The People's Perspective on Medicine

Pharmacist Challenges Concept of Chronic Conditions and Maintenance Meds

Pharma has a financial incentive to convince people that many ailments are “chronic conditions" even though much is known about preventing those conditions.

You’ve probably heard the term “chronic condition” in relation to elevated blood pressure, elevated cholesterol, elevated blood sugar (in type 2 diabetes), and other medical problems. You may have been told that these chronic conditions must be treated with medication for the rest of your life. The implication is that these conditions are “chronic” just like type 1 diabetes and require maintenance meds.

What Are Maintenance Meds?

Pharmacists have a short-hand term for medications that are used to treat chronic conditions. When speaking with pharmacy technicians, pharmacists often refer to drugs that are taken long term as “maintenance meds.”

Soon after graduation from pharmacy school, I worked for a large chain that (at least in my district) had a very relaxed attitude toward pharmacists phoning doctors for refill authorizations for what were viewed as “maintenance meds” (those for blood pressure, cholesterol, type 2 diabetes, etc.).

Refills Without Prior Authorization?

For example, the unstated and unofficial attitude in my district seemed to be: The patient isn’t going to be cured of his/her hypertension (or elevated cholesterol, type 2 diabetes, depression, etc.) any time soon, so what’s the big deal with pharmacists going ahead and giving a few more refills and calling the doctor for authorization when we’re not busy at some point in the future?

As a result of one of my commentaries in Drug Topics, I received the following e-mail from a pharmacist who, like me, questions the common use of the term “chronic” disease:

“Whenever the doctor’s office had not called back with the customer’s refill authorization, besides being annoyed, many customers would respond by saying:

“’I don’t know why the doctor does not give more refills. I’m going to be on the medication for the rest of my life.’”

“I always felt like going over to the customer and saying, ‘How do you know that you are going to be on the medication for the rest of your life?’”

Pharma clearly has a financial incentive to expand the concept of chronic illness. Pharma wishes every illness were seen as chronic, long term, permanent, unpreventable, genetic, or an unavoidable consequence of aging. With such an outlook, people are not motivated to look for things they could do themselves (like dietary and lifestyle changes) that could eliminate the need for drugs.

Examples of True Chronic Conditions:

Of course, there are some conditions that can legitimately be defined as “chronic” and the term “maintenance meds” is accurate for these conditions. People with type 1 diabetes are maintained with insulin. Similarly, people with underactive thyroid are maintained with drugs like levothyroxine. Other truly chronic conditions include Parkinson’s disease, epilepsy, multiple sclerosis, rheumatoid arthritis, psoriasis, etc.

Are Classic “Chronic” Conditions Really Chronic?

But are elevated blood pressure, elevated cholesterol, and elevated blood sugar (in type 2 diabetes) necessarily chronic or permanent? That’s like asking whether obesity is permanent. Many people have been obese for a very long time but that does not mean obesity is permanent.

Is depression necessarily a chronic condition? If your spouse or coworkers are abusive toward you, or if your income is insufficient to cover your expenses, or if you have a mind-numbingly repetitive job and you are depressed as a result, does that make depression a chronic condition? Is depression caused by a chemical imbalance in your brain (as Pharma claims) or is it caused by many different factors?

Is Shyness a Chronic Condition?

Or consider shyness. Pharma has rebranded shyness with the more impressive-sounding moniker “social anxiety disorder” to make it sound like a serious medical condition requiring medication. I once read that someone who won millions of dollars in a state lottery suddenly lost his/her shyness. How is that possible if shyness is, as Pharma seems to imply, a chronic mental disorder?

In fact, many behavioral problems are closely related to our life circumstances. Getting a divorce, changing jobs, avoiding abusive relationships, etc. may be better solutions than pills for shyness, anxiety and depression.

How Pharma Distorts the Meaning of Chronic to Sell More Pills:

We need to re-examine Pharma’s strong desire to classify every persistent problem as a “chronic condition” for which “maintenance meds” are the solution.

Pharma clearly loves the concepts of chronic conditions and maintenance medications. That’s why drug advertisements on TV are overwhelmingly for conditions that are viewed as long term. You see very few (if any) drug ads on TV for antibiotics.

Antibiotics treat infection and are frequently prescribed for only 5 to 10 days. Pharma doesn’t like to advertise drugs that are used for acute conditions like infections.

Advertisements for drugs that treat heartburn or gastro-esophageal reflux are common because acid problems are increasingly viewed as chronic. However, people who chronically take antacids, H2 antagonists and proton-pump inhibitors may be able to get off these drugs with weight loss and/or a significant change in diet.

You don’t see ads on TV for epinephrine injectors because the use of this drug is highly sporadic to treat severe allergic reactions to things like bee stings or peanuts. This is in contrast to drugs that are taken every day for high blood pressure, elevated cholesterol, type 2 diabetes, psoriasis, Crohn’s disease and depression.

Many cases of hypertension and type 2 diabetes are preventable and are thus not necessarily chronic.

For example, The Merck Manual (16th edition, p. 984) states:

“Thus weight reduction will lower the BP [blood pressure] of most hypertensives, often to normal levels, and will allow 75% of type 2 diabetics to discontinue medication.”

Ninety percent of people with diabetes have diagnoses that fall under the heading of type 2.

According to Dr. Jeffrey S. Bland (The Disease Delusion: Conquering the Causes of Chronic Illness for a Healthier, Longer, and Happier Life, New York: Harper Collins, 2014, inside front dust jacket):

“Contrary to conventional wisdom, chronic disease is not genetically predetermined but results from a mismatch between our genes and environment and lifestyle.”

Pharma clearly wants to expand the category of chronic conditions to assure the long term (chronic) profitability of the pill business. There have been many initiatives to “improve compliance” or “enhance adherence” to medication regimens. Not surprisingly, Pharma wants to enlist physicians and pharmacists to ensure patients continue to take their maintenance meds regardless of cost or adverse reactions.

I wish more doctors and patients would team up to prevent or control so-called chronic conditions with practical plans to implement lifestyle changes. It is time for health professionals to embrace tested techniques of health coaching to make this more feasible (Work, May 24, 2019; PLoS One, April 18, 2018; Global Advances in Health and Medicine, May, 2013).

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    Citations
    • Edman, J.S., et al, “Health coaching for healthcare employees with chronic disease: A pilot study,” Work, May 24, 2019, DOI: 10.3233/WOR-192907
    • Gotthelf, L., et al, “High intensity lifestyle intervention and long-term impact on weight and clinical outcomes,” PLoS One, April 18, 2018, DOI: 10.1371/journal.pone.0195794
    • Lawson, K.L., et al, “The impact of Telephonic Health Coaching on Health Outcomes in a High-risk Population,” Global Advances in Health and Medicine, May, 2013, DOI: 10.7453/gahmj.2013.039
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    Once a heart patient is placed on blood thinners, the patient, according to the doctors will be on blood thinners the rest of their lives. I paid $400 to $500 per month. When I was diagnosed with a-fib in 2008, I was immediately placed on blood thinners. I took them for several months, and I stopped. No heart attack, no strokes: Prior to a catheter oblation in 2017 I was placed on blood thinners again, and I took them for several months and was hospitalized for the side affects.

    I was on blood thinners for one week prior to my ablation in Aug 2017. I have not taken any blood thinners since, as my diet is totally plant-based. I have a cardiologist who does not insist that I take blood thinners as the side effects from all of them are very serious. The bottom line here is that I am not taking blood thinners, and I will not take them. I am 82 ,and I am in good health now. No A-fib any more.

    Please reconsider including “rheumatoid arthritis” as one of the so-called True Chronic Conditions. I was diagnosed with RA in 2004 and prescribed prednisone. It definitely helped ease my pain but I was aware of the long-term serious side-effects and requested to be taken off it as soon as possible.

    Fortunately my rheumatologist agreed and put me on a DMARD with fewer negative potentials. But after a few months I made the same request and was gradually weaned off of it.

    I have been symptom free and in remission since 2006. I have attended some events for RA sufferers and heard numerous times that they must take the meds the rest of their life. When asked why I don’t I can just reply I was fortunate enough to have early diagnosis, aggressive early treatment and a cooperative physician willing to go against the accepted tradition.

    I wish more people were thinking this way, and that we would learn to take responsibility for our health, rather than abdicating to physicians and Big Pharma.

    While I agree that Big Pharma is a money hungry problem, I’m not sure how portraying it as an evil, brainwashing force is helpful. What is the message here? Don’t listen to your doctor or take your meds? Take your meds, but only until you can make lifestyle changes that may reverse your so-called chronic condition that you weren’t smart and/or lucky enough to prevent in the first place? Don’t trust your pharmacist to call your doctor for authorization?! (Is that legal?)

    Yes, in a perfect world we would all be doing our best to avoid all theoretically preventable diseases and we would know just what that all is for us individually. And Pharma would put people before profit. Heck, I’d settle for people on an equal level as profit! But, as a person with autoimmune diseases (truly chronic disease, apparently), I rely on pharmaceuticals to keep me functioning.

    I do think it’s good to educate people that some conditions may not be lifelong and that Pharma has a self-serving agenda. Let’s foster programs such as the ones in the studies you cited and more. And keep putting political pressure on Pharma to be more humane. But demonizing Pharma and taking meds long-term for what may be a reversible condition may lead to pressure to stop taking meds prematurely and/or wholesale distrust of prescribing healthcare providers. Yes, we all need to be judicious, but not everyone in medicine is trying to keep us unhealthy and medicated beyond necessary.

    (By the way, it was the American Psychiatric Association and not Pharma that defined “social anxiety disorder” – which is not simply synonymous with shyness.)

    This writer claims that hypertension is not chronic and all that’s needed is weight reduction. I have had hypertension for 25 years. Both my parents had it and at least one grandparent. None of these people were overweight. I have normal weight also. I am sure that some people could do away with their condition if they did a few sensible things. But I have a hard time believing that my hypertension is due to my lifestyle.

    This seems like an extreme oversimplification of chronic illnesses. There is no one-size-fits-all fix and suggesting that a divorce or weight loss are the answer to complex health issues is not only misleading but sounds an awful lot like patient-shaming.

    Many years ago I did private duty home health. My patient showed signs of type II diabetes. MD confirmed, put on meds and a diet. After a few months no meds needed, Diet only kept it under control.

    The question is: in whose best interest do we act? An act of good service should be an act on a two way street. Good service and satisfaction for all. Thanks. Always a treat.

    I can’t get over how common diabetes 2 has become. When I do go to a pharmacy, the most prominent thing there is blood testers, and even displays for insulin. What’s going on? I live in a rural community, and it seems like the majority are overweight, with a high number being morbidly so. Scooters are common, and the number of handicapped parking spots seems to grow. I’m thinking the next thing for grocery stores is going to be valet service, and I’m not kidding.

    Why are so many seemingly unmotivated to take care of themselves? Why does anyone want to be a slave to insulin? With all the complaining about high drug prices and healthcare, why isn’t personal responsibility given some focus? I’m not saying that we don’t need healthcare reform, and that there aren’t people who actually have trouble maintaining a healthy weight, but growing up I never saw anything close to what we’re seeing now.

    About 4 years ago, one of my doctors told me that I would be on acid blocking drugs for the rest of my life (age 65). I had had trouble with acid reflux for about 10 years and finally needed to see an “expert”. They couldn’t tell me what causes acid reflux. After about 3 months of taking the meds, I started checking into the causes of my problem. After doing my own research, I soon quit taking the drug and figured out how to change my eating habits and get control of the reflux. I have had good success over the last few years and now that I am fasting regularly, acid reflux is seldom an annoyance.

    A few months back, my sister-in-law (age 69) passed away from a terrible bout with brain cancer. I was shocked to discover that she had been taking acid blockers for 20 years prior to her illness. I don’t know if there was a connection, and for certain the medical community would never admit it if there was.

    It’s kind of scary not knowing if there might be long term interactions that might lead to further troubles down the road. But it is similar to keeping the patient medicated with no hope of ever curing a disease. You take your meds and years later you have other problems and the medical system sucks you back in and you end up paying them to keep you sick.

    I think this article is fear mongering.

    I would also add that thyroid issues shouldn’t be considered chronic either. There are underlying issues why this gland is out of order. Be that as it may, this particular diagnosis is one that has increased dramatically over the last decade.

    * Be nice, and don't over share. View comment policy^