Thursday, May 19, 2011

Our demand for drugs: the case of oxytocin

In the first two posts of this series, I outlined the current prescription drug crisis and the responses of physicians, the managed health sector (PHA) and the pharmaceutical industry (PhRMA). I believe these drug shortages reveal the unsustainability of certain healthcare industry practices as well as fundamental flaws in how we think about health, technology, and progress. To build the foundation for this argument, I will sketch brief case histories of three drugs over the next few posts, beginning here with oxytocin.

The January 2000 British Medical Journal report I referred to in Part 1 of this series noted that in October 1999, the Harvard-affiliated Brigham and Women’s Hospital abruptly found itself unable to procure oxytocin, which it used “in almost every one of its 10,000 annual deliveries.”  Speeding along in my first reading, I suddenly stopped short. Oxytocin was used in nearly every delivery?

As most of you know, oxytocin is administered to induce labor. The hormone actually serves many purposes; all of us produce it naturally, men as well as women, and it has been touted as “the social bonding factor.” It was discovered by accident in 1909 when Sir Henry Dale noticed that pituitary gland extract induced uterine contractions in a pregnant cat; as early as 1911 pituitary extract was being used to stimulate labor [1]. In 1953, oxytocin became the first peptide hormone to be synthesized in a lab. Both Dale, who discovered the hormone, and Vincent de Vigneaud, who synthesized it, went on to win Nobel Prizes.

By 1998, about 16% of labors were induced, by oxytocin, an additional 16% that began naturally were augmented with oxytocin, and the drug was also used post-partum to prevent hemorrhage [1]. Oxytocin use peaked in the late ‘90s and early 2000’s before greater caution set in, as much from an increasing cultural preference in the West for ‘natural’ childbirth as from evidence that exogenous oxytocin could have adverse effects on the infant [2].

The BMJ noted that Brigham and Women’s Hospital did not find that the oxytocin shortage compromised care or the results of labor and delivery. Why, then, was it used in almost every delivery in the Boston hospital? Perhaps self-selection was involved: BWH is a renowned, high-tech hospital that likely draws more women with high-risk pregnancies (or women who are anxious about their pregnancies, or who are technologically inclined). A medical article published in 1999 sheds some light on the attitude of physicians at this time:
In an ideal world, all pregnancies would go to term, and labor would begin spontaneously. In reality, it is often best to deliver the infant before the onset of natural labor... In the past decade, our knowledge of the mechanisms of labor has increased tremendously. In addition, the ability to detect and manage antepartum maternal and fetal complications has greatly improved. As a result, labor can be induced in an increasingly rational and successful manner.
The authors clearly have a strong conception of what an “ideal world” looks like and the kinds of “rational management” that can lead us there. These ideas deserve consideration, but for now, let me just note that last April, a study conducted by Iraqi physicians from 2004 to 2006 concluded that acupuncture largely eliminated the need for oxytocin in women who had undergone ceasarean deliveries [3]. (Persistent shortages of oxytocin had compelled physicians to seek alternatives.)

Along the same lines, a 2004 paper published in Hospital Pharmacy evaluated the results of an antibiotic shortage on patient outcomes and costs and found that the alternative antibiotics they substituted for piperacillin/tazobactam (P/T) reduced the average hospital length of stay by about one day and slightly reduced costs, without adverse effects on patients. This is not to say that drug shortages never have ill effects—they increase the risk of errors, for one thing—but this question has not been formally addressed in most cases. Given that experts consider only about two to four dozen compounds to be the core of our pharmacopia, with the remainder being "me-too" drugs, it is possible that lack of a particular drug poses a problem less because of the drug's unique characteristics than because of the structural consequences of the scarcity (secondary shortages, time spent locating alternatives, etc.).

The oxytocin story does raise other questions, however. How much of our reliance on drugs is necessary, or even beneficial, to our long-term health? And how much does the availability of a drug create our "need" for it? How different is our desire to control events like labor and delivery from our desire to control events like erections? (Have Viagra and Cialis ever been scarce?) And how does the desire for control shade into the wish to enhance abilities like pitching a fast ball, or concentrating in school, or simply feeling happier? Where does treating illness cross over into self-improvement or simply extend our strong cultural tendency to want to dominate nature, subdue our bodies, control our wayward physiology?

The next post will concern the curious case of colchicine.


[2] See, for example, Oscarsson, ME et al., Outcome in obstetric care related to oxytocin use. A population-based study.  Acta Obstet Gynecol Scand. 2006;85(9):1094-8.


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