Latest Drugwonks' Blog
Henry Miller on Susan Wood and revisionist history …
Susan Wood laments that “our federal health agencies seem increasingly unable to operate independently and that this lack of independence compromises their mission of promoting public health and welfare.” However, Ms. Wood is a fifteen-year veteran of the federal government, which makes one wonder where she spent the 1990’s.
Although there is no question that many of the Bush administration’s science-related appointments and its record leave much to be desired — witness the litmus tests for appointees to science-related positions, distortion of information to consumers about health and safety issues, antagonism toward embryonic stem cell research, and the FDA’s apparently politically motivated decision not to permit over-the-counter sales of the Plan B morning-after contraceptive — the Clinton administration’s blatant perversion of science was even more pervasive and egregious.
As President Bill Clinton’s science and technology czar, Al Gore was entrusted with choosing many top appointees to regulatory agencies, thereby obtaining the leverage to politicize the administration’s policies and decisions. There was no room for dissension or respect for data-driven policy in the Clinton administration, no participation in the marketplace of ideas unless you were a true believer and toed the party line. And on many environmental and public health issues, it was a very radical party line, indeed.
As to the politicization of decision-making, I was a senior FDA official at the time and, like many of my colleagues, was appalled at the willingness of then-FDA Commissioner David Kessler to take orders from above about which products should be expedited and which delayed by regulators. For example, the agency approved a dubious female condom after being informed by the secretary of HHS that it was a “feminist product,” and that delay was not acceptable; and FDA officials went to extraordinarily lengths to look for reasons not to approve biotech-derived bovine somatotropin, a veterinary drug, because the vice-president’s office considered it to be politically incorrect.
At a recent conference of biotech executives, frustration seemed to be the order of the day with venting the inevitable result. Both are understandable. The remarks (dutifully reported by Lisa Richwine of Reuters and reprinted below) show an industry and an agency engaged in a life-or-death battle. Actually, two life-or-death battles. The first is corporate survival, the second, patient survival. And while saving lives is more important than making money (is it even necessary to say that?) you can’t have one without the other. No biotech industry, no new lives saved, extended, or enhanced.
The general frustration is the on-going dichotomy of predictability versus ambiguity at the FDA. One reviewer deals with a sponsor one way while two doors down data is addressed in an entirely different manner. Predictability is power in pursuit of the public health. And while that’s always been true, today it’s become an urgent public health imperative.
Reform is crucial. Or should I say “critical” … like in Critical Path.
Here’s the Reuter’s article. Read beyond the frustration and the venting and you’ll see an opportunity for greater collaboration between regulators and regulated. A high-wire balancing act? Certainly. But one well worth the effort.
Business as usual is not an option.
Biotechs say FDA ranges from good to ‘horrifying’
By Lisa Richwine
BOSTON (Reuters) — Biotechnology companies trying to get new drugs to the market have had experiences with U.S. regulators that range from productive to “horrifying” as they craft early development plans, senior executives told Reuters this week.
Interactions can vary vastly between Food and Drug Administration divisions that review products and provide guidance to companies long before they seek approval to sell a drug, company officials said.
“We have some very good experiences and we have had some horrifying experiences, where you wonder, ‘Where did that come from?’” Genzyme Chief Executive Henri Termeer said at the Reuters Biotechnology Summit in Boston. “What is reasonable and what is not reasonable differs by individual … It’s quite frustrating,” he added.
FDA officials have acknowledged inconsistencies, or a lack of clarity, from some reviewers during early stages, when companies are seeking input on how to design clinical studies of experimental medicines. They have pledged improvements and launched major efforts to work with manufacturers earlier in the process to help more drugs make it to the market.
The agency holds more meetings than ever with drugmakers, more than 2,000 annually.
“We believe more and better interactions will lead to better outcomes and have invested a lot of resources in these efforts,” Scott Gottlieb, FDA deputy commissioner for medical and scientific affairs, said via e-mail. The FDA also is providing guidelines on how to develop better applications, he said. Officials will announce other measures to improve the review process soon.
Biotechs can face more challenges than traditional pharmaceutical companies. Many biotechs are small, inexperienced and testing their first product. Their technology may be new and unfamiliar to regulators.
Alnylam Pharmaceuticals Inc. CEO John Maraganore said his company has had “remarkably good” dealings with the FDA on efforts to develop treatments based on a new “gene silencing” technology.
“You can engage them in a science-based discussion … People that run into troubles don” engage them in that type of dialogue,” he told the Reuters Summit.
FDA staff are very responsive on potential breakthrough drugs, said Ariad Pharmaceuticals Inc. CEO Harvey Berger. Having “fast-track” status for promising medicines helps insure regular communication, he said. His company’s employees talk often with the agency in person and on the phone and get answers to questions within days. “I think the key is you have got to have a drug that they see a real opportunity for,” Berger said.
Cell Therapeutics Inc. CEO Jim Bianco agreed FDA staff will move quickly for drugs that are “sexy,” but said less exciting, though still important, medicines can get left behind. His company has been frustrated in its development of a cancer drug, Xyotax, which he described as a traditional chemotherapy medicine with fewer side effects.
European regulators are open to clearing the drug based on evidence it is equivalent to other chemotherapy, rather than superior, because it has less toxicity, but U.S. regulators are not, Bianco said.
FDA staff “are not equipped to handle that,” he said. To the agency, “standard chemo is not what moves the field forward,” he said.
Genzyme’s Termeer said it has become easier to deal with European regulators, who routinely approve his company’s products before the FDA does.
“The Europeans are willing to delegate much more of the process … to expert opinions. Much more of the work is done outside the bureaucracy,” he said.
Remember the January 30th Federal Register notice where FDA said they were going to investigate whether or not coupons in DTC ads were legit because they might “foster consumer misperceptions about the advertised prescription drug product.” Well, they’ve withdrawn it — quietly. When asked why the agency replied, “The agency withdrew the notice because the matter required additional consideration.” Well said. Translated that means (and this is my best guess) that cooler heads in the agency (most likely in the Office of Chief Counsel) pointed out that FDA has no authority to regulate this area.
Good decision. Good press statement. Face is saved.
Plastics.
It was good advice in “The Graduate,” but it’s bad news for internet profiteers masquerading as pharmacists.
Both Visa and MasterCard rules prohibit the processing of any illegal transactions such as those from illegal online pharmacies. Both card companies have issued fines for doing so. Several online pharmacy accounts, in fact, were recently terminated as a result of card Association and member bank pressure.
To do business with online pharmacies it is required that the member bank conduct an investigation for every online pharmacy. This will include providing a copy of the pharmacy’s license, a statement that the merchant’s sales activity is in compliance with all applicable laws, proof that valid prescriptions are required before medications are dispensed and proof that only prescriptions from licensed physicians are accepted.
Any questions?
The Ol Perfessor (in this case, the young and vibrant Dr. Bob Goldberg) tells it like it is …
The study put out by the Democrat minority staff of the House Government Reform committee, “Medicare Drug Plan Prices Are Increasing Rapidly,” is misleading and inaccurate in many respects.
It deliberately leaves out drug plans that allow patients to pay a fixed low price for all the drugs they survey. There are many drug plans that allow consumers to pay $30 for a month’s supply of each drug (or $25 a month if purchased through mail order). All these prices are substantially lower than any of the average prices cited by the Democrat staff. For example, the Democrat House staff quotes average prices of about $150 for a month supply for Aricept and Advair whereas most plans quote about $27.
Nor does the study does control for different co-pays and prices for drugs depending on its tier placement. Zocor, Prevacid and Lipitor have been shifted into higher co-pay and price tier by some companies and not others. At the same time, some companies have pushed Celebrex off their formulary and raised prices accordingly while others have kept it on formulary.
Even when these errors and oversights are taken into account, a significant number of companies offer drug prices lower than those quoted by House Democrat staff. In many cases the prices quoted by the various plans are about 75 percent lower than the average price cited by the House Democrat staff.
Like Casey said, you can look it up.
I recently had the privilege of a private meeting with Nobel Laureate Joshua Lederberg. The topic of conversation was the future of the FDA and the agency’s Critical Path initiative. We talked about the state of applied research and “the texture” of the agency, the prioritization of development science, biomarkers and a host of other future-oriented issues. He talked. I took a lot of notes. At the end of the meeting he put everything into perspective in a single sentence. He leaned over the table and said, “The real question should be, is innovation feasible?”
I hope so.
Smart thinking from Bob Goldberg, CMPI’s new Vice President for Strategic Initiatives …
Meet the challenge
By Robert Goldberg
Published February 21, 2006
The Washington Times
Democrats are gearing up to make health savings accounts and Medicare battering rams against the Republican Party in in the midterm Congressional elections. Liberal think tanks and congressional Democrats first attacked the Medicare drug benefit as a “a complex program that does nothing to bring down the costs of soaring drug costs.” Now, they are trashing health savings accounts as a tax shelter for the rich without offering an alternative of their own.
They don’t have to. The Bush administration and congressional Republicans have done a poor job responding to criticisms of the Medicare drug benefit and HSAs. Conservatives and think tanks have largely stood on the sidelines as the beating has taken place. Many think they are standing on principle, but in fact it reflects a lack of vision on their part.
The fact is, most conservative think tanks and conservatives frame Medicare and health insurance in terms of reducing health-care costs. As a result, they cede the moral high ground on the health-care issue that is all about coverage and quality of care. Similarly, as I have argued before, conservative griping about the cost of the Medicare drug benefit has blinded Republicans to the fact that Medicare modernization is counterweight to single payer health care.
Liberals complain that even if HSAs become the norm, they won’t slow health-care costs because 80 percent of all health-care spending is incurred after the high deductible ($2,100) is met and would still be generated by consumers using insurers’ money instead of HSAs. That’s true. Then again, the same thing is even more true about single-payer systems or managed care plans where the out-of-pocket cost are nearly hidden.
In either case, it’s the 20 percent of people with chronic illness that generates 80 percent of the cost. Medical progress, not administrative machinations, will reduce the cost of disease.
Conservatives are doomed to lose the HSA debate because they regard them largely as cost cutting tools. To the extent that anxiety about health care coverage is at the heart of uneasiness about a vibrant economy, it behooves the Republican Party to retool their health-care message in general and their HSAs policy in particular.
Republicans must commit to expanding and protecting medical insurance for all Americans. HSAs should be hailed as one way for achieving that goal. Last year, people with incomes of $35,000 or less per year were the fastest growing segment of HSA-eligible health insurance plan purchasers. Sales to this segment grew 104 percent over 2004. MIT economist Jonathan Gruber estimates that more than 1 million working class people will lose their insurance as a result of HSAs being offered. He doesn’t explain why. Maybe the 1.5 million lower-and middle-income people, who were previously without insurance were too stupid to follow an MIT economist’s theory. They actually obtained obtain insurance that included well baby visits, prescription drugs, ob-gyn care and other medical care for about $125 a month, less than what they paid last year.
To continue to boost and maintain insurance coverage among low and middle income Americans, the Republicans should introduce legislation that allows employers to put the full amount of the deductible into HSAs in order to eliminate any out of pocket cost. Working-class and poor families should receive pre-funded debit cards for HSAs with the full deductible amount as well.
The Department of Health and Human Services could help people comparison shop by posting Medicare prices for every single service. It could work with WebMd and other private health-information services to share news about who is doing a good job delivering medical care. Further, since most people rarely spend more than a small percentage of their account, the legislation should allow unused funds — as well as any additional monies contributed by the individual to be used tax free to pay for health care premiums during periods of unemployment as well as any deductibles or co-pays.
Third, HSAs must be compared to liberal efforts to prop up a single-payer and an employer-based health system that is providing less coverage for more money each year. Liberals are responsible for the loss of health care coverage in America. Now they shriek that HSAs would leave less money for subsidizing the increasingly expensive health insurance demands of labor unions, demands that send jobs overseas. Meanwhile, HSAs are giving more working class people more coverage they can keep and call their own for less money.
HSAs are not for everybody or a panacea. They’re only part of a long-term effort to expanding access to health insurance. But if Republicans frame the HSA debate in terms of coverage, they can stop playing defense on health care. First, they have to get passionate about the value of medicine and not what it costs.
Robert Goldberg is vice president for strategic initiatives for the Center for Medicine in the Public Interest.
According to an article in today’s edition of The New York Times, psychiatrists say they have been getting panicked phone calls from patients worried by an FDA advisory panel’s recommendation this month that drugs for attention-deficit disorder carry a prominent warning about heart risks.
Can you say “unintended consequences?”
The calls are coming not just from parents of children who take the drugs but from adult users, who the panel warned might be at the highest risk for heart problems.
Can you say, “irresponsible advisory committee causing increased non-compliance?”
“Every single adult patient I saw today, the first thing out of their mouth was, ‘Am I going to drop dead on this?’ Every single one of them,” said Dr. Timothy Wilens, a psychiatrist at Massachusetts General Hospital in Boston.
Can you say “fear replacing caution?”
Can you say “Precautionary Principle?”
Because if you can’t say it, you can’t fight against it.
And fight against it we must.
The just completed WHO meeting on counterfeit prescription medicines is over. And what took place in Rome should have a chilling effect on us all.
Consider these few facts (direct from WHO, so nobody can say they’re “industry” numbers) —
Between 1998 and 2004 there has been a 1000% increase in seizures of counterfeit prescription drugs
That is not a typo. A 1000% increase.
Between 2001 and 2004 there were 170 official cases of counterfeit medicines originating from an illegitimate supply chain
And most frightening …
Between 2001 and 2004 there were 27 official cases of counterfeit medicines that originated from the legitimate supply chain.
Sound frightening? It is.
Action is required.
While some in the US still don’t believe that counterfeit prescription drugs are a real problem (“Show me the dead Canadians!”) Europe is taking it dead serious.
On Wednesday, the Center for Medicines in the Public Interest (home to this blog) and the Brussels-based Centre for the New Europe co-sponsored a conference titled, “A False Sense of Security — The Growing Threat of Counterfeit Prescription Products.”
Shortly I will post all of the presentations from that event. A book will follow.
The next day (last Thursday) the World Health Organisation and the international pharmaceutical industry launched a global taskforce aimed at stemming “the growing epidemic” of counterfeit drugs that has become a magnet for organized crime.
Here’s what the Financial Times wrote on the subject …
On some estimates, fake drugs account for more than 10 per cent of the medicines market worldwide, worth nearly 40bn US dollars (34bn euros, 23bn pounds) a year. But in developing countries that proportion is more like 25 per cent and in some countries it may be as high as 50 per cent.
Howard Zucker, WHO’s top official on pharmaceuticals, said: “People donç©° die from carrying a fake handbag or wearing a fake t-shirt. They can die from taking a counterfeit medicine.”
The taskforce will focus on strengthening national laws and enforcement, raising awareness by consumers and health professionals, improving international co-operation and developing “innovative technology solutions” including electronic tagging to track fakes.
However, WHO is no longer pressing for work to start on an international treaty to tackle counterfeit medicines, which critics feared could simply serve as an excuse for delay and inaction.
“Clearly what’s needed here is action and we don’t need a convention to take some action,” said Harvey Bale, director general of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), which is co-sponsoring the Rome conference.
The Centre for Medicines in the Public Interest has predicted that counterfeit drug sales could nearly double to $75bn by 2010. While the problem is worst in poor countries with weak regulation and enforcement, where counterfeiters fake medicines for life-threatening diseases such as malaria, tuberculosis and Aids, much of the growth is fuelled by internet sales into western markets.Counterfeiters are now focusing not just on “lifestyle” drugs such as hormones and remedies for erectile dysfunction, but also expensive treatments for cancer and drugs in high demand, most recently the anti-viral Tamiflu.
The absence of criminal laws against counterfeiting in many countries has encouraged organised crime rings to enter the business.
“Organised crime is gravitating towards the industry because the risks are a lot less than forging currencies or trafficking heroin,” said Mr Bale. “You can make a fortune, at no risk.”
Dr Zucker said: “International police action against the factories and distribution networks should be as uncompromising as that applied to the pursuit of narcotic smuggling.”
WHO said it planned to extend to more regions a web-based system for tracking the activities of drug counterfeiters it set up last year to link national health authorities and other agencies in the western
Pacific.
As I arrived back in the US my mobile phone rang. It was a radio station in South Korea wanting to interview me on the fact that North Korea is now in the business of counterfeiting prescription drugs for profit. The world is paying attention. So must we.
It’s time for US regulators to join this working group and address the problem from a truly transatlantic perspective.
The lives we save may be our own.
Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.
