Which comes first, the drug or the disease?

Today's NYT reports that Pfizer has begun direct-to-consumer advertising for their drug, Lyrica. It's not a new medication, having been approved for some time for the treatment of nerve pain (as experienced by some people with diabetes or shingles).

What's news is that the advertisements are for a new indication: fibromyalgia. Fibromyalgia is a condition for which no definitive diagnosis exists, and its cause and mechanisms are not understood by medical science. People who have it, most of whom are middle-aged women, complain of chronic, widespread pain and tenderness, as well as extreme exhaustion.

But whether fibromyalgia really exists is a contentious issue. Those who suffer from fibromyalgia insist that it is a real, and debilitating, problem. Numerous advocacy and support groups exist online and offer individuals the chance to compare notes with fellow sufferers. Skeptics charge that it is essentially a psychosomatic complaint--i.e., "it's all in their heads."

A few features of this story are worth comment (in my view, anyway). One is that we should be aware of the long-standing tendency of the medical establishment to minimize symptoms it can't explain by saying they are psychological--i.e., not "really real," and outside the purview of "real medicine." Many of these conditions (like irritable bowel syndrome, multiple chemical sensitivity, and chronic fatigue syndrome) tend to affect middle-aged women more than other groups. Coincidence? Maybe. But maybe not. Either way, it's worth thinking about whether these issues are being too easily dismissed.

Another is the influence that pharmaceutical companies have in our society over what "counts as" illness or disease. On one view, if there's a drug for it, then it's a disease. Thus shy people may actually suffer from social anxiety disorder and require Paxil; short people might have idiopathic short stature and need human growth hormone; and the list goes on. Is this trend toward medicalization a good thing? What does it mean, in practical terms, when we move a condition from the "some people are like this" (normal human variation) column into the "people who are like this have a disease" (illness) column? Who benefits from those effects?

One more thing to consider: the challenge of pain. As a subjectively experienced phenomenon, it's tough for medicine to deal with. Most medical problems are objectively measurable in one way or another, but pain is particularly tough to pin down. People have different pain thresholds, experiencing more or less pain in response to the same stimulus. It's been the standard view for a while now that women experience pain differently from men, though whether these differences are biological or social (or both) is still unclear. And the data source for pain? We mainly have to rely on self-report--and as a general rule, science doesn't like self-reported data. But the flip side could mean denying needed relief to people who are suffering ... and who wants to do that?

Help your doc help you....

The illustrious Dr. Jerome Groopman (who was recently interviewed on NPR) recently published a new book, How Doctors Think. It's an expanded version of an article he wrote for The New Yorker.

This is a more engaging read than one might think at first blush, in part because of Groopman's liberal use of stories and anecdotes. These illustrate the information he really wants to share with us: the facts that (a) doctors are not perfect, (b) they make predictable errors in diagnosis, often due to cognitive or emotional biases, and (c) we--the general public--can help doctors avoid these pitfalls if we know what they are. By asking, for example, "Is there anything else it could be?" or "Is it possible that I have more than one problem?" we can help the doctor consider options she may have overlooked.

So why is this relevant to you, the WBP reader? Well, two reasons leap to mind. The first is that women continue to play the role of healthcare decision maker for their families, and so we're often in the best position to ask the right question at the right moment. The second is that my own mom, and many other moms of my acquaintance, have shared their stories of "knowing something was wrong" with a loved one, even when the doctors weren't able to find anything at first. Though Groopman doesn't seem to think of it this way, a piece of advice that fits right in with the rest of his argument is "Trust your own intuition--at least far enough to ask the doctor that one more question."