Drugs and Medical Devices

Direct URL: drugs.globe1234.com
Patients can get independent information on drugs and medical devices from sites listed farther down on this page (many track your IP address; you can check their privacy statements).

A. This page is not about substance use disorders, but here are 2 resources

1. 800-662-4357 (HELP) is a government referral number in English and Spanish, 24/7/365. They have other languages at 877-696-6775. They say, "The service is confidential. We will not ask you for any personal information. We may ask for your zip code or other pertinent geographic information in order to track calls being routed to other offices or to accurately identify the local resources appropriate to your needs." For zip code (and phone number if it appears in their system), "We will retain the information only for as long as necessary to respond to your question." 
2. Thousands of counseling and treatment programs are listed on a map by the government. They use Google maps and Google Analytics, so Google will know that you're looking for help on that website. A private company lists its own and some other rehab centers, not clear what the criteria are. The company makes you waive class actions, but they don't require indemnification or arbitration. It has ad tracking from Google and Microsoft, so those companies will know you're looking for rehab. If that concerns you, the phone number above may be better, but if you do any web searches, major web companies and advertisers know it. 

The sources in italics below cover medical devices, like pacemakers, artificial joints, lenses, etc. as well as drugs. FDA has a search box for US recalls of medical devices, and the press has an international list. Many devices have serious problems, and experts advise finding how many patients a device was tested on, how many times your doctor has installed it, and how it can be removed if necessary, before getting it implanted.
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B. GENERAL SITES ON DRUGS AND MEDICAL DEVICES:
Advice from WorstPills.org, the first site below:

• ​​List all your drugs and supplements, and keep the list up to date [carry in your wallet or purse for emergency responders, even if you don't take any, so they know that, along with other information].
• Ask your doctor every 6 months if you can stop or reduce any drugs.
• When you or a family member starts a new drug, assume every new symptom is caused by the drug. Research common side effects. Most of us don't notice our own side effects, so watch for family members.
• When a specialist orders a new drug, tell your primary care doctor's office [they need the record in case of emergency, and they may change another drug].
• Discard unused drugs carefully [without polluting ground or water, by taking to most police stations or many private sites, or mailing needles back to the drug company].

1. WorstPills.org ($15/year, cites many studies), side effects, advice and comparisons among drugs, run by Public Citizen. 
2. Multiple prescriptions have gotten more common since the 1990s, so people need to be more careful with each and with interactions. 4 of 5 people over 65 use 5+ drugs per month, as do 2 of 5 people 45-64.
3. Drugs.com (free, paid by selling your searches) shows side effects. The professional tab shows their frequency. Less information is at RxList.com, pdr.net and MedLinePlus.gov. A source without tracking is a site at the University of Modena and Reggio, Italy, but sometimes it fails to open. You can name your collection of items and come back to it later without giving your own name.  The free Italian tool shows side effects, but not interactions, which you can see for 88 euros per year.
4. Interactions among  drugs and vitamins are available free at some websites listed on another page.
5. Medical Letter (many citations, free trial with online access for 6 weeks, $10/article, $159/year or $98 for cumulative file from 1988 to previous December or June) Reviews new drugs and compares drugs and recommendations for common diseases. Some major diseases are listed as most read. Others are searchable as "drugs for". Comparable to UpToDate, which has cheap access but not free trials. More comparisons than GuideToPharmacology. French version for Canadian drugs comes out a few weeks after English version.
6. UpToDate.com ($20/week, $45/month, covers medical and surgical treatments as well as drugs, detailed, many citations), recommendations for most conditions, interactions, side effects. Many doctors go here to get complete info and training.  Or if your doctor depends on drug company presentations (see article), you can get more information here than s/he has. Comparable to Medical Letter on drugs, which has free trial, but UpToDate also covers all medical approaches, not just drugs. More comparisons than Guide to Pharmacology. For major life decisions, people can check all three.
7. ​When those sources give citations, you may find free copies of academic articles through Google Scholar. If not, you can find which libraries get each journal at worldcat. You can check citations and identify later articles citing them, and systematic reviews at pubmed.gov. A similar search site for free pre-prints is prepubmed. A more controversial source is Sci-Hub, which stores millions of papers and accesses others as needed. It uses login codes from anonymous academics who have free access.
8. TRIPdatabase.com (free version or $40/year pro version) lets you search for primary research, or systematic reviews, or TRIP's own summaries, called "answers". Not just drugs, it covers all medical interventions, like UpToDate, which is more thorough, but not free. TRIP says drug companies "do not have any editorial say in Trip".
9. AskaPatient.com (free, cites FDA), patient reviews, and FDA reports of adverse events, for over 4,000 drugs. Much easier than FDA. Ad-supported, not sponsored by drug companies. Adverse events are rarely reported, in part because doctors who report them get scant response from FDA, and disapproval or threats from drug companies. 
10. GuideToPharmacology.org (free, technical, many citations). Search "Ligands", which are bio-active drugs. For example if you type "statin" in the ligand search box and just wait without clicking anything, it will suggest Atorvorstatin, Lovastatin, and many more. Click on one to see chemical and clinical research about it. You can type brand names in the same search box.
11. MedShadow.org (free, some citations), many articles on side effects and advice, and links to patient forums

C. SPECIALIZED 

1. ​DrugDangers.com (free) broad list of US lawsuits against makers of drugs and devices. It summarizes suits by the law firm which maintains it and other firms, though not giving other firms' names.
2. Compare-Trials.org (free, full citations) Read some of their letters to see the poor quality of random trials in top medical journals.  Letters cover articles published October 2015 to January 2016 in NEJM, JAMA, Lancet, Annals of Internal Medicine, BMJ. (Also: 538, RetractionWatch, Guardian, Ioannidis, Gizmodo, Chocolate hoax)
3. HealthNewsReview.org (free) comments on accuracy of articles and press releases about health care.
4. Open Science Framework (free) stores articles and their original research designs, so you can tell if they changed their approach. You can enter a drug, like "statin" and find articles on it.
5. PubPeer.com (free, comments on citations), not specifically on drugs. It compiles comments on each published article, so if you find a significant article, you can check what others said about it.
6. Drugs.com (free), factual, no comparisons, run by 2 pharmacists, supported by ads from drug companies and drug stores
7. Consumer Reports Drugs (free, no citations), little information
8. MedWhys.com (free, no citations), factual, lets you ask a pharmacist questions, which you can also do at most drug stores and hospital pharmacies
9. ClinicalTrials.gov (free, technical, original data), shows random trials started, and results for a few (story on lack of results, and number of missing results by company and university)
10. Mayo Clinic Shared Decision Making National Resource Center, (free, no citations). Graphs compare risk and benefit of drugs and other treatments for a few conditions (angina, heart attack, osteoporosis). Descriptions but no risk comparison for arthritis, depression, diabetes, and quitting smoking.
11. Varied articles on Canadian drug issues

D. Electronic Prescriptions

There are two big problems when doctors send prescriptions to pharmacies electronically. This is more reliable than hand-written faxes, but:

• Most doctors cannot send, and most pharmacies cannot receive, electronic cancellation orders
• If the patient does not get a copy, the patient cannot check if the pharmacy filled it correctly.

Cancellation orders are crucial to correct mistakes and cancel refills. Patients can overdose when they keep getting the old medicine after the doctor orders a new one. Only a third of prescribers and 40% of pharmacies use software certified to handle cancellations, so less than a third of cancellations can go through. "Electronic health records allow prescribers to stop a prescription, but what many physicians may not realize is that in most cases that directive is not sent to any pharmacy," even though original prescriptions are reliably sent. Some doctors put cancellation orders in the notes of a new prescription, where many pharmacists will not see it.

Health systems like the Veterans Health Administration and Kaiser Permanente can cancel electronically, where prescriber and pharmacy are in the same organization. Otherwise only 5 pharmacy chains accept e-cancellations (CancelRx): 

• CVS/Caremark (which sells $61 billion of US prescriptions, 23% of the total),
• ExpressScripts,
• RiteAid ($18 billion), 
• Kroger ($10 billion),
• Wegmans (under $1 million). 

Many non-chain pharmacies accept e-cancellation. You can ask the pharmacy if their software accepts e-cancellation (CancelRx) .

No other chain is certified for e-cancellation, such as Walgreens ($57 billion of US prescriptions) and Walmart ($19 billion). Consumer Reports unfortunately recommends Costco and Sam's Club for price (uncertified), Walgreens for its apps (uncertified), and supermarket chains for convenience (only Kroger's is certified). CR should know better.

Doctors can cancel electronically only if their software is certified under "CancelRx". Out of 954 systems, only 156 are marked as certified, and usually only the latest updates. If your doctor is part of a large group, you can ask the group to ensure its software gets certified and updated. Individual doctors have little control. CancelRx is getting more widespread, but the sponsor, Surescripts, is not willing to say how many doctors or pharmacies use it.

Automatic refills are even more dangerous. When pharmacies call patients to say, "Your prescription is ready," patients and callers do not know whether the doctor recently ordered it or it is a zombie renewal. Costco, CVS, RiteAid and Walgreens encourage patients to sign up for automatic refills, so patients at Costco and Walgreens (two which lack e-cancellations) can get undesired medicine for long periods, thinking their doctor ordered it.

Prior authorization for prescriptions is a system where an insurer tells a pharmacy that a doctor needs to send the insurer detailed information and get the insurer's approval for the prescription. Insurers tell pharmacies, not doctors or patients, when prior authorization is needed, and pharmacies say they have no obligation to tell doctors, though they have the forms and information which the doctor needs, and no one else does. A Massachusetts court says pharmacies must tell doctors, and a doctor says the entire circuitous system of prior authorization for drugs kills patients.

E. Drug Companies Influence Doctors 

F. Cost and Number of Prescriptions, Overall, and for Each Doctor

Dr. David Belk has clear data on wholesale (NADAC) and retail costs of generic and branded drugs (from GoodRx) and what drives the costs.

IQVIA reports on wholesale and retail costs and number of prescriptions.

Express Scripts has numerous articles on drug pricing and 11 billion prescription records (paid access).

Drug stores in half the states are not allowed to volunteer to you that the cash price is less than your co-pay, but the other half of states have laws letting them tell you. You can always ask anyway.

Drugs are distributed to retail pharmacies primarily by three companies: AmerisourceBergen, Cardinal, and McKesson, which have paid small fines, relative to their revenue, for not reporting excessive deliveries of opioids.

You can find the number of drug prescriptions from each doctor and costs for Medicare patients in at least 2 places, described below. For non-Medicare prices see above.

ProPublica has Medicare Part D cost for each drug: number of prescriptions and total spending. You can get separate totals for US and each state, so you can get average cost per prescription, and for each doctor who prescribed a drug 50 or more times in 2013.

Medicare itself has more complete Part D data. The US and state summary files (bottom of the link) show for each drug: the number of beneficiaries as well as prescriptions and spending, so you can get average per beneficiary (total during a year), as well as per prescription for each drug.

Medicare's detailed files show number of days prescribed, so you can get average cost of a daily dose, as well as each doctor who prescribed a drug 11 or more times in 2013. This info is in 23 million records, without state or US summaries. However you can get good state and national estimates by opening any of their 36 spreadsheets (divided by last name of prescriber) and getting averages there. The average costs do not vary much by last name of prescriber. (Tips for working with large spreadsheets)

Some doctors and drugs typically have 30-day or 90-day prescriptions, which may be renewed all year. Their averages include the cost for each  whole long prescription (30 or 90 days). Docs & drugs with shorter prescriptions only include that lower cost. Medicare's focus seems to be on cutting total costs, not cost per dose.

ProPublica's methodology says it has "retail cost" for these prescriptions.

Medicare's fact sheet gives more detail, saying it includes,

• total drug cost includes the ingredient cost of the medication, dispensing fees, sales tax, and any applicable administration fees. It's based on the amounts paid by the Part D plan, Medicare beneficiary, other government subsidies, and any other third-party payers (such as employers and liability insurers). Total drug costs do not reflect any manufacturer rebates paid to Part D plan sponsors through direct and indirect remuneration or point-of sale rebates

It does not directly include patients' monthly premiums, though on average those premiums may cover all drugs, administration, and profits.

After seeing which drugs a doctor prescribes, you can find drug safety and effectiveness from the sources at the top of the page.