'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.

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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 American pharmacist Caleb Bradham from North Carolina. He first called it "Brad's Drink" and then a couple of years later renamed it Pepsi-Cola, from pepsis, the Greek for digestion, and cola, from the caffeine-containing kola nut. He wanted this drink to help with digestion and give him energy. He prepared it in his own pharmacy and sold it there.

How to become a pharmacist in America

Studying to become a pharmacist in the USA is a fairly long process that can take anywhere from 6 to 11 years. About 20 years ago, a new rule was introduced that required every pharmacist in the United States to obtain a Ph.D. The pharmacy school itself, or college of pharmacy, takes 4 years, but in order to enroll in it, you must already have some kind of basic education, which would include courses in the natural sciences, such as chemistry, physics, and biology. The competition is quite big. When Elena entered in the mid-200s, 1200 applications were submitted for XNUMX places. The training is quite difficult.

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 a residency, and works very closely with other healthcare professionals in the selection of medications and treatment regimens. Clinical pharmacists also advise patients on the properties and dosage of medications. Clinical pharmacists can work in many different areas: hospital specialists, infectious disease specialists, they work in dialysis departments or organ transplant departments. Their task is to recommend certain drugs and make sure that the prescribed drugs are the most effective and safe at the moment.

In clinics, clinical pharmacists often provide individual appointments with patients. People come by appointment and the pharmacist helps them understand their medications. Before seeing a patient, the clinical pharmacist takes the patient's medical history, looking at liver function, kidney function, and medication history. Let's say you take 12 different medications, all prescribed by different doctors. At your appointment, a clinical pharmacist will discuss each of these with you, paying particular attention to the effectiveness of each drug, and will also analyze side effects. Maybe your headache is not a result of stress at all, but a side effect of a certain drug. We will also analyze the compatibility of all medications, as well as prescription medications with vitamins and dietary supplements that you take.

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

Drug development and approval in the United States is a fairly long process, taking approximately 10 years on average, and the average cost of developing a single drug is more than $1 billion. First, the pharmaceutical company does animal studies to obtain the most basic information about the safety and effectiveness of the drug. If the FDA gives the go-ahead, a human study begins. In the first phase, a study is carried out on the safety of the drug - that is, what side effects there 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 effectiveness: whether the drug will even work for a particular disease. They give it to about a couple hundred people who already have the disease and see if it helps. In the third phase, the drug is given to a wider range of patients, a thousand or even several thousand. After this, the results are transferred to the FDA, and they decide whether this medicine can be released onto the American market.

How Americans View Medications

According to Elena, it is difficult for her to answer this question, because all her clients are people who take a fairly large number of medications (15-20 or more). The largest number that the expert has seen 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 matter: as of 2016, approximately half of the US population took at least one prescription drug in the last 30 days. A quarter of the population took 3 or more medications. The largest category is older people over 65 years of age, due to a higher 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 healthcare system encourages prescribing a medicine for every symptom and complaint. It also happens that it is difficult to cancel a medicine that a person is already taking. There is such a concept as “if something isn’t broken, don’t 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, the prescription for that drug will most likely continue. There is also a demand for a quick solution to the problem from both the patient and doctors. For example, due to a poor diet and insufficient exercise, a person becomes overweight, which leads to certain symptoms, such as heartburn and knee pain. He asks the doctor to prescribe him medicine. He does not want to make efforts to change his lifestyle; it is faster and easier for him to take pills that will relieve symptoms.

How and why are drugs prescribed in the USA?

In America, great emphasis is placed on the practical application of evidence-based medicine. This is an approach to medical practice in which decisions about the use of preventive, diagnostic and therapeutic measures are made based on 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 suitable 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 “shared decision making.” A doctor is an expert on diagnosis and treatment regimens, but you are an expert on yourself. No one knows better than you how illness feels and how it affects your 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 distinctive feature of American medicine is the lack of emphasis on alternative medicine. That is, when you go to the doctor, you are unlikely to be prescribed, say, chamomile or a massage. Chances are, if you have a problem, you will be prescribed medication. According to statistics, approximately 3/4 of all visits to the doctor include a prescription.

Why drugs are so expensive in the USA

Unlike other countries, the United States does not have drug price controls. That is, there is no government organization that monitors pricing. Pharmaceutical companies dictate prices and control the market. For drugmakers, the US market can be one of the most lucrative. Not 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 manufacturer, Novartis, has set the price for this medicine at more than $2 million for a course of treatment, which consists of one dose. This is the world's first gene therapy treatment 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 under 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 without treatment, many children with SMA die due to respiratory failure), but also showed previously unprecedented achievements for children with SMA: they can move their heads and sit without additional support. In another early clinical test in a group of children given the increased dose, 75% were able to sit without support and 17% were able to stand and walk.

There is an opinion that America to some extent subsidizes clinical research and progress in the field of drugs. In general, Americans pay much more for the same drugs than people in other countries, and manufacturers use this money to continue clinical research. There is also an opinion that if the drug business were not so profitable for manufacturers, progress and such a variety of drugs and treatment innovations would not exist. One striking example is the treatment of hepatitis C. Before 2011, the drugs on the market were imperfect, not entirely effective and had many side effects. Now there are medications that cure hepatitis C in more than 95% of patients, but the price tag is high - up to 90 thousand dollars per course of treatment.

Another reason why drugs are so expensive to bring to market is that the FDA gives the manufacturer exclusive rights to sell the brand-name drug for a certain period of time. Therefore, for several years there is no competition and the manufacturer dictates its price. When a patent expires, analogues - generics - appear on the market. And usually the price goes down. To register a generic drug, the company must 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 duration of 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.

When it comes to painkillers and very strong opioid pain medications, millions of people suffer from pain every day in the United States. Unfortunately, many medications are ineffective or simply treat the symptom but do not treat the cause. America continues to struggle with 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 direct doctors to help patients with acute pain. At your doctor's appointment, in addition to taking your blood pressure and temperature, you will be asked about your pain. And if you have moderate to severe pain, your doctor will be required to talk to you about that pain and offer you some treatment. These and other factors have led to opioids becoming increasingly prescribed. By 2018, the number of deaths caused by opioid overdoses forced recognition that the country was in crisis. Since then, many measures have been taken and the number of opioid prescriptions has decreased 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 available by prescription only. There are about 20 thousand prescription drugs on the market and about 800 can be sold without a prescription. In 1938, a law 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 its drug was safe and effective. Later, a law was passed describing the difference between prescription and over-the-counter drugs. The FDA only allows drugs to be sold without a prescription that pose minimal risk to the patient if used without medical supervision. These are paracetamol, Nurofen, medications for heartburn, allergies. But drugs for the treatment of chronic diseases, such as diabetes, hypertension, as well as antibiotics and antivirals, are available only with a prescription.

About American drug advertising

The ad looks like this - first you see a sad person. Then they tell you that he started taking a certain medicine, and now he is laughing happily, spending time with friends... And in the background of 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 is not always to the benefit of the patient. This is very scary for some: the advertisement does not say what the likelihood 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 accustomed to hearing that every medicine has a huge list of risks.

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