by Ray Garton
When Eli thought of Lydia, he preferred to remember the pictures of her that had hung on the walls in the Dreyfuss house. She’d been beautiful in her youth, with long golden-blond hair and the face of a movie star. She’d started self-medicating with alcohol early, and the effects of liquor blended with the knife work of inner pain had stripped her of youth and beauty far too soon. Eli remembered the pain in Lydia’s wet, sunken eyes as she watched the television screen, pain that had nothing to do with the movies. Even more vividly, he remembered the pain in Roger’s eyes whenever he saw his mother that way. It only grew worse, until she ended it with an overdose of sleeping pills and a bottle of vodka one Christmas when the boys were fifteen.
From Lydia, the boys had developed a mutual love of movies, particularly old ones, and had even tried their hand at making movies themselves with a video camera. For awhile, they’d become quite passionate about filmmaking and agreed that when they grew up, they would go to film school together and become great directors. Their interest in pursuing careers as filmmakers had faded, but their love of movies had not. Now they often tried to stump each other with lines from old movies.
As they passed through the foyer, Chloe said, “I think my favorite Bette Davis movie was The Letter.”
Turning to them again, Roger said in a dramatic Bette Davis impression, “With all my heart, I still love the man I killed!”
Until he smiled, Roger appeared quite average in every way. His smile involved his entire face, especially his eyes, and was transformative. It turned him into a handsome, mischievous boy who harbored a naughty secret. Over the years, Eli had watched that smile work wonders. In bars and nightclubs or at parties, women seemed unaware of Roger’s presence, but as soon as he smiled they paid attention to little else. That had been back in the old days, when he was just another guy. Now he was rich. His brown hair was unfashionably shaggy and stubble darkened his jaw. He wore sneakers, jeans, and a plain grey short sleeve shirt unbuttoned over an old red T-shirt. He didn’t look like he was worth millions, but he didn’t have to—his sprawling house, which he’d helped design, did that for him.
The spacious sunken living room had a picture window that provided a view of the rolling, neatly manicured lawn, surrounding shrubbery, and the brown, dirty sky. Behind the thick smoke, the dulled sun was nearing the end of its descent for the day.
Eli said, “My favorite is Whatever Happened to Baby Jane?”
“You wouldn’t be able to do these awful things to me if I weren’t in this chair,” Roger said to Eli.
Doing his own Bette Davis impression, Eli replied loudly, “But ya are, Blanche! Ya are in that chair!”
As Chloe laughed, a young woman in her late twenties came down the steps into the room with a small bunch of grapes in her hand. Tight jeans hugged her long, slender legs, and she wore a red T-shirt sporting black letters that read, “If you have to ask, you can’t afford me.” The shirt was just a little too short to cover her flat, tanned belly. She popped a grape into her mouth. “Who’s Blanche?” she said as she chewed.
Roger smiled as he went to her and slid an arm around her narrow waist. “Kids, this is Jandie. Jandie, this is Eli Dunbar, my best friend in the world, and this is Chloe, his best fiancée in the world.”
Jandie’s pretty face brightened as she said, “Oh, hi! I’ve heard so much about you, Eli. Nice to meet you, Chloe. Want some grapes?”
“We’re eating dinner soon,” Roger said. To Eli and Chloe: “She eats constantly, but look at her. She has the metabolism of a meth addict. Anything to drink?”
“I need to use the bathroom first,” Eli said.
“You know where the closest one is,” Roger said.
In the nearest bathroom, Eli took his cell phone from his pocket. Everett had not returned his call. He tried to punch in Everett’s cell phone number but hit the wrong keys. When he tried again, he made the same mistake. He put the toilet lid down, sat on it, and took a deep breath.
Since getting home from work, Eli had tried not to think about it, but he could not stop imagining the two remaining Paaxone pills in his medicine cabinet. After tomorrow morning, there would be only one, and after that—the thought made his chest tighten.
It had been awhile since he’d felt such anxiety and he’d forgotten how unpleasant it was, how consuming and draining. He remembered how that anxiety would fill him when his supply of liquor or cocaine began to dwindle, how he used to worry about where his next drink or line would come from. The anxiety he felt there in Roger’s bathroom was no different—but this time it was over the pill that had allowed him to get away from the alcohol and cocaine. It annoyed him that he was allowing himself to get so worked up over something so small.
But it’s not small, he thought. Without Paaxone, I might go back to being what I was.
He took another deep breath, then called Everett. Eli tried to sound calm and relaxed as he explained the problem.
“You’re not the first person to tell me this,” Everett said. “I’ve probably mentioned this before, but I don’t prescribe psychiatric drugs anymore. For one thing, I’m not too convinced they work. I’ve seen them do more harm than good to a lot of patients.”
“They sure helped me.”
Everett made a doubtful sound. “Well, I don’t know. To be honest, Eli, I think you helped yourself. I’m not so sure things would have been any different if you hadn’t started taking Paaxone. Maybe the catalyst was meeting Chloe, not starting the drug. Or going to meetings to fight your addiction to alcohol. It’s hard to tell. Anyway, we’ve gotten off track, here. In the last week, a couple of my patients who take Paaxone have mentioned in passing that they were having trouble getting it refilled. No explanation from the pharmacist?”
“Neither pharmacist I talked to had any idea why it’s unavailable. The guy at Walgreens told me their supplier’s out of stock.”
After a moment of silence, Everett sighed and said, “That’s very odd. Did you call Dr. Myerson?”
“She’s on vacation this month.”
“Well, let me ask around.”
“Maybe I should order some from one of those online pharmacies. You think?”
“No, don’t do that. I don’t trust online pharmacies because you can never be sure of what you’re getting and some of them are downright crooked.”
“Well, there’s got to be something I can do. Isn’t there a generic version of Paaxone that I can get?”
Everett laughed.
“What’s funny?”
“Sorry, but no, there’s no generic. Paaxone hasn’t been on the market long and it’ll probably be years before there’s a generic. It’ll be years if Braxton-Carville can help it, anyway.”
“What do you mean?”
“Drug companies spend a whole lot of money and energy on keeping their patents. They extend them as long as they can, then when they run out, they come up with a me-too drug.”
“A what?”
“A me-too drug. It’s a prettied up retread of a drug that already exists.”
“I’m not sure I understand.”
“Well, a good example is the proton pump inhibitor Nexium.”
“The purple pill? For heartburn?”
“Ah, the power of advertising. Yes, the purple pill. It’s manufactured by the British company AstraZeneca. Before Nexium, AstraZeneca had another drug that did the same thing—Prilosec. It was a huge hit. AsraZeneca had the patent on Prilosec, which meant there were no other generic knock-offs on the market. Prilosec was the only one. They advertised the hell out of it, charged four dollars a pill and made a fortune. It pulled in six billion dollars a year, one of the best-selling drugs in history, because everybody gets heartburn now and then, right? But the patent was scheduled to expire in 2001, which meant Prilosec would become virtually useless to them. There would be knock-offs, generics, and the price they were charging for Prilosec would collapse. So they got a patent on the active Prilosec molecule, renamed it Nexium and said it was an impr
ovement over the new drug. AstraZeneca launched a gigantic half-a-billion-dollar advertising campaign for ‘the purple pill called Nexium, from the makers of Prilosec.’ They had to convince Prilosec users and their doctors to switch to the new pill. Nexium’s price was a little lower than Prilosec at first, which helped. They showered doctors with free samples, put coupons in newspapers, gave discounts to hospitals and managed care plans. And it worked. Prilosec became an over-the-counter drug and AstraZeneca convinced the world that Nexium did the same thing only better, even though it isn’t better.”
“It’s not? Then how can they claim it is?”
“Two reasons. First, drug companies are required by law to show only that a new drug is effective, not more effective than existing drugs that treat the same condition. In fact, they don’t even have to prove a new drug is as effective as the existing drug. Only that it’s more effective than taking nothing at all.”
“That’s the law?”
“Yep. Also, AstraZeneca rigged the clinical trials required for FDA approval of Nexium. Most of these trials compared Nexium to placebos, which is standard—a placebo is the same as taking nothing, and all they have to prove is that taking a drug is more effective than nothing. But their marketing strategy called for four trials in which Nexium was compared to Prilosec. The trick was that they used higher doses of Nexium than of Prilosec. The trials used twenty milligrams of Prilosec, but twenty to forty milligrams of Nexium. This skewed the results and they were able to say that Nexium was better than Prilosec. They just didn’t happen to mention that they used higher doses of Nexium to get that result.”
“And this isn’t illegal?”
“Like I said, the requirements of the law are being met.”
Eli stood and paced the length of the bathroom as they talked. “But they’re lying.”
“Outside of perjury, tax forms and the ten commandments, lying isn’t against the law. And in the case of pharmaceutical companies, it’s pretty standard procedure, especially when it comes to me-too drugs. These days, the pharmaceutical industry is propped up mostly by me-too drugs. Schering-Plough did the same thing with its allergy drug Claritin. The patent was due to expire in 2002. It was a blockbuster, made billions every year, and they didn’t want to lose it. So they marketed the Claritin metabolite as Clarinex. The FDA approved it not only as a treatment for seasonal outdoor allergies but for year-round indoor allergies as well, which meant Schering-Plough could say it was an improvement. But the only reason Clarinex was approved for that was that the company tested it for that. Claritin wasn’t tested for that treatment, but if it had been, there’s no reason to think it wouldn’t have passed just as well, because it’s the same active ingredient.”
“How often does this happen?”
“Me-too drugs? It’s the bread and butter of the pharmaceutical industry. The great majority of what the industry produces is me-too drugs. Statins are nothing but me-toos. So are most antidepressants. Eli Lilly’s Prozac was the first one and virtually everything that’s followed has been a me-too. In fact, Eli Lilly did something really ballsy with Prozac. They changed the color from green and white to pink and lavender and the FDA approved it as a drug for “premenstrual dysphoric disorder,” which used to be plan old PMS. It’s still Prozac, but now it has a different function and a whole new market, which means billions more in revenue. These days, the pharmaceutical industry is virtually nothing but me-too drugs. All that’s needed for a me-too drug to work is a large market and an expandable market.”
“I don’t understand what that means.” Frowning, Eli sat back down on the toilet.
Everett chuckled. “Are you sure I’m not boring you? I’ve got a friend who pitches a fit every time I start yammering on about this stuff.”
“I’m not bored at all. It’s fascinating. If I didn’t think so, I’d change the subject.”
“Well, the market has to be large enough for all these drugs to compete for the consumer’s dollar, and the drugs have to have a broad appeal to survive in that market. That’s why they’re made to treat common conditions that don’t go away. Things like high blood pressure, or arthritis, or depression, or something as mildly annoying as hay fever. Serious illnesses have a tendency to kill the patient, which doesn’t do the drug companies any good. They want you to stick around and suffer from your ailment long enough to keep buying their product.”
“Okay, but what do you mean by an expandable market?”
“That’s a market that can expand to include more people. Like blood pressure. Not so long ago, the definition of high blood pressure was anything higher than 140 over 90. Now we treat something called ‘prehypertension,’ which is anything between 120 over 80 and 140 over 90. It used to be that you had high cholesterol if your blood cholesterol level was over 280 milligrams per deciliter. Then the cutoff point was lowered to 240. Now the ideal level is 200 or less.”
“You mean those levels are wrong?”
“I’m not saying they’re wrong. There’s never anything wrong with lowering your blood pressure and cholesterol. But these cutoff points are lowered because studies show that they should be, and the thing about the studies is that most of them are funded by pharmaceutical companies. Every time the cutoff points are lowered, suddenly more people have a medical problem. Now, any doctor will tell you—well, any good doctor will tell you the best way to treat these conditions is with diet and exercise, which are always effective and which improve your overall health. But nobody wants to do that. I’d say nine times out of ten—hell, usually ten times out of ten—a patient will say, ‘Can’t you just give me a pill?’ And with that, some drug company has a new long-term customer, which translates into millions of new long-term customers.
“Blood pressure and cholesterol aren’t the only examples of drug manufacturer manipulation. Pharmaceutical companies used to market drugs that treated diseases, but now they market diseases to create a demand for its drugs. Markets are not only expanded, sometimes they’re created. Heartburn is a pretty common condition. Except it’s not heartburn anymore. Now it’s ‘acid reflux disease,’ or more ominously, ‘gastroesophageal reflux disease.’ You’ve had pretty good physical health in your lifetime, Eli, but I bet there’ve been times when you haven’t been able to get it up. Right? Admit it. It’s happened to all of us at one time or another and it becomes more likely as we get older, it’s a natural part of aging. We used to get past it. But now, just a single limp dingus is a symptom of—” He mimicked the sound of menacing movie music. “—dun-dun-duuun—erectile dysfunction. You watch a couple hours of TV at night, how many commercials do you see for me-too drugs like Cialis or Levitra? Handsome middle-aged men frolicking with their beautiful middle-aged wives with naughty looks in their eyes while happy music plays. You want to be like them, don’t you? You don’t want to be some loser douchebag with erectile dysfunction. So you tell your doctor and he writes you prescription. Another natural result of aging is hormone depletion. Women have been taking hormones to treat postmenopausal symptoms for decades, but now men are told they have ‘testosterone deficiency,’ and they need to wear a patch, or take growth hormones. As a nation, we’ve gone pill crazy, but we’ve been shoved into that state by pharmaceutical companies looking to tap our wallets. They’re the drug cartels of the new millennium, and they’ve made doctors the new pushers.”
Eli slowly shook his head back and forth as he said, “But... this just doesn’t sound right.”
“It doesn’t sound right because you, like just about everybody else on the planet, are laboring under the misconception that drug companies function to treat sickness with their products. That’s just not true. Pharmaceutical companies are interested in one thing and one thing only—maximizing their profits. That’s why they flood the market with me-too drugs, because they’re gargantuan moneymakers. Meanwhile, there are a lot of very important drugs, some of which save lives, that just don’t make a lot of money, so drug companies ignore them.”
“You’r
e kidding. What kind of drugs?”
“Early in the last decade, there were severe shortages of some very necessary drugs. Anticlotting drugs for hemophilia, some anesthetics, an injectible drug for cardiac resuscitation, poisonous snakebite antivenins, drug overdose antidotes, gonorrhea antibiotics, even adult vaccines for things like pneumonia and influenza, and even worse, childhood vaccines. But pharmaceutical drugs are far more interested in blockbusters, and none of those drugs fit that description, so the supplies were allowed to dwindle because the manufacturers see them as a waste of time and money for relatively small returns. A drug company has to get the FDA’s approval before it can market a drug, but it can pull out of a market anytime it wants, for any reason. The reason is always money. That’s why drugs for deadly diseases in Third World countries are so rare. Things like sleeping sickness, malaria—drug companies aren’t interested in developing drugs for those diseases. Developing those drugs would cost money, and the people who need them live in poverty. They aren’t paying customers. No money, no druggy.”
“But why does the FDA approve so many drugs that treat only common, non-lethal conditions? Why aren’t there laws preventing this kind of thing?”
Everett laughed again. “The relationship between the FDA and pharmaceutical companies has gotten a lot cozier than it used to be. In the last two or three decades, it’s gotten downright intimate, if you know what I mean. And laws... well, laws are made by lawmakers. Lawmakers are elected officials who need donations to run campaigns so they can stay in office. The pharmaceutical companies have a lot of money to donate. They’ve got more money than they know what to do with. They’ve got so much money, they aren’t all that concerned about breaking existing laws, because the fines they have to pay are minuscule compared to the monstrous profits they make each year. This is a two hundred billion dollar a year industry by conservative estimates, and that’s in America alone. Globally it’s at least twice that. With that kind of money, pharmaceutical companies can pretty much do whatever they want. They’re the 800-pound gorilla in the room.”
