go against the Standard of Care? Sorry we have to let you go.

Part of the tragedy is that we would in fact save vast amounts of money by giving the pharmaceutical companies 10 times the inflated prices they currently receive for drugs as part of a bargain where their marketing ensures that only 10% of those currently taking lipid-lowering drugs, antidepressants, biphosphonate and other drugs end up on them – and perhaps slightly higher proportions for hypoglycemic drugs, antihypertensives and antibiotics. The savings would come from shutting down osteoporosis screening services. From the savings on not having to treat treatment induced disabilities. From Elective patients (patients on cancer chemotherapy) not having their bed blocked by an antidepressant induced suicide attempt or biphosphonate triggered fracture of the femur, or a hypoglycemic episode (the biggest cause of brain damage) triggered by the use of extra hypogylcemic drugs being used to lower blood sugars elevated by the use of Statins that current standards of care mandate in diabetes.

Most of us thankfully won’t get tangled up in these elements of the tragedy – the final scenes where as in King Lear the corpses are strewn around the stage. For most of us the ending will more like the ending of a play by Samuel Beckett – The Algorithm will See You Now.

Go Figure on Perversity


In 1936, three workers at the Halowax Corporation in New York State, who had been working with chlorinated naphthalenes, developed chloracne – a skin condition that Viktor Yushenko’s face brought dramatically to world attention in 2004, when he was standing as the pro-Western candidate for the presidency of Ukraine.

Chloracne can be caused by many chlorinated compounds from vinyl chloride, through polyvinyl chloride (PVC) and polychlorinated biphenyls (PCBs). Many medicines are chlorinated. I have no idea if this chlorination, as in Zyprexa, olanzapine, for instance can be a problem but Zyprexa and other compounds can certainly give rise to chloracne.

The three workers went on to develop jaundice and then liver failure and died. Halowax had shortly beforehand increased the strength of the chlorinated compounds that went into their halowaxes, which were used as insulators for electrical wires.

The company called in Cecil Drinker, then the dean of Harvard School of Public Health. Drinker and colleagues had helped create industrial hygiene. In this case, the approach involved taking air samples and then testing the chemicals found in the air on laboratory animals – chlorinated naphthalenes and biphenyls. The new more intensely chlorinated compounds were in fact more likely to cause liver damage than the older mixes. The trick then was to find the dose that could cause this problem in rats, half the dose, set this new dose as the maximal exposure permitted, and then recommend ventilation and related measures that would ensure the factory milieu never reached these levels.

There was a tacit understanding that industrial hygienists would not recommend safe levels too difficult for factories to reach. Having undertaken work to manage the issues, factories were well placed in the case of litigation to show they had acted responsibly.

Your point being?

The problem was these tests measured the acute effects of chlorinated compounds – six weeks. They assumed the problems arose from inhalation. And they measured the average effects. This leaves no room for an unusual sensitivity to a chemical, or chronic exposure or exposure that arises from chlorides or related compounds absorbed in unexpected ways.

Vinyl Chlorides can be very safe if used acutely and with discrimination. They are among the materials of choice for dominatrix outfits – as in the featured image.

The vinyl chlorides however also give rise to dioxins. Viktor Yanushenko’s chloracne likely came from dioxin levels that were at 4000 times the safe level in his body. He survived this apparently very acute exposure, which is widely thought to have been a poisoning.

But the cancers that lots of other people have developed since have come not from poisoning by political opponents, or from Sexual Games even those that until recently might have been seen as perverse (longer than usual exposure, variations on the norm and… ), but from chronic exposure to much lower doses than were in the Halowax air in the form of dioxins that have ended up in the food chain.


Without any conspiracy involved, the best science of the day, stamped with a Harvard imprimatur, completely missed the problem. But it did give industry great cover, and helped create the Harvard Department of Public Health and now Global Health.

To be continued.

Go Figure: Digging for the Truth of Injuries

Quarry men

Editorial Note: In her comment, reproduced below, Sally was the person who best got to grips with what I was struggling with in last week’s post and this week’s and for the next few weeks. Drug induced injury is one sphere in which we get injured. Turning to other spheres may give us some ideas about how to handle the dilemma of a treatment induced injury – how to avoid being singled out the system, how to build a community that can resist and seek redress.

The Silver Lining Clouds the View outlined how working with mercury can cause a distinct psychosis or tremor or confusion that clears when the person leaves work.

But what about when a worker gets an illness like tuberculosis? This is not a specific industrial injury.

For fifty years around 1900, North Wales had the biggest slate quarries in the world. At a time when deaths from tuberculosis were falling in Britain, these quarries had increasing rates of tuberculosis and deaths. Repeated enquiries reviewed all options. Quarrying gave the workers silicosis. Did silicosis make tuberculosis more likely?

Local doctors said no. The problem was down to poor diet. The modern housewife spent too much time at school and her only domestic skill was the ability to use a tin opener. These medical views passed muster as the considered judgments of scientifically trained men.

Silicosis does predispose to TB. But, just as the mirror workers in Furth fifty years earlier took their chances with mercury, so too the quarrymen kept quiet about their chest problems. They steered clear of doctors. There was no other employment in the area if they were signed off. Both workers and employers knew that jobs in the mines were dying out.

You don’t have to silver a mirror or go down a mine to appreciate the psychology and politics at play here. You just have to take a medicine. Drugs come with risks. Even when things go wrong on treatment, short of being invalided, most people opt to cope with it, often silently, rather than own up. Owning up, especially if there is no treatment, makes you a loser, and the herd leaves losers behind. The injured worker or patient is like a dog barking at the passing caravan.

Your point being?

Sometimes truth is not something you dig for.

The link between treatment and injury may be a social one. The entire community may know what is going on. But the doctor will see a picture where it is not proven what causes what, and one of his options is to take your moral failings into account. This is often the most convenient option – for him, especially if you’re a woman.

This is a delicate world, a world in which there are no accidents if by accident we mean random events. An unexpected or unintended event is not an accident – although we use the word that way when we are knocked down by a car, and lawyers advertise their expertise in accidents. But Road Traffic Accidents, no less than Drug Traffic Accidents are rarely Acts of God.

An Act of God is when a cow jumps over a ditch and onto your car. In Road Traffic Accidents or Drug Traffic Accidents, someone has always been careless. It may be like the carelessness that started with the American Civil War when rifles that could hit a target at long range replaced muskets that couldn’t and all of a sudden troops could be picked off by a sniper. Being picked off by a sniper sounds almost random, but after the first time it happens, the military top brass are responsible for your death if, having seen what can happen, they do nothing to prevent it happening again.

If the event is not random, the question of responsibility comes into play. Before 1800 roughly we used to be able to attribute misfortune to God or Fate. It is now down to us. If I didn’t intend to hurt you, I am unlikely to concede that something I did in fact did hurt you. The bystanders, those with a superficial knowledge, will side with the likely winner rather than the likely loser, unless forced to delve deeper. Everybody takes steps to avoid being the person responsible, or on the side of the person responsible.

In nurseries for 4 year olds now if a mother brings in a cake on her son’s birthday, the staff will not let other children have a piece because they cannot validate her cake-making. A piece of cake will be put in a take home bag for the children, whose parents can let them have it, if the parents take responsibility.

For the loser in games like this, beyond the injury an identity is destroyed, as surely as if acid has been thrown in a face. I am now marked as a loser and the only people who can understand that are those marked in the same way. But no-one, not even a loser, likes the company of losers. The loser in the lottery of life will also likely lose any contest about what has happened her.

In the world of treatment induced injuries, God fails as an explanation. The modern replacement for God, Science, also fails. We are Shipwrecked and on our own.

Go Figure: The Silver Lining Clouds the View

The Mad Hatter

Editorial Note: Sally’s first Go Figure post with its 100 comments outlines the basic dilemma facing RxISK – how can anyone who has been injured by treatment get people who have not yet been injured to wake up. The next 5 – 10 posts will pick up various ways this dilemma has been answered over the last century. All comments welcome along with any posts – something more than a comment – anyone figures they have.

In 1861, the Furth Provincial Medical Association reported on mercury poisoning among mirror workers in the Furth-Nuremberg area. Along with Venice, Nuremberg was a center of the European mirror industry. The first Guild for Mirror Makers opened here in 1373. The craftsmen were using a technique developed in Venice of silvering the backs of mirrors with a mercury tin amalgam to improve the reflection.

The workers were suffering. Few complained. Their problems were only detected when they came to the doctor with other issues or if some new treatment, such as electrotherapy appeared, that some workers figured might be worth getting the doctor to try to manage the problems they were having.

The workers could see in the mirror exactly what mercury was causing when doctors hadn’t – a flush, tremors, irritability, and madness. It caused their feet to burn or go numb.

But against these risks, the only cure was to stop working which brought the certainty of pauperism and maybe death. So the workers lied to their doctors out of fear of losing their jobs. Besides pay was tied to risk – make the job safer and the rates of pay were likely to drop. Did they want a safer job or more pay? The factory owners denied the link.

Mercury had been causing problems for centuries. It was used in felt hats and caused confusion and disorientation to hatters, leading to the phrase Mad as a Hatter and to the Mad Hatter in Alice in Wonderland in 1865.

Administered as a paste for syphilitic sores from 1600 onwards it seemed to help them heal. This led to its use internally and after 1780 to the use of the stronger form – mercuric chloride or Calomel. Soon after this began to be used widely, dementia paralytica appeared, a psychotic disorder commonly put down to syphilis but which only happened where mercuric chloride was used in its treatment. The combination of syphilis and mercury likely did for Mozart (kidney disease), Beethoven and Schubert. See The Day the Music Died.

But in 1861 the link between mercury and health problems, always known at one level but persistently denied, didn’t go away. Adolf Kussmaul, a university physician, agreed with the link the Furth “general practitioners” were proposing.

There was another factor. Chemistry was flourishing and Justus Liebig and others came up with alternate ways to silver mirrors. Mercury was no longer needed and in 1886 its use for silvering was banned.

Your point being?

Faced with a plague, many of us emigrate, a smaller number stay and resist, but most of us get on the train. It is only if there are options that anything else happens. In Furth there were options in terms of new ways to make a living and perhaps some unusual doctors.

In 1848, revolutions across Europe led to changes of government. Doctors played a big part in these uprisings as they had in Paris in 1790. Two of the revolutionaries in Germany, Rudolf Virchow and Karl Marx, had an enduring impact on politics and healthcare politics. Virchow saw doctors as a revolutionary class, where Marx saw workers.

Industrial health issues, exactly like those the Furth mirror workers demonstrated, triggered the formation of a German Workers Association in 1863. A German Socialist party appeared in 1869. There was a growing number of strikes. In 1869, the response from Bismarck, the German Chancellor, was a Factory Act that left owners free of obligations other than those they voluntarily took on. Factories were regarded as private property – not part of the public realm, and not subject to inspections.

In 1875, the Worker’s Association and Socialist party merged to form the Socialist Workers Party, later the Social Democrats. The socialists accepted the validity of the state and the need to work with its institutions to bring about change – workers health and safety were a critical testing ground for whether this was possible.

Industry argued that technology was so diverse and growing so rapidly that it was not possible to legislate in a way that would work. Bismarck again accepted the employers’ argument that money put into health and safety was a tax on jobs and at a time of growing international competition this was not in the national interest.

In 1878, he enacted a set of punitive Anti-Socialist laws.

But he also took another step. Just as the Republican President Dwight Eisenhower put in place a program of interstate highway construction in the United States in the 1950s as a form of state socialism, so in the 1880s Bismarck put State sponsored health insurance schemes on the table as a means to stave off revolution:

“A duty of a state preserving policy should be to cultivate the conception among the non-propertied classes which form at once the most numerous and the least instructed part of the population that the state is not merely a necessary but a beneficent institution”.

The certification or not of workers as sick was a new role that opened up for doctors, a source of income. But it also made them part of the apparatus of the State. They “matured”. As Adolph Beyer in a lecture to the German Association for Public Health in 1877 put it:

“Precisely in this field, prudence and caution are necessary and one should not try to support a safety which risks or neglects the main priority, the securing of the daily bread. That is why it is necessary to openly oppose those immoderate demands which hide behind their pleasant mask of safety and humanitarian ends quite different aims. One should not let emotions reign, but considerations and experience”.

Welcome to Troy

A lot people it seems have been singing and dancing in the street at news last week that AbbVie the pharmaceutical company that make Humira have dropped a legal action against the European Medicine’s Agency (EMA) that was aimed at blocking any access by researchers or others to their clinical trial data.

Stacy of Arc

Not everyone will be pleased though. Stacy London might wonder whether she should fire her advisers. She could have featured as a Joan of Arc leading a RxISK campaign against oppression had she responded to our Open Letter to Stacy. She might be sitting pretty now had she adopted a position that Humira can be a tremendous drug but hiding clinical trial data is just not acceptable. But we got no response, and it didn’t seem fair to harass her.


AbbVie’s action was set in train several years ago when one of medicine’s most extraordinary figures, Peter Gøtzsche from the Danish Cochrane Center took a case for access to clinical trial data to the European ombudsman and won a ruling that the European Medicines’ Agency should make the data from clinical trials submitted to them for regulatory purposes available more generally. This was a wonderful breakthrough. In November 2012 EMA convened meetings to work out the ground rules for what was expected to be the new way of doing things.

But on April 30th 2013 just as the post Brand Fascism was posted on saying that we might all be better off if company efforts to hide their data were successful, a legal action was taken in the European Court against EMA’s data access by two companies. AbbVie and InterMune.

Rights to privacy

AbbVie applied to block access to two clinical study reports that focused on the safety and efficacy of their blockbuster Humira, responsible for 70% of the company’s profits. The reports were on its use for the treatment of Crohn’s disease. Another clinical study report concerned safety risks linked to combinations of Humira and corticosteroids.

InterMune tried to block disclosure of data on its only drug Esbriet, an anti-inflammatory drug it hopes to push for the treatment of a lethal – largely drug induced condition – idiopathic pulmonary fibrosis. Esbriet might weirdly become the first drug to become a blockbuster out of managing an adverse effect caused by other drugs.

AbbVie and InterMune claimed that the decision to provide access to all clinical data violates their’ ‘fundamental right to the protection of confidential commercial information’, and their ‘legitimate expectations’, and copyrights they hold. The bottom line is company rights to privacy are being breached.

RxISK petition

This legal action led to an enormous brouhaha. RxISK got involved and over 6000 of you from over 120 countries signed our petition calling on AbbVie and InterMune to drop their action – See Extreme Petitioning.

There is a wonderful moral case to be made for transparency of clinical trial data and a compelling case to have a petition to raise awareness of the issues more generally but as we made clear in a number of posts almost anything in this area is hazardous.

Welcoming AbbVie’s apparent dropping of their action feels terribly like the Trojans welcoming the apparent departure of the Greeks and opening a hole in the City Wall to haul in a Wooden Horse. We scream at them not to.

Trojan horse

The press coverage of AbbVie’s withdrawn legal action suggests that most major companies have now embraced an option for transparency pioneered by GSK.

All Trials are among those taking credit for pressuring AbbVie into submission. They have aggressively welcomed the offer by GSK to make clinical trial data available with no questioning of the terms on which the data is being produced.

But GSK’s offer is a manoeuvre worthy of Ulysses himself. You’d never guess from company self-congratulation that it was forced on GSK by a New York Court as part of the resolution of a Fraud action. The Fraud Action happened because GSK had written up a positive portrayal of a trial when in fact the company itself thought the trial had shown their antidepressant, Paxil, did not work.

The trial – Study 329 – was test of Paxil in children. As mandated by the Courts in the wake of Study 329, GSK put up company study reports for all of their trials, Paxil and other drugs including the diabetes drug Avandia. These could be downloaded. Steve Nissen of the Cleveland Clinic did just this for the Avandia reports and was able to show that Avandia killed. A company blockbuster was stopped in its tracks.

Poacher turned game-keeper?

Putting study results up on the web must have seemed like a very bad idea to GSK. So why are they now championing data access?

GSK and other companies are reaping kudos for apparent transparency. And they can say with a straight face to any TV anchorman or Congressional committee that they are making data available.

But in fact here is what is happening. Having seen what happened with the Avandia study reports GSK now know what to do when writing a Study Report to avoid a repeat. Suitably Doctored Study Reports for other drugs will go up on their website.

The Study Reports however do not contain the data. A first approximation to the data in the case of Study 329 comes in a series of 7 appendices to the 329 Study Report – something GSK did not put up on the company website until the omission was spotted nearly 10 years later by Peter Doshi and New York State required them to do so.

In the case of Study 329, the ghostwritten article that led to GSK being sued for fraud, is 11 pages. The Study Report is over 700 pages. There are then 7 appendices that between them come close to 5500 pages. Even this however is not the raw data. The raw data lies in Clinical Report Forms.

You can look but you cannot see

As things stood before GSK’s offer of transparency, the 5,500 page of appendices and 700+ pages of the Study Report could be downloaded and printed off. Finding what went on in a clinical trial from paperwork like this is a bit like playing Memory – where there a bunch of cards with faces or plants or whatever turned face down and if you turn one up you have to remember where the matching face you turned up before is. It can be done with 5,500 pages printed off.

GSK open science

But playing Memory is much harder to do now with the new improved access GSK is offering.

If you apply to access a GSK trial now you are forced to submit an analytic plan which essentially stops an applicant from accessing any adverse events on the drug. Adverse events are the material the company tries hardest to hide.

Should you get access to the full set of appendices that contain company listings of adverse events, there is almost no way to play the Memory Game because access is through a remote desktop. It may be that a younger generation used to playing Digital Memory will be able to work the system, but it’s not easy. It takes multiple passwords to access the desktop. You are logged out regularly. And while on the desktop, GSK can monitor your every keystroke.

Nightmare in Harlow

But here’s the rub. To really nail down what’s going on, you need access to the approximately 70,000 pages of patient level data. Through a remote desktop this becomes a nightmare.

This scheme to deliver frustration cloaked in the appearances of transparency was devised several years ago. The history of the idea was outlined two years ago in May Fool’s Day. Last year the details of GSK’s scheme were outlined in April Fool in Harlow.

Selling a message to the media and public that the appearances of more transparency are being used to hide the data is not an easy sell. Telling them that companies can devise trials that use a problem their drug causes to hide a problem their drug causes is something that makes the machinations of House of Cards seem innocent. A nice company like GSK or AbbVie wouldn’t do this.

Let’s do the AbbVie again

But we are not faced with an insoluble problem. Company efforts reveal their Achilles Heel. They are vulnerable to adverse event data. And this is where the original RxISK campaign to get people to do the AbbVie comes in. The more people who report adverse events in good quality reports and get their doctors on board in helping them grapple with the issues, the more between us we can restore sanity.

This led to the creation last year of an AbbVie – the opposite to a Boycott.

We asked you to pay close attention to these drugs – shine a spotlight on them – and communicate with them and each other rather than shun them. If you are part of any of the patient organization dealing with Crohn’s Disease or Ulcerative Colitis, such as the Great Bowel Movement, or arthritis you may be able to spread the word rapidly and mobilize many people. If you are Stacey London, Phil Mickelson or Mick Jagger you could make a big difference – Mother’s Little Poisoner.

The beauty of this that unlike the nineteenth century Irish tenant farmers who had to endure the hardship of not earning a living off Boycott’s farms, doing the AbbVie will not hamper your treatment or access to treatment in any way. Just the opposite – it will improve your treatment.

A good medicine is a chemical plus good information. GSK, Lilly, Pfizer and AbbVie want to degrade the quality of your medicine in particular and all our medicines in general by restricting access to key information on the full range of things these drugs do. We need to tell them this is unacceptable. The best way to do this is to share unexpected events on treatment in a forum they can’t block and to shout louder when told to keep quiet.

Illustrations: © 2013 created by Billiam James