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Testosterone: Another Case of Physician Enabled Drug Abuse

Posted on | October 27, 2016 | 2 Comments

article-low-tAd From MedicineNet.com

Mike Magee

Is testosterone the next Oxycontin? It certainly has many of the same earmarks. It’s widespread abuse is being aided and abetted by sloppy prescribers. Its’ benefits are being exaggerated and its’ risks understated. It is associated with heavy marketing by pharmaceutical companies and a range of profit seeking intermediaries. And it promises psychic relief from reality.

As with Oxycontin, the FDA has, until recently, exhibited a very light touch. But this week they attached additional warnings to the product. The official statement said that this action “will alert prescribers to the abuse potential of testosterone and the serious adverse outcomes, especially those related to heart and mental health.” But what the AMA, its’ Federation members, and medical educators ought to be asking is, “Why do our prescribers require FDA messages to absorb facts that the public has already internalized? Why are our physicians so out of touch, so far behind the trends?”

To most consumers “Low T” is a joke. And yet doctors in 2013 prescribed it to 2.3 million patients, a 75% jump in just four years. A quarter of those scripts were written for men who never had a blood test for testosterone. There is also ample evidence that doctors are prescribing this in large numbers as a hedge against aging with no evidence that it is useful, but plenty of evidence that it is harmful.

The FDA this week listed all the bad things it does: “Reported serious adverse outcomes include heart attack, heart failure, stroke, depression, hostility, aggression, liver toxicity and male infertility. Individuals abusing high doses of testosterone have also reported withdrawal symptoms, such as depression, fatigue, irritability, loss of appetite, decreased libido and insomnia”. But the reality is that injections and pills and gels now sell in the billions in the US.

As with Oxycontin, this is physician enabled drug abuse, pure and simple. The National Institute of Drug Abuse said as much. Their appraisal: “Long-term steroid abuse can act on some of the same brain pathways and chemicals — including dopamine, serotonin and opioid systems — that are affected by other drugs. This may result in a significant effect on mood and behavior.”

Over the past century, the AMA has vigorously defended and ligated the sole right of the physician to “prescribe”. Their defense has rested on the fact that this is an awesome responsibility, one that has potential life and death consequences for America’s patients. The pharmaceutical industry has been their reliable ally through all these many years, more than happy to transfer liability for their products to the physician “learned intermediary”. But as the manmade opioid epidemic revealed, and as the explosion of testosterone use confirms, physicians in large numbers are more aptly described as “sloppy prescribers”  than “learned intermediaries”. What the AMA, the AAMC, academic medical centers and their training programs, and medical schools need to be asking is, “Why?”

Comments

2 Responses to “Testosterone: Another Case of Physician Enabled Drug Abuse”

  1. Lachlan Forrow, MD
    October 27th, 2016 @ 1:12 pm

    Jerome Groopman had a nice story on this issue in The New Yorker back in 2002, including a profile of a physician colleague at my hospital, Dr. Abe Morgentaler, who is one of the most active proponents of diagnosing and treating “Low T”. Apart from concerns about over-prescribing, the article raises obvious questions about whether identifying a patient’s problem as “Low T” might also distract both patient and doctor from addressing multiple other reasons for a patient’s symptoms and concerns:

    As Groopman describes:

    “Morgentaler’s next patient was a construction worker in his forties. The man was on cardiac medication and had an implanted defibrillator, because he was prone to life-threatening arrhythmias, and occasionally he received electric jolts from the device. His wife had died some three years before, but in the previous six months he had been in a stable relationship. He had come to the clinic because he had difficulty reaching orgasm.

    Morgentaler asked about other symptoms.

    “I used to be able to play racquetball non-stop, but I’m tired now after four games.”

    Morgentaler nodded. “We caught it just at the right time.”

    “But my primary-care doctor checked my testosterone and said it was 800, which is normal. He told me he couldn’t do anything about my problem.”

    Morgentaler looked at the results of the man’s blood assay. Total testosterone was in the normal range, at 509 nanograms per decilitre. But his free testosterone, Morgentaler told him, was another matter. At any moment, about two per cent of circulating testosterone is “free”—unbound to any protein—and thus biologically active. The patient’s free testosterone was a little under the lower limit of normal. (“Normal” testosterone levels refer to what’s normal for men in their twenties.)

    “If I had a magic wand and I could do anything for you, what would it be?” Morgentaler asked.

    “Get rid of the problem with orgasm.”

    “Well, I believe we have a very good chance of helping you.” Morgentaler wrote out a prescription for AndroGel. “We’ll check your P.S.A. today, but we don’t need to do biopsies of your prostate gland until after the age of fifty. So you can get started right away.”

    “I can’t thank you enough,” the patient said.

    See full article here: http://www.newyorker.com/magazine/2002/07/29/hormones-for-men

  2. Mike Magee
    October 27th, 2016 @ 1:43 pm

    Thanks for your comment, Lachlan!

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