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“Medical Conspiracy?” Part II

Published: April 8, 2014

The medical profession moves slowly to embrace new treatments. The public is well-served by this given the pervasive nature of panaceas, miracle foods and dubious devices touted to improve health. There is an old saying: “you never want to be the first to do something”. It has a second part, however, which is “nor the last”.

In the treatment of ED most doctors are coming in late, or not at all. American primary care physicians have embraced PDE5 inhibitors in a lukewarm fashion. Again and again we see patients in our clinic whose doctors were reluctant to even prescribe Viagra. Large HMOs like Kaiser or the VA provide patients with some of these meds, but only a few per month, as a rule. Which drug they give out has more to do with the contracts they worked out with the pharmaceutical industry than what is best for the patient.

The situation with Trimix is far worse. Urologists drag their feet in ordering it. They often steer patients away from it completely despite the fact that injections produce satisfactory results in most men at a fraction of the cost of implant surgery. Per-does Trimix treatment is cheaper than PDE5 inhibitor pills. It defies logic that surgery costing tens of thousands of dollars is often covered by insurers, while Trimix is not, but that is reality.

Is this a kind of medical conspiracy?

We see many patients whose urologists refused to test them for Trimix. We are not quite sure what their reasoning is, but I know from speaking to them time constraints are a big factor. At Kaiser, for example, doctors are compelled to move patients in a snappy way. Evaluation for Trimix dose levels, however, require a 90 minute visit. Something this time-intensive is guaranteed to not be popular with administration.

For their part insurance companies treat erectile dysfunction as a “lifestyle” matter. In avoiding the treatment of ED they dodge pay-outs. Perhaps insurers cover implant surgery (despite its great expense) because few men are willing to do it given that it is a major surgical intervention with lackluster effectiveness. It is easy to imagine the bean counters in HMOs (and insurance companies) wanting to avoid the whole area.

Not accepting this liability surely saves them money that would otherwise go to treat the millions of men currently going without, but this whole thing is puzzling. And it gets weirder when we re-visit data on anti-depressants from previous blogs.

SSRI antidepressant medications have little value for anyone not suffering from a major depressive episode, yet they continue to be used for patients with mild or moderate depression including Fido’s separation anxiety. Since 11% of the American population is on an antidepressant drugs according to the CDC, this puts the absolute number of recipients somewhere around 34 million people.

If we assume that the rate of sexual dysfunction associated with these medications runs 30 to 70% (which is where most such drugs place when one examines this – see prior blog) then antidepressants themselves would be at the root of not just millions, and possibly even tens of millions of cases of sexual dysfunction; including ED, loss of libido and problems with orgasm.

This startling fact seems to have not sunk in with prescribers or patients.

As discussed previously most patients diagnosed with erectile dysfunction in America receive no treatment to go with their diagnosis. Given the continued popularity of antidepressant medications it seems certain that the startlingly high numbers of patients with significant “non-transient” side effects will climb higher. Most disturbing, perhaps, is the fact that nobody seems sure how to translate “non-transient” into probabilities of the side effects, nor estimates of their duration. How many will have a permanent disability? The patient and physician could and should use such probabilities to help their decision making, but the data seems impossible to come by.

In our clinic the number one and two diseases which bring people to us are diabetes and hypertension. Causation is often multifactorial, so we are hard-pressed to ascribe an exact cause to any given man, but about 30% of our patients with ED have antidepressant use in their medication history.

America’s primary doctors time is ever-more limited. It is easier to write a prescription than spend lots of time talking to patients. And patients often do not feel the doctor has “done something” unless they get a prescription. Add this to the economics of HMOs, big pharma and insurers and it is easy to understand why we have gone overboard in using antidepressants. They are cheaper than alternative therapies for HMOs and insurers alike, while creating a ten billion dollar market for the pharmaceutical industry. The doctor does something, the patients gets something. Everybody wins.

Except if the drugs don’t really work nobody wins, and to a large degree they do not work. And as we have seen, there is a huge, if overlooked, problem with their use.

If antidepressants are being overused; treatments for ED (in particular Trimix), are underused. This requires more explanation than economics. Economics is involved. By dodging such therapy money is saved by insurers and HMOs that seems clear. Yet the pharmaceutical industry has a different incentive. It has done well with Viagra, Cialis, and Levitra. Why most American’s men with ED are going untreated (with pills at least) cannot be laid at the feet of big pharma. They promote their drugs. What is going on?

The explanation seems to lie with the resistance of physicians to getting involved. Not having a sex life is not going to kill the patient, so many doctors think sexual health is relatively unimportant. Medical students were taught decades ago that ED or “impotence” as it was called then was 80% psychological. While we now know this to be untrue the stigma of this affliction being a “mental condition” seems to still hang over the field.

We find it highly disturbing that physicians have remained resistant to getting involved. We think sexual health is very important. Practitioners should not be squeamish about discussing it. A number of patients still come to us with that “80% in-you-head” figure quoted to them by their physician, who is skeptical we will be able to do much for them. Many men come to us, after being denied even a prescription for Viagra by their doc – who counseled them that we will probably not be able to do anything to help them. PDE5 inhibitors and/or Trimix do fail be we prove these pessimistic doctors wrong about 90% of the time. This is not because we are magicians. The fact is, these are good medicines. If they get used they will generally produce good results.

Unlike antidepressant Trimix comes in many formulations produced by compounding pharmacies. A practitioner can pick one concentration, and have the patient experiment with dosing, which we do NOT recommend. That is a haphazard approach. It is far better if the doctor can order a concentration based upon the patient’s response to a test dose. This requires a bit of extra work, and will mean that the patient’s initial visit will take 90 minutes.

Such a consideration should not be a large hurdle, but it seems to be hindering the entire process.

PDE5 inhibitors serve 60% of ED patients well, but they do fail, for one reason or another, to satisfy the needs of the remaining 40%.

The majority of this 40% will find Trimix to be of value of them, and doctors need to wake up to this fact.

We plan to keep sounding the alarm about it. So too should patients.