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'Chamomile will not be prescribed here': a Russian-speaking pharmacist told what medicines are taken in the USA

Do you want to know how much the most expensive medicine in the world costs? Is it true that Americans love antidepressants? What is evidence-based medicine? "Voice of America" talked with clinical pharmacist Elena Vagicheva about American medicines and the specifics of her profession in the United States.

Photo: Shutterstock

Is it true that everyone in America takes antidepressants? Is it true that the most expensive drugs in the world are made in America? Is it true that in America they don't know that tea with raspberries helps against colds? Elena knows everything or almost everything about medicines. She even knows what the connection is between pharmaceuticals and the most famous soda on the planet.

Cola as medicine

According to some statistics, 94% of the world's inhabitants have heard of the Coca Cola brand at least once; the drink is officially sold in all countries of the world, except Cuba and North Korea. Coca-Cola was invented by pharmacist John Pemberton in Georgia. He served in the army in the civil war and was wounded there, and then became addicted to morphine. In search of a cure for addiction, he experimented with coca, as well as wines, and created his original cocktail, which he called Pemberton French Wine Cola. In 1885, Prohibition was introduced in the state and the pharmacist had to make a non-alcoholic version of his drink, replacing alcohol with caramel syrup.

The original version of the drink contained about 8 mg of cocaine. It began selling at Jacob's Pharmacy in downtown Atlanta for just 5 cents a glass. Coca-Cola was originally advertised as a drug for the treatment of morphine and opium addiction for war veterans, but was later recommended for depression and nervous disorders.

In the Soviet Union, Pepsi-Cola began to be produced and sold earlier than Coca-Cola. In a historic photo taken at the American National Trade Fair in Moscow in 1959, First Secretary of the CPSU Central Committee Nikita Khrushchev tastes American soda and a similar drink made in Moscow specifically for the exhibition. After the tasting, Khrushchev said that the Soviet Pepsi-Cola is better than the American one.

Pepsi-Cola was invented in 1883 by the American pharmacist Caleb Bradam from North Carolina. At first he called it “Brad's drink,” and then a couple of years later renamed it Pepsi-Cola, from the word pepsis from the Greek for digestion and cola from the caffeine-containing cola nut. He wanted this drink to help with digestion and give energy. He prepared it in his own pharmacy and sold it there.

How to become a pharmacist in America

Training to become a pharmacist in the United States is a rather long process that can take from 6 to 11 years. About 20 years ago, a new regulation was introduced that obliges every pharmacist in the United States to obtain a doctorate. The pharmacy school itself, or college of pharmacy, takes 4 years, but in order to enter it, you need to already have some kind of basic education, which would include courses in natural sciences, such as chemistry, physics, biology. The competition is pretty big. When Elena entered in the middle of the 200s, 1200 applications were submitted for XNUMX places. The training is quite complex.

To work in the United States, a pharmacist must be licensed by the state where he lives and works. To do this, you need to pass exams, including knowledge of federal and state laws, which may vary depending on where you live. To maintain licensing, you are also required to take courses continuously.

A clinical pharmacist is a pharmacist who has received additional education and training, usually in the form of residency, and also works very closely with other medical professionals in the selection of drugs and treatment regimens. Also, clinical pharmacists advise patients on the properties and dosage of drugs. Clinical pharmacists can work in very different fields: hospital specialists, infectious disease specialists, they work in dialysis departments or organ transplant departments. Their task is to recommend certain drugs and to make sure that the prescribed drugs are the most effective and safe at the moment.

In polyclinics, clinical pharmacists often provide individual patient appointments. People come by appointment and a pharmacist helps them sort out their medications. Before admitting a patient, a clinical pharmacist reviews the patient's medical history, liver function, kidney function, and medication history. Let's say you are taking 12 different medications that are prescribed by different doctors. At your clinical pharmacist appointment, each will be discussed with you, focusing on the effectiveness of each drug, and a side effect analysis will be performed. Maybe your headache isn't the result of stress, but a side effect of a certain drug. We will also analyze the compatibility of all drugs, as well as prescription drugs with vitamins and dietary supplements that you are taking.

It is important to emphasize that a clinical pharmacist cannot diagnose. He can only select treatment in the presence of a diagnosis, monitor, change the dose of drugs. Often, patients have little idea of ​​what they are taking, and sometimes they cannot even say the name. The task of the pharmacist is to ensure that the person has complete and reliable information about each medicine he takes.

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How drugs are developed and hit the shelves of pharmacies

The development and approval of a drug in the United States is a fairly long process, on average it takes about 10 years, and the average cost of developing one drug is over $ 1 billion. First, a pharmaceutical company does research on animals to get the most basic information about the safety and effectiveness of a drug. If the FDA gives the go-ahead, human research begins. In the first phase, a study of the safety of the drug is conducted - that is, what side effects may be. The medicine is given to several dozen healthy people. Also in this phase, the metabolism, or processing, of drugs in the human body is studied. In the second phase, the emphasis is on efficacy: will the drug even work for a particular disease. It is given to about a couple of hundred people who already have an illness and they see if it helps. In the third phase, the medicine is given to a wider circle of patients, a thousand or even several thousand. After that, the results are submitted to the FDA, and there they decide whether it is possible to release this drug on the American market.

How Americans View Medications

According to Elena, it is difficult for her to answer this question, because all of her clients are people who take a fairly large amount of drugs (15-20 or more). The largest number that the expert saw in her practice is 37. In her opinion, taking medications is quite common in the United States, but the attitude towards them is individual. There are official statistics on this score: as of 2016, about half of the US population has taken at least one prescription drug in the past 30 days. A quarter of the population took 3 or more drugs. The largest category is the elderly over 65, due to the greater number of chronic diseases.

The United States is the leader in overall drug spending and per capita spending among developed countries. As of 2018, $ 335 billion was spent on prescription drugs, about $ 1000 per capita.

According to Elena, the US health care system encourages the prescription of medication for every symptom and complaint. It also happens that it is difficult to cancel a medicine that a person is already taking. There is a concept “if something is not broken, you don’t need to fix it”. That is, if the patient does not complain of side effects, and also does not have the symptoms for which the drug was prescribed, most likely the prescription for this drug will continue. There is also a request for a quick solution to the problem from both the patient and the doctors. For example, a person becomes overweight due to a poor diet and insufficient exercise, which leads to certain symptoms such as heartburn and knee pain. He asks the doctor to prescribe medicine for him. He doesn’t want to make an effort to change his lifestyle, and he is quicker and easier to take pills that will relieve symptoms.

How and why are drugs prescribed in the USA?

In America, there is a lot of emphasis on the practical application of evidence-based medicine. This is an approach to medical practice in which the decision to use preventive, diagnostic and therapeutic measures is made on the basis of evidence of their effectiveness and safety. That is, a drug is prescribed not because the doctor likes it, but because research has shown that it is one of the most appropriate treatment options for patients with similar problems. For example, you have high blood pressure. There are about 60 drugs on the US market for this problem. If you have no contraindications, you will be prescribed a drug from the initially recommended three groups, taking into account individual characteristics. One concept that is increasingly being used by physicians in the United States is “collaborative decision making”. A doctor is an expert in diagnostics and treatment regimens, but you are an expert in yourself. No one knows better than you what feelings illness brings and how it affects the quality of life.

Coming back to the hypertension example. These three groups of drugs have approximately the same effectiveness, but different side effects and different monitoring. The doctor will sit with you and discuss in detail all the pros and cons of these three groups. And you yourself can decide what to choose.

Another hallmark of American medicine is the lack of emphasis on alternative medicine. That is, when you come to the doctor, you are unlikely to be prescribed, say, chamomile or massage. Most likely, if you have a problem, you will be prescribed medication. Statistically, approximately 3/4 of all doctor visits involve prescriptions.

Why drugs are so expensive in the USA

Unlike other countries, there is no drug price control in the United States. That is, there is no government organization that would monitor pricing. Pharmaceutical companies dictate prices and control the market. For drug manufacturers, the US market can be one of the most lucrative. Not so long ago, the most expensive drug in the world was approved in the United States - its name is Zolgensma, this is the first drug based on gene therapy. The drug manufacturer Novartis has set the price of the drug at over $ 2 million for a single-dose course of treatment. It is the world's first gene therapy for children under 2 years of age with spinal muscular atrophy. The drug corrects the damaged gene that causes the disease and has shown impressive results in clinical trials. The drug was approved through a special accelerated program that was guided by the results of an ongoing clinical trial. Of the 21 children in the test group, 19 not only survived (while many children with SMA die without treatment due to respiratory failure), but also showed unprecedented achievements in children with SMA: they can move their heads and sit without additional support. In another early clinical test, in the group of children who received the increased dose, 75% were able to sit without support, and 17% were able to get up and walk.

It is believed that America is subsidizing clinical research and drug progress to some extent. In general, Americans pay a lot more for the same drugs than people in other countries, and manufacturers use this money to continue clinical research. It is also believed that if the drug business were not so profitable for manufacturers, there would be no progress and such a variety of drugs and innovations in treatment. One of the striking examples is the treatment of hepatitis C. Until 2011, drugs on the market were imperfect, not entirely effective, and had many side effects. Now there are drugs that cure hepatitis C in more than 95% of patients, but the price tag is high - up to 90 thousand dollars for a course of treatment.

Another reason why drugs are so expensive to go to market is because the FDA gives the manufacturer exclusive rights to sell a brand name drug for a specified period. Therefore, for several years there is no competition and the manufacturer dictates its price. When the patent expires, generic analogues appear on the market. And usually the price goes down. Registration of a generic drug requires the company to prove that the drug is bioequivalent to the original. For example, that they have the same absorption rate, maximum concentration of the substance in the blood and the duration of their presence in the body.

Approximately 20 to 60 new drugs are released into the US market each year.

Is it true that all Americans regularly take antidepressants or pain relievers?

Overall, America has less stigma about mental illness. Depression is considered to be the same clinical illness as diabetes or hypertension. It is not regarded as a weakness of character and is recognized as the result of an imbalance in neurotransmitters in the central nervous system. Therefore, when symptoms appear, people are more likely to discuss them with their doctor and ask for help. Doctors also take such complaints seriously. There are certain diagnostic criteria and certain symptoms for which medications are prescribed. Therefore, people talk about it, not afraid to admit that they have such a disease, but the diagnosis is better, so more people with symptoms receive help and treatment.

In terms of pain relievers and very strong opioid pain medications, millions of people in the United States suffer from pain every day. Unfortunately, many medications are ineffective or simply treat the symptom without treating the cause. America continues to fight the opioid epidemic. Their use began to grow in the mid-1990s. Some factors are misleading information from manufacturers, as well as medical practices that prescribe doctors to help patients with acute pain. At the doctor's appointment, in addition to taking your blood pressure and temperature, you will be asked a question about your pain. And if you have moderate to severe pain, your doctor will be required to talk to you about the pain and suggest some kind of treatment. These and other factors have led to the prevalence of opioids being prescribed. By 2018, the number of deaths caused by opioid overdose made it admit that the country was in crisis. Since then, many measures have been taken and the number of opioid prescriptions has dropped by 40%. But it's too early to talk about victory.

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Relatives often ask to buy drugs in the USA, but they are all prescription

In the United States, most drugs are dispensed by prescription only. There are about 20 thousand prescription drugs on the market and about 800 can be sold without a prescription. In 1938, legislation was passed requiring the FDA to test and approve all drugs before they could be sold in the United States. The manufacturer had to prove that his drug was safe and effective. Later, a law was passed describing the difference between prescription drugs and over-the-counter drugs. Over-the-counter, the FDA only allows drugs to be sold that pose minimal risk to the patient if used without medical supervision. These are paracetamol, nurofen, medicines for heartburn, allergies. But drugs for the treatment of chronic diseases, for example, diabetes, hypertension, as well as antibiotics, antivirals - only with a prescription.

About American drug advertising

The ad looks like this - first you see a sad person. Then you are told that he started taking a certain medicine, and now he is laughing happily, spending time with friends ... And in the background to this picture you see a long list of side effects, after which you no longer want to take anything. The fact is that in the USA it is allowed to advertise drugs directly to the consumer. The FDA, in turn, obliges manufacturers to disclose all potential risks and side effects. According to Elena, this does not always play into the hands of the patient. For some, this is very frightening: the advertisement does not say what the probability of a certain side effect is. Or, on the contrary, a person does not pay attention to these warnings, since too much information is given and everyone is used to hearing that each medicine has a huge list of risks.

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