as for idealism…

Posted on Tuesday 26 November 2013

I think, by nature, I might be an idealist – someone who thinks that right will prevail sooner or later. I never really thought that, but it seems to be true. Watching what happened in psychiatry in the 80s didn’t fit for me personally, but I thought things would strike a balance sooner or later. But later didn’t come, and much "later," I learned that the reason was because the pharmaceutical industry had essentially purchased psychiatry and our literature, or at least a big enough piece at the top of the heap to carry the day. That put a real damper on that that idealism I think I had. And seeing the same forces ripple throughout Medicine hasn’t helped a bit. So these days, I can get just as disillusioned as many of psychiatry’s critics, maybe even more so  because it’s my hood that has been invaded.

Peter Gøtzsche calls what happened Organized Crime [a major force…]. Just a couple of years ago, I would have seen that as a gross exaggeration, but not any more. Nowadays, I think he’s hit the nail on the head, and if anything, we probably needed to face up to that some years back rather than "finally." Talk about tarnished idealism. This exceeds anything that I could have ever imagined. And I think that in my case, idealism about Medicine and The Academy actually interfered with my seeing what is now so damned obvious.

But from my perspective, there’s a clear ray of sunshine in this gloomy story. In just the several years I’ve been following these matters, there’s been a groundswell of resistance to perpetuating the carnage. Coming from many different directions, there seems to be a consensus about one way to go after this particular problem – transparency. All kinds of transparency. We have a million rules in place from multiple attempts to fix things in the past. The problem is that the antagonists have found ways to slither around them using the rules to their advantage. A good rule comes along like, and the journals and companies just ignore it. No enforcing agency. Or we require Clinical Trials, and then weak-sister-at-best drugs sneak through on p-values rather than clinical usefulness. We require marketing to be limited to approved use only and industry ignores the rule and pays the price out of pocket change. The lists goes on and on. Sensible reform, recurrently thwarted by loopholes and creative slithering. So the consensus? Transparency: transparency in Conflicts of Interest; transparency in authorship; transparency in funding; transparency in matters regulatory; and TRANSPARENCY in the data from Clinical Trials.

Some leaders have emerged in this arena, notably the people after the studies on Tamiflu, and they have had an enormous impact – Peter Doshi, Tom Jefferson, Cochrane people, Ben Goldacre, Fiona Godlee. We owe them for taking the idea and putting it into action in a real live case. But the forces that have derailed all those previous attempts to keep the très lucrative market of medicinals très honest and scientific are not just sitting around cheering. They’re laying the groundwork to undermine things. And right now, two pharmaceutical companies, abetted by organized PHARMA in Europe and the US are blocking a major step on the road to transparency – the European Medicines Agency‘s decision to release all trial data submitted for approval. Yesterday, Peter Doshi posted an update as a letter to JAMA: Internal Medicine:
by Peter Doshi
JAMA Internal Medicine. November 25, 2013, Volume 173, Number 21.

A colleague and I recently reported on the first 2 years of the European Medicines Agency’s (EMA’s) November 2010 freedom of information policy on access to documents.1 The policy made a wide range of regulatory documents potentially accessible to anyone who asked for them, including clinical study reports. As of November 19, 2012, the EMA had released approximately 1.66 million pages of clinical trial data and other documents in response to 457 requests.

On April 25, 2013, the General Court of the European Union, in 2 interim decisions, ordered the EMA not to provide documents in response to 3 specific requests. The injunction followed legal action by AbbVie (Wilmington, Delaware) about 2 separate requests for clinical study reports for adalimumab (Humira), a drug for rheumatoid arthritis, and legal action by InterMune( Brisbane,California) about a request for similar documents on pirfenidone (Esbriet), a drug for idiopathic pulmonary fibrosis. Both companies contended that the requested EMA documents contain commercially confidential information.2,3 The EMA had planned to provide the documents, consistent with the view that “clinical trial data should not be considered commercial confidential information.”4 A hearing on the case may not be held until 2014.

On April 30, the EMA responded to the court order by declaring an intention to “continue with its policy to grant access to documents” but that “requests for access to documents similar to those contested by AbbVie and InterMune will be considered on a case-by-case basis.”6 In addition, the EMA confirmed that it would continue to develop a forthcoming policy on proactive publication of clinical trial data, pending the final decision of the court, and has since released a draft policy for public comment.

I recently obtained a logfile (eAppendix in Supplement) from the EMA of all 728 requests for documents handled under its policy through June 4, 2013. The logfile showed that on May 28, 2013, the EMA rejected requests for documents related to 54 products. Academia/research institutes (27 requests), health care professionals (11), legal professionals (11), the pharmaceutical industry (8), and media (3) made the requests. (I received 1 such rejection letter, which cited the ongoing lawsuits as the reason for rejection.) The rejected requests were primarily for clinical study reports (46) and other regulatory documents related to the marketing authorization applications for medications, including Common Technical Document summaries (13) and nonclinical study reports (8). Previously, the EMA had released all these types of documents, with redactions as deemed necessary by the agency. The summary rejection of so many requests indicates that the EMA has substantially curtailed its release of documents, most likely as a result of the ongoing lawsuits.

The logfile showed an increase in the rate of requests between November 19, 2012, and June 4, 2013. Compared with the period before November 19, 2012, the number of pages released per month has decreased (Table). The logfile also indicated that regulators outside the European Union have requested and received documents and that the majority of requests originated from the pharmaceutical industry, legal professionals, media, and academia/research institutes. Industry has consistently made more requests for documents than other groups (Figure).

Before releasing documents about a product, the EMA informs the company and, depending on the specifics of a request, may seek the company’s view regarding the release and possible redactions. As of July 27, 2013, AbbVie and Inter-Mune are the only companies to challenge the release of documents in court. Other companies, such as GlaxoSmithKline and Roche, have recently announced new data transparency policies emphasizing a commitment to transparency.8,9 However, the Pharmaceutical Research and Manufacturers of America and the European Federation of Pharmaceutical Industries and Associations, the leading trade organizations that represent most major companies, including Roche and GlaxoSmithKline, have filed briefs supporting AbbVie. The views of most companies are unclear. Nonetheless, the curtailment of EMA’s policy on access to documents is a major step backward for the transparency of clinical trials and for public health.
In a now infamous appearance, Neal Parker, the lawyer for AbbVie made their position clear [a deal-breaker?…]. They want loopholes in transparency for competitive advantage and they’ve had a temporary success in the courts. As Doshi documents, they’ve slowed the flow of data from EMA for the moment. The issue comes to court early next year, and there’s little that’s more important to the cause of transparency than this decision. This is what has happened repeatedly in the past. A great wave of reform passes through, and it’s undermined, often quietly, joining the ranks of previous failed good ideas. I’ve taken to saying "the devil’s in the details" way too much lately, but looking back over the string of doomed attempts to get at this particular cancer and the magnitude of its damage, no detail is too trivial. To my thinking, there’s no argument against full data transparency that has benign consequences. I hope Doshi and his fellow campaigners don’t run out of energy or get discouraged, and that we’ll all join them in whatever way we can. Their quest is "mission critical." As for idealism. It’s hard work…
    November 26, 2013 | 8:32 PM

    Transparency is needed everywhere, not just drugs WHEN IS DISCLOSURE NOT DISCLOSURE?.

    November 27, 2013 | 11:20 AM

    Yes! It IS hard work . . . I’m married to an idealist; and I read one every morning with my first cup of coffee (I’m referring to you, Mickey). If it weren’t for the idealists, I don’t know how we pessimists and cynics would continue to function. Thank you!

    November 27, 2013 | 12:33 PM

    i never cared much for the idealism critiicism

    noun: idealism

    1. the practice of forming or pursuing ideals, esp. unrealistically.
    “the idealism of youth” (in art or literature) the representation of things in ideal or idealized form.
    2. Philosophy any of various systems of thought in which the objects of knowledge are held to be in some way dependent on the activity of mind.

    i see nothing bad about the representation of things in idealized form

    i cannot think of where we might be if we did not have ideals

    i see nothing wrong with the idea that objects of knowledge are held to be in some way dependent on the activity of mind.

    i don’t associate idealism with right or wrong

    i am pleased to have found your continuing stream of enlightening and encouraging discourse about science, mental health care, psychiatry, and life.

    i think you are a very practical guy, with strong commitment to responsibly arguing for idea(l)s you believe in and it is good for me that you are doing that because i share your ideals and you express your argument so well.

    you need to be able to rely on a strong commitment when you challenge the actions of powerful forces

    November 27, 2013 | 8:41 PM

    Didn’t transparency used to be called honesty?

    November 27, 2013 | 9:41 PM

    Yeah. And idealism used to be called medical ethics…

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