Fish – Now By Prescription

I.

LOVAZA™®© (ask your doctor if LOVAZA™®© is right for you) is an excellent medication. It is extraordinarily safe. It is moderately effective at its legal indication of lowering levels of certain fats in the bloodstream. It has moderately good evidence for having other beneficial effects as well, including treating certain psychiatric, rheumatological and dermatological disorders.

Lovaza is fish oil.

“Come on,” you say, “surely there’s some difference between Lovaza and the fish oil I buy at my local health food store for a couple of tenners per Giant Jar?”

And you’re right. The difference is, Lovaza costs $300 a month.

“Come on,” you say, “surely there’s some other difference”.

The company behind Lovaza certainly thinks there is. They boast about how they use a patented process to filter out blah blah purity blah toxins blah certified to be blah blah blah quality blah. On the other hand, every fish oil supplement maker uses about the same phrases. I’m sure it’s not exactly the same patented process and that they check for toxins in a slightly different way, but the evidence that Lovaza’s methods are superior in some interesting way is, basically, nonexistent.

So, fish oil pills cost $30 at the store, Lovaza costs $300, which would you rather get?

And the answer is: the Lovaza, of course. Because you’re paying the $30 for fish oil, and your insurance is paying the $300 for Lovaza. Maybe you’ve got a copay. Is the copay more or less than $30? Well, there you go.

This isn’t an unusual business model. Off the top of my head I can think of a second drug that works the same way. It is called Deplin, and it treats depression. On the one hand, it is a good medicine and I wish it was used more. On the other hand, it is l-methylfolate, which is basically a very shiny chrome-plated version of the folate that your cereal box tells you it has 200% of the recommended daily allowance of. Most studies suggest that for most people without a particular mutation there’s not much difference between the folate in your Cheerios and the l-methylfolate in Deplin – but if you have the mutation or are among the significant minority of people who believe there is, you can also walk into a health food store and buy l-methylfolate itself, chemically identical to Deplin, at about $10 per Giant Jar. Deplin costs $100 per month.

Ask your doctor whether she recommends people go to supplement stores and buy folate or fish oil, and likely she’ll say supplements sometimes make people feel livelier but that they have minimal place in responsible medical practice. Then ask your doctor whether she gives out prescriptions for Lovaza and Deplin and she may very well tell you she writes a dozen of them a day.

II.

When I search the web for people’s Lovaza and Deplin opinions, I see a lot of people talking about greedy pharmaceutical companies. Fair enough. Pharmaceutical companies are pretty greedy, and it’s hard to deny that’s a pretty big factor in how these kinds of drugs (I don’t know a good category name for them, but Deplin bills itself as a “medical food”, so we’ll go with that) come to be.

This blog sometimes looks at things from a libertarian perspective. The libertarian perspective says that usually if a for-profit company is making money, it’s probably providing someone with a service somewhere. Is the public getting any service from Lovaza and Deplin?

I say: yes! The companies behind these two drugs are doing God’s work; they are making the world a much better place. Their service is performing the appropriate rituals to allow these substances into the mainstream medical system.

A doctor who prescribes boring regular old supplement fish oil pills is taking a dangerous step into uncharted territory. If anything goes wrong and their conduct comes under review, a clever lawyer could say “I notice your patient had severe hypertriglyceridaemia, a very dangerous condition, and instead of giving her any medicine, you just told her to get fish oil from her local health food store! Fish oil has never been FDA-approved and you have only your personal opinion that it does anything at all.”

And that’s if the patient even gets the fish oil. What does the insurance company say if there’s a patient too poor to pay the $30 for a Giant Jar? This is really common, both in a “a lot of people are legitimately poor and only able to get things Medicaid subsidizes for them” way, and in a way that’s sort of the reverse of how people can always find $50 a day to support their heroin habit. “You want me to pay money for pills to treat a condition which is not at this moment causing my limbs to fall off? Sorry, can’t afford it.” But insurance companies will laugh in your face if you ask them to pay for some random supplement at a health food store which is made out of some slimy animal that swims in the ocean and which doesn’t even have a ® after its name.

And this is even assuming there’s a health food store to get it at. What if you’re in a hospital? Or a nursing home? They don’t have health food stores. They just purchase a bunch of medications, put it all in a big room somewhere, and dispense it to patients who need it. Exactly which medications they purchase is highly highly regulated both by government laws and internal regulations, and it is probably not going to include a Giant Jar of fish oil pills.

I mentioned before that, in a hospital pharmacy stocked with hundreds of different rare and wonderful substances – substances that must be kept frozen at very specific temperatures, substances that can only be given through complicated surgical tubing, substances which must have the dose be absolutely right to within a thousandth of a gram or they will kill you instantly – they don’t have melatonin. The drug that is probably in the bathroom cabinet of half the people reading this post is totally missing. Because it’s not Official.

The point of Lovaza and Deplin is to make fish oil and folate Official. I wish someone would do the same with melatonin so I could start prescribing it in-hospital already.

The high prices of these drugs? Likely at least in part an attempt to recoup costs. In order to make them Official, their parent companies had to perform very specific studies on them. Not just “there are hundreds of studies on fish oil, we’ll just attach them to an email and cc the FDA”. No, that would be too easy. They had to perform exactly the studies the FDA wanted, using fish oil that came from their factory, with their patented process of extraction. That was a couple million to a couple billion dollars. Then they had to hire a bunch of lawyers and lobbyists to make the FDA like them. Then they had to price in the cost of risk from the dozen drugs they try to develop that never get approved and make zero money. Then they had to hire really pretty women to go around to doctors and give them nice pens that say “Lovaza” on them, because despite attending medical school for four years and residency for another three, the number one way doctors learn about drugs is through pens with the drugs’ names on them given to them by pretty women. Then lawyers and accountants and executives had to go through a bizarre process in which they all argued among themselves about how much Lovaza should cost and who should pay for it, which ended up, like all such drug negotiations end up, with parties A, B, and C marking up the sticker price by ten times, parties X, Y, and Z demanding it at one tenth the sticker price, and both sides thinking they pulled a fast one on the other while everybody else facepalms.

My point is, the drug companies are probably making an obscene profit off of it, but less obscene than you might imagine from their ability to stick a fish in a blender and sell you what comes out the other side for $300.

And if you’re still not convinced that this whole thing benefits society, think about this.

Naturopaths and alternative medicine people and “healers” of all sorts have a common form of apologetics for their chosen folk remedy: “Everyone ‘in the know’ has figured out this is a miracle cure, but because it just grows out of the ground Big Pharma can’t make a profit off of it. That’s why they’re suppressing it and poisoning you with toxic medications instead.”

And I used to think that the alternative medicine people were overestimating how evil Big Pharma was. But now I know that’s not right.

Now I know they’re underestimating it.

If it were discovered tomorrow that potatoes cured cancer, then people wouldn’t “suppress” this “natural” remedy. Two years from now there would be an ultrapurified potato extract called POTAXOR™®© that was, on closer examination, physically and chemically identical to mashed potatoes. But these mashed potatoes would be mashed in a giant centrifuge by scientists with five Ph. Ds each. Any time someone got cancer, their doctor would prescribe POTAXOR™®© and charge $6,000 per dose, and the patient would get better, and the thought of just going out and eating a potato would never occur to anybody. Not to the doctor, who doesn’t want to sound like the idiot who tells her cancer patients to eat potatoes. Not to the FDA, who doesn’t know whether potatoes might be contaminated with lead or potato fungus or ketchup or God-knows-what. And certainly not to the patient. They would have to pay 60 cents for a potato at the supermarket, but if they have a good enough insurance the POTAXOR™®© is free!

This system, bizarre as it is, is your guarantee against the pharmaceutical companies suppressing a promising new natural medication. Your insurance company pays $300 on fish oil, and in exchange you go to sleep at night secure that no one has discovered that potatoes cure cancer but decided to cover it up to protect their bottom line. Good deal? Given the current health system, it’s better than you had any right to expect.

III.

I promised yesterday I’d talk about a Jacobin article, so here it is: Bad Science.

Apparently there’s a company called Myriad Genetics which charges a lot of money to test BRCA1 and BRCA2, two genes in which mutations are associated with a very high risk of breast cancer. This is outrageous because genetic testing is very cheap. Worse, they don’t even have the excuse of “the customer is paying extra to reimburse the cost of the research that discovered this”, because the relevant research was done by the government at public expense. From the Jacobin article I don’t understand exactly what their patent/monopoly status is, but it seems to be enough that they can price gouge without repercussion.

I don’t want to comment on the broader points about the scientific community Jacobin is making, but when I read that I thought “Wait! I had an opinion about BRCA testing at one point!”

Yeah. After searching my memory I remembered that the FDA recently banned popular genetic sequencing companies like 23andMe from offering BRCA testing bundled with their other services. The problem was that 23andMe was nonprescription. It was outside the Official Medical System. It was fish oil, not Lovaza. I was pretty annoyed about that decision.

But after reading this new article I have learned something that puts the whole thing in a new light. Whole genome sequencing companies can sequence all 20,000 or so coding genes for about $1000. Myriad Genetics will sequence two genes for $3000.

[EDIT: Douglas Knight, more expert in this area than I, discusses some of the subtleties here: 1, 2, 3]

I’m not saying that the FDA is in bed with the genetic testing companies. But if the head of the FDA gives birth to a child who looks suspiciously similar to the CEO of Myriad Genetics, I hope her husband gets a paternity test. Assuming those haven’t gotten banned yet.

I am willing to write off Lovaza as a weird but successful way of adapting to an increasingly crazy medical system. I even find it darkly hilarious. But the high cost of BRCA testing probably turns off a lot of women who would otherwise get the test, and some of them probably develop preventable breast cancer. Lovaza is a farce. BRCA is a tragedy.