The Bitter Pill

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Reviewing ADHD Drugs – FDA Goes Through the Motions

Evelyn Pringle March 12, 2006

Some of the top-selling drugs of all time are those prescribed to treat attention deficit disorders. Drug companies have physicians in every field of medicine pushing these medications and dole out millions of dollars worth of free samples each year to make sure they are passed out like candy.

A new ADHD drug is set to come on the market that supposedly can keep people awake for days at a time with no problems. Just what we needed, especially for hyper little kids.

I wonder if this means they will remain calm as they sit wide-awake watching TV and playing video games for days while the rest of the family sleeps.

The drug Sparlon is manufactured by Cephalon and is a clone of Provigil, another drug already on the market. Sparlon contains modafinil, the same exact active ingredient contained in Provigil which is approved for the treatment of patients with narcolepsy, sleep apnea and shift work sleep disorder, according to the FDA.

The drug’s approval will be considered by the FDA’s Psychopharmacologic Drugs Advisory Committee at a public hearing scheduled for March 23, 2006.

The day before the Sparlon hearing, the FDA’s Pediatric Advisory Committee is scheduled to meet to discuss neuropsychiatric adverse events and cardiovascular adverse events reported on patients who were treated with ADHD stimulant drugs already on the market.

The drugs under review include Ritalin from Novartis, Adderall and Adderall XR from Shire Pharmaceuticals, Concerta from Johnson & Johnson, and generic versions of Ritalin.

On February 9 and 10, 2006, the FDA’s Drug Safety & Risk Management Advisory Committee held hearings on the same topic, and after reviewing the information provided at the hearing, the panel recommended that black box labels be added to the labels of all stimulants.

However, the FDA is not bound by the recommendations of its advisory panels, and critics of the drugs say the close 8-7 vote by the panel, means there will be spirited debate within the agency over whether black box labels will be added.

Several members of the panel said they voted for the warning in part, because they were alarmed over the sharp rise in prescriptions written for both children and adults. During the hearing, the committee was informed that between 1999 and 2003, roughly 78 million prescriptions were written for children under the age of 18, and 14 million more were written for adults.

In a stark contrast, only 190 million prescriptions were issued for children and adults during the 12 year period between 1992 and 2004.

According to the FDA numbers on adverse events, between 1999 and 2003, there were 25 deaths reported for persons using ADHD drugs, and 19 were children. The agency also acknowledged that more than 50 cases of cardiovascular-related events were reported in the same time period including stoke, heart attack, hypertension, palpitations and arrhythmia.

Critics say the numbers revealed at the hearings represent a gross understatement because only 1% to 10% of adverse reactions are ever reported to the FDA, and it would therefore be better to add a black box now and remove it later if studies prove there is no link between the stimulants and sudden death and heart disease.

Supporters of the drugs, say the warning is based on inconclusive evidence and would deter physicians from prescribing the medications and scare patients away from taking the drugs.

Because Cephalon claims Sparlon should not be classified as a stimulant, analysts predict the company could get a boost if the FDA agrees and requires the other drugs to carry a black box warning. One of the issues discussed at the March 23, hearing will likely be how to distinguish Sparlon’s labeling from other ADHD drugs.

If approved, Sparlon will be co-marketed under an agreement with Johnson & Johnson, which will focus on the pediatric market through its McNeil Consumer & Specialty Pharmaceuticals unit.

McNeil’s sales team will promote Sparlon to psychiatrists, pediatric neurologists and pediatricians, while Cephalon’s 400-person sales force will focus on non-pediatric specialists and primary care physicians.

When Cephalon requested FDA approval for Sparlon, it submitted the results from three clinical trials on children aged 6 to 17 that the company said indicated better results in children taking Sparlon compared to children who received a placebo. Each trial lasted 9 weeks and the most common side effects noted were loss of appetite, mild insomnia and headaches.

But Cephalon has not been sitting idle while waiting for approval of its Provigil clone. Last year it had to figure out a way to deal with the fact that Provigil’s patent was set to expire in 2006. Through some last minute legal footwork, the company was able to negotiate agreements with 4 generic firms that will allow Cephalon to continue to sell the drug unchallenged until at least 2011

Provigil’s approval for a silly diagnosis like “shift-work sleep disorder” is a good example of disease-mongering, described in the book, “Selling Sickness: How The World’s Biggest Pharmaceutical Companies Are Turning Us All Into Patients,” by Ray Moynihan and Alan Cassels, which explains how drug companies foster the creation of bogus disorders to create markets for their pills, through “medicalization” of normal states of health.

In the same vein, many experts say the sale of ADHD drugs in general is nothing but a racket. Dr Fred Baughman, a board certified child neurologist and Fellow of the American Academy of Neurology, calls ADHD the “greatest health care fraud of modern times.”

Clinical social worker Peter Dwyer, has seven years’ experience working with troubled children, and has served as director of a large therapeutic foster care program. He also attributes the ever-rising sales numbers for ADHD drugs to a grand marketing scheme.

“It is easy to see why stimulants dominate the treatment of ADHD,” he says, “drug companies spend over $20 billion a year on promotion – more than they spend on research.”

“The bottom line,” Mr Dwyer explains, “professionals and the public are bombarded with a stream of “research” and “information” financed and spun by the people who make and sell these drugs.”

“The conflict of interest is palpable,” he adds.

And anyone who believes Provigil is free of the side effects associated with other ADHD medications needs to speak to Susan Florence who experienced a terrifying adverse reaction to the drug.

“I took one pill and I thought I was coming out of my skin,” she recalls, “I felt as if someone had climbed inside me.”

“It was one of the worst experiences of my life,” she says.

Nonetheless, Cephalon has done an excellent job of promoting Provigil. The US Air Force has even adopted the drug as one of its official “go pills” for pilots whose missions stretch out more than 12 hours, according to Business Week on November 1, 2004.

Ever since Provigil hit the market, Cephalon stayed busy figuring out ways to promote its off-label use for a multitude of ailments including ADHD, and with obvious success. SG Cowen & Co analyst, Eric Schmidt, told Business Week he figures more than 50% of Provigil sales are for unapproved uses.

And 50% in off-label sales adds up to enormous profits. In 2004, US doctors wrote 1.9 million prescriptions for Provigil, generating $414 million in sales. In 2005, Cephalon saw Provigil sales reach $512 million, according to Forbes.com on March 13, 2006.

While waiting for Sparlon to be approved, the company has been using every trick in the book to boost sales of Provigil for the treatment of ADHD.

For instance, Dr Fletcher Taylor, from Tacoma, Washington, was paid to meet with small groups of doctors to talk about Provigil.

He conducted a study on the use of Provigil for ADHD, which he claims showed positive results. However, according to Business Week, Dr Taylor says “he does not bring up the use of Provigil for ADHD in his talks, but he answers questions – as he is permitted to do – if one of the doctors in the group brings it up.”

“Usually people do ask,” he told Business Week.

I’m quite sure they do ask, probably much like the people on TV who used to just happen to step out of the audience to be cured by faith-healer 50 years ago.

Cephalon also employs the well-known off-label marking technique of funding continuing medical education seminars (CMEs), under the guise of providing doctors with information related to how certain ailments can be treated by drugs that the company just happens to sell.

For example, Cephalon paid for a CME that focused on the treatment of daytime sleepiness experienced by Parkinson patients and explained how Provigil might be a useful therapy.

The sponsor of the program, a firm called Projects in Knowledge, told Business Week that Cephalon paid for the program but had no input on the material discussed.

And of course I believe that.

Another tried and true method of promoting off-label use involves publishing the results of favorable studies funded by drug companies in medical journals. “Journals have devolved into information laundering operations for the pharmaceutical industry,” according to Richard Horton, editor of the Lancet, in March 2004

In a prime example of this practice, the August 4, 2005 New England Journal of Medicine, published a report on a study funded by Cephalon in which the lead author, Dr Charles Czeisler, from Harvard Medical School and Brigham and Women’s Hospital, had a professorship endowed by $2 million from Cephalon.

In the report, Dr Czeisler claimed night-shift workers remained more alert with Provigil and wrote a glowing summary of the study. “I would characterize [Provigil] as the treatment of choice with patients with shift-work disorder,” he said.

However, Dr Robert Basner, director of Columbia University’s Cardiopulmonary Sleep and Ventilatory Disorders Center, published an editorial on the study in the same issue of the NEJM and said the researchers’ data showed only slight improvements in workers wakefulness and productivity with Provigil, and pointed out that the drug seemed to exacerbate insomnia for some patients.

“That’s not a very robust endorsement of the drug coming from the investigators themselves,” Dr Basner wrote. “This drug is little better than nothing in terms of making them less sleepy during shift work at night,” he added.

Experts pretty much agree that Sparlon will be approved for treating children with ADHD so before too long the “little better than nothing” clone will not doubt be ringing up the cash registers all over the US.

Filed under: 'ADHD', 2006, Adderall, Cephalon, Concerta, FDA, FDA hearing, Johnson and Johnson, Novartis, Provigil, Ritalin, Shire, Sparlon

Legal ADHD Speed – Becoming Drug Of Choice For Americans

Evelyn Pringle March 20, 2006

A study published online in the February 2006, Journal of Drug and Alcohol Dependence, that examined data from a 2002 survey of about 67,000 households, estimates that more than 7 million Americans have misused stimulant drugs meant to treat ADHD, and “substantial numbers of teenagers and young adults appear to show signs of addiction, according to a comprehensive national analysis tracking such abuse.”

The statistics are alarming because people are using the drugs recreationally or to boost academic and professional performance. The scientists who published the study concluded that about 1.6 million teenagers and young adults had misused these stimulants during a 12-month period and that 75,000 showed signs of addiction.

Last month, the FDA’s Drug Safety and Risk Management Advisory Committee held 2 days of hearings, and after listening to all the testimony and reviewing the data presented, recommended that all ADHD drugs carry a black box warning on increased cardiovascular risks.

This month, the Pediatric Advisory Committee is meeting on March 22, 2006, and will focus on neuropsychiatric adverse event reports and trial data on ADHD medications. The committee will also receive an update on efforts to better understand cardiovascular adverse events possibly related to ADHD medications, according to the FDA web site.

During the hearings last month, the Alliance for Human Research Protection, asked the FDA to issue (1) a public advisory; (2) a “dear doctor” letter to every doctor in America to apprise them of the essentially lethal side effects that are being tracked; and (3) to solicit the reporting of any and all adverse events of which they are aware.

Allen Jones, speaking as a representative of the Alliance, told the panel the FDA should instruct the pharmaceutical industry to advise the FDA of all adverse events that have been reported concerning ADHD drugs immediately, and also it should demand that all clinical trials in possession of the drug companies be turned over to the FDA so that independent researchers can review them for adverse events.

“We don’t have the luxury of time to wait for the future trials,” he pointed out. “Children are dying,” he said.

Ellen Liversridge, having lost her son to side effects of the drug Zyprexa before they were made known in a black box warnings, appeared to speak on behalf of all parents who have lost their children due to adverse reactions to prescription drugs.

“I grieve particularly today for the 51 dead of ADHD drugs that were announced yesterday by the FDA,” she told the panel.

“I guess my up-front message, front and center,” she continued, “is that you know that ADHD drugs can cause serious side effects and death, including sudden death, hypertension, myocardial infarction, stroke, and possibly bipolar disorder.

“This being the case,” she said, “I urge you to recommend that these drugs have an appropriate black box warning placed on the label starting immediately.”

Sandra Lucas, appeared at the hearing to speak on behalf of the Citizens Commission on Human Rights, a psychiatric watchdog group, and told the panel, “we do know that the side effects of the stimulants are not only present, they are extremely serious and sometimes lethal.”

“So,“ she asked the committee, “while the FDA ponders the problem of studying the issue and conducting the studies that may have inherent flaws, what real, immediate protections are to be put in place for parents and children?”

During the hearing, Drug Safety panel member, Dr Art Levin, told the committee, “I think we have to recognize that when a drug is approved and marketed the public assumes a level of comfort in the safety of that drug unless they are told otherwise.”

“And, for us to sit around and talk about this,” he continued, “to have three advisory committee meetings discussing the signals and not to make, at the very least, a very strong warning to people that there is uncertainty here about the safety of these drugs and that they need to be aware of that pending clarification I just think is inappropriate, unethical behavior.”

Committee member, Dr Steve Nissan advised, “we have to elevate the level of concern and if it slows the growth of this, that is probably appropriate because I think most observers would argue that ten percent of ten year-olds do not have this disease and what has happened is that this is out-of-control use of drugs that have profound cardiovascular effects and, as a cardiologist, I can tell you that,” he said.

Panel member, Dr Curt Furberg, recommended that ADHD drugs also come with a patient guide “so that when parents are filling prescriptions for their kids they get a written document laying out the state of knowledge, or lack of the state of knowledge and the potential risks so they are reminded each time that there is a potential risk and we are trying to find solutions to it,” he advised.

Since last month’s recommendation for a black box warning on cardiovascular events, FDA reviewers announced a recommendation for stronger warnings on all ADHD drugs due to reports of numerous adverse events like mania and psychosis in clinical trials, including modafinil.

On March 14, 2006, an FDA review was posted to the agency’s web site in advance of next week’s meeting. The FDA said stronger warnings are needed on the risk of psychosis, a mental disorder characterized by the inability to distinguish real and imaginary events.

“The most important finding of this review is that signs of psychosis or mania, particularly hallucinations, can occur in patients with no identifiable risk factors, at usual doses of any of the drugs used to treat ADHD,” according to a memo dated March 3 from two members of the agency’s ADHD psychiatric review team.

The review said current labeling neither addresses those concerns nor does it “clearly state the importance of stopping drug therapy in any patient who develops hallucinations or other signs or symptoms of psychosis or mania during drug treatment of ADHD.”

From January 2000, through June 30, 2005, the review found nearly 1,000 reports of psychosis or mania possibly linked to the drugs, including Adderall, Concerta, Ritalin and Strattera. The reports were pulled from the FDA’s database and from the drug makers themselves after the FDA had requested additional information from the drug companies.

The FDA found a “substantial portion of the psychosis-related cases were reported to occur in children 10 years or less,” an age group which according to the FDA, does not typically suffer from psychosis.

“The predominance in young children of hallucinations, both visual and tactile, involving insects, snakes and worms is striking and deserves further evaluation,” the FDA noted.

Last fall, on September 29, 2005, the FDA issued a public health advisory to alert physicians of reports of suicidal thinking in children and adolescents associated with Strattera, and directed Eli Lilly, manufacturer of Strattera, to develop a Medication Guide for patients and caregivers.

Although Strattera is marketed as a “nonstimulant” medication, according to pediatrician, Dr DuBose Ravenel, MD, FAAP, of Cornerstone Pediatrics, “it is in fact a stimulant every bit as much as the traditional stimulants, as evidenced by even a cursory consideration of its pharmacological action, and evidenced by the fact that it is classified as such by the World Health Organization.”

Dr Fred Baughman, ADHD expert and well-known author, will testify before the committee next week on behalf of the International Center for the Study of Psychiatry and Psychology.

“We know these drugs are poisons,” Dr Bughman warns, “and we know they are highly addictive, dangerous and sometimes deadly.” He points to the senseless death of children on ADHD drugs. “Matthew Smith is dead today not because of ADHD,” he says, “but, as carefully delineated by the medical examiner, his chronic Ritalin/methylphenidate exposure.”

“Nor is there any other plausible explanation for the death of Stephanie Hall, 11 years old of Canton, OH,” he advises. “No physical predisposing factor other than Ritalin was present,” he notes, “leading up to her death, in bed, by cardiac arrhythmia.”

“The main question the FDA needs to answer concerns ADHD,” Dr Baughman says, “the “disorder” these addictive, dangerous, sometimes deadly drugs are used to treat.”

“The shocking fact of the matter is that it is not a disorder/disease at all,” he explains, “children said to have it are entirely normal meaning they bear no objective, demonstrable, diagnosable, abnormality, meaning there is no justification for prescribing these or any other drugs for so-called ADHD–a wholly fictitious, wholly subjective entity.”

According to Dr David Stein, Ph D, Professor of Psychology at Longwood University, “the risks of psychiatric drugs in the bodies of children and teenagers is well documented and needs no further elaboration.”

He wants the advisory committee to address two issues: (1) the validity of ADD/ADHD as diseases; and (2) effective alternative behavioral treatments that reduce reliance on drugs.

Dr Stein’s behavioral/cognitive treatment methods have won awards from the American Psychological Association (One of top ten research projects at the 1998), the International Center for Psychiatry and Psychology (2005), and the Ritalin Litigation Conference (2001).

“It is my hope,” he says, “that the committee will consider that within the decision tree, the physician’s choice to use drugs can be lowered in favor of, at the very least, recommending properly designed behavioral parent training.”

“The risks of legal liability and the risks of medical damage to children,” Dr Stein advises, “can be reduced with the augmentation and further development of proper behavioral treatments.”

According to court certified expert and author of many books on ADHD, Dr Peter Breggin, all stimulants commonly cause “a continuum of stimulation, including agitation and irritability, anger, hostility, disinhibition, hypomania and mania.”

The stimulant or activation syndrome, he advises, was originally observed decades ago with stimulant drugs such as amphetamines, Adderall, and Dexedrine, and methylphenidates such as Ritalin and Concerta.

It also occurs, he notes, with dexmethylphenidate such as Focalin, and selegilines like Sparlon and Provigil, as well as the atomoxetine, Strattera.

In a review of the summary data for the FDA Spontaneous Reporting System through March 1997, Dr Breggin counted the following: Psychosis, 43; hallucinations, 44; and psychotic depression, 11. His review also counted more than 50 reports in the combined category of overdose, overdose intentional, and suicide attempt.

“In regard to both amphetamines and methylphenidate,” he explains, “there are a surprising number of animal and human studies showing persistent biochemical changes and atrophy after several weeks or more exposure.”

“While the changes in children are sometimes mistakenly attributed to ADHD or OCD, they are a known effect of stimulants on the animal brain,” he advises. “A known toxic drug effect is a far more likely culprit than a highly speculative “biochemical imbalance” in these children,” he adds.

Dr Breggin will also testify at the advisory committee hearing on behalf of the International Center for Psychiatry and Psychology, and will recommend that labels for stimulant drugs include the following neuropsychiatric warnings:

(1) A warning concerning depressive/OCD ADRs that includes depression, apathy, lethargy, listlessness, tiredness, sadness, crying, withdrawal, and social isolation as well as worrying, ruminating, over-focusing, and other obsessive-compulsive behaviors.

(2) A warning concerning stimulation or activation ADRs that includes insomnia, anxiety, agitation, panic attacks, irritability, hostility, aggressiveness, violence, impulsivity, disinhibition, hypomania, and mania.

(3) Strengthened warning concerning psychosis, paranoid ideation and hallucinations.

(4) Strengthened warning about rebound, dependence and abuse, especially for methylphenidate products (all current methylphenidate labels especially inadequate).

(5) A specific warning that the combination of depressive, obsessive-compulsive and stimulant ADRs poses a serious risk of dyscontrol or disinhibition with suicidal and/or violent behavior.

(6) A warning in the labels for amphetamine and methylphenidate products about persistent brain dysfunction and atrophy.

Information released by the FDA last month showed that between 1999 and 2003, seventy-eight million prescriptions were written for ADHD drugs in children ages 1 to 18, and more than 14 million prescriptions were written for adults.

During last month’s hearings, Safety Drug committee member, Dr Steve Nissen, said he is certain the public is not aware of the risks. “If the current warnings were adequate we wouldn’t have 2.5 million children and 1.5 million adults taking these drugs.”

Filed under: 'ADHD', 2006, Adderall, Concerta, FDA, Focalin, front groups, Provigil, Ritalin, Sparlon, Strattera

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