“The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.”1
So quoted my professor of pharmacology as he marveled that some of his patients were taking as many as 6 to 8 prescription medications. He went on to say that all of our expanding knowledge of pathology, physiology, and biochemistry would one day reveal that indeed all disease had a molecular basis. (This prescient notion presented just a few years after Watson and Crick and 3 decades before the human genome project.) Concurrent with that assertion was the emerging sense that society’s ills (read evils) as disparate as violence, atherosclerosis, kleptomania, intolerance, or gluttony could also have molecular explanations. Thus the solution to just about everything might be in a pill. The future leaders of our pharmaceutical industry were also in the room … and they were taking notes.
In the 70s, our film, literature, and music culture began to actively feed the desire for pills to sleep, to wake up, to feel rosy, for pep, to relax, to prevent conception, to lose weight, to breathe easy, or treat heartburn and constipation. Drugs were becoming recognized as vehicles for intended or unintended societal transformation. For example, consider the enormous impact of “the pill.” Oral contraceptives were in the midst of transforming the populations of Europe and North America resulting in a complex cascade of profoundly influential events. Major changes in the workforce, in sexual behavior, and in disease patterns impacted squarely on society. The birthrate in the industrialized West dropped precipitously. STDs soared. DINKs (dual income/no kids) emerged as a societal force. Even the condominium and increased fast food choices emerged as entities in part because of “the pill.” For the first time, a prescription medication became a key element colliding with the goals of religion and government. The pill society had emerged.
Advertising for over the counter (OTC) medications began in earnest in the 1970s. The public first learned of the relative attributes of various new agents from the manufacturers, rather than their physician. More ominously, the drug sellers began to define medication as the only effective solution to every problem. Benzodiazepines were the prototype of mood/mind altering medication that created a molecular response to life’s visible events. Cocktail and water cooler conversation fed the desire for more pills. Not just all disease but all life had become molecular. The pill culture had emerged.
2006, Portland
“I see you are on 23 prescription medications, 5 naturopathic preparations, and a various number of OTC supplements. Do you have a primary care physician?”
“Why, no,” she replied.
“Any major illnesses?”
“Why, no. I am just old, I guess.”
Who prescribed them? For what purposes? Is the patient compliant with their medication? What are the drug interactions? What drugs will affect current treatment needs? While in the past such questions were solvable, today they are worse than daunting.
Drugs, like surgery, used to be prescribed by a single provider and only when the patient had a presenting illness or complaint. Today more drugs are used for conditions for which the patient has no current symptoms. Hypertension and type 2 diabetes management are the prototype of success in the management of asymptomatic disease. Careful preventive drug strategies to lower blood pressure and blood glucose have sharply mitigated many of the adverse events associated with these “silent killers.”
These successes have set the stage for preventive drug strategies for less well-defined goals. For example, liver suppression to control cholesterol, hormone replacement therapy to control the symptoms of menopause, anti-aging drugs, and bisphosphonates to increase bone density are examples of highly complex preventive drug strategies with potentially confounding risks and benefits.
Into this mix is an aging population with an accelerating urge to self-medicate. This urge to medicate with the absence of symptoms is driven by their fears and enabled by expert marketing. Take a walk down the 4 or 5 aisles of your local supermarket now devoted to self-medication. While these pills are (perhaps facetiously) called “supplements” in order to escape both federal regulation and quality control, those that are not useless often have profound physiologic effects. Their interaction with prescription medications is often only partially revealed.
The unintended side effects of pills are a key factor in causing falls, daytime somnolence, suicide, intimate partner violence, motor vehicle crashes, hospitalization, and death. Important to the practice of oral and maxillofacial surgery, pills are a key factor in anesthesia morbidity and mortality as well.
The pill culture is here to stay. Expect the pill society to get ever more complex and difficult to manage in the oral and maxillofacial surgery clinical setting.
A curiosity to consider is whether society is driving the pill culture, or has the pill become the vehicle to drive society?
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