The reputation of the medicine

In some patients, it undoubtedly affects the attitude towards the drug, the expectation of its therapeutic effect, faith in it and hope. We do not know of any studies on the effect of a drug’s reputation on the attitude of patients towards it. However, it can be assumed that reputation is one of the peculiar fashion options. There are cases when the therapeutic effect of a drug or placebo was largely determined by information received by the patient before taking the drug from relatives, acquaintances, former patients, that is, from non-physicians. Therefore, it is practically important to find out from the patient before treatment what he has heard about this medicine and how he feels about what he has heard.

Name of the drug

Special studies have established the importance of the name of the drug, its euphony, pronouncability, length, and the language of the label on the packages, all of which have a psychological effect. The recent rules, system and practice of naming medicines have been thoroughly described in the All-Russian scientific journal (Lieberman S. S., Lyubimov B. I., 1999). Example. The idea that the attitude to a medicine depends on its name was aptly expressed by the satirical writer Emil Meek (“Excerpts from the Unwritten”): “She recognized medicines only with Latin names, in the Russian translation they did not affect her.” There is no need to comment on the persistent preference of imported medicines by many patients, their insistent requests to prescribe, for example, nootropil rather than piracetam, seduxene rather than sibazone, tofranil rather than melipramine. And the point here, of course, is not only in the name. The choice of a drug is determined even more by the idea of its guaranteed quality and, therefore, the effectiveness of the drug. The brand name often takes into account the psychological impact. For example, levomep-romazine (tizercine), released in small doses (2.5 and 5 mg) for children, was called “tizercinetta”, which is associated with a little girl, a gentle character from some forgotten fairy tale. This association makes the attitude towards the drug warmer. The novelty of the drug and its name may determine its magical effect. Hence the well-known practical recommendation: “Use new medicines as long as they work.” Some patients prefer long-known medications because they provide a sense of reliable protection, while other patients perceive such medications as “ordinary” and ineffective. And here a universal “individual approach to the patient” is required: in order to optimize pharmacotherapy, it is necessary to find out from the patient his expectations, attitude to medicines in general and to this drug in particular. Of course, it is not necessary to prescribe the drug in exact accordance with the patient’s expectations, especially since they can often be erroneous, typical biases. As always, a subtle psychotherapeutic correction of any appointment is necessary. But there are also completely different preferences. For many years, they keep in mind the names of medicines that once, many years ago, helped. Examples. I have been repeatedly approached by elderly people, sometimes at a very advanced age, former fellow citizens who have been living in the USA, Israel, and Germany for many years, with a request to send… valocordin and corvalol, which used to “work great.” They didn’t take into account that “before” was twenty or more years ago, when they were much younger and healthier, and many medications, even relatively “light” ones, helped them. The efforts of relatives and local doctors to convince them that modern medicines can now be used, which are much more effective than valocordin and corvalol, turned out to be in vain, especially since the latest modern drugs did not really help those who asked for these two “proven and true” medicines. Attempts to replace valocordin with combinations of its active ingredients, phenobarbital and ethylbromisovalerianate, with the addition of mint and hop oils, were also unsuccessful. The “old” valocordin or corvalol were needed. When “their” medicines were delivered to them, they took them with great pleasure and the hope of quick success. Both drugs continued to help, as they had many, many years ago. The domestic nootropic and tranquilizing drug Phenibut, which the author participated in the creation of in the early 60s, was first called Fenigama (a phenyl derivative of gamma-aminobutyric acid). Under this name, the drug was mentioned in the first publications about its pharmacology and clinical use. The Nomenclature Commission, in accordance with international rules, changed the name to “Phenibut” (“feni” — from the phenyl radical of the formula, “but” — from “butyrum” — oil). The late Professor Theodor Yakovlevich Khvilivitsky, an experienced pharmacopsychiatrist who led the first clinical trials of the drug at the Bekhterev Institute, criticized the new name several times for its rougher sound (“Boot”, he said, resembles a punch, boot, boot). The masculine gender of the new name of this drug, in his opinion, also made it sound rougher. If the name of the drug contains an indication of the direction of action, the expectation and attitude based on the understanding of the name may be more significant than the actual pharmacological effect. Therefore, it is methodically very important to design the study in such a way that the subjects cannot assume what type of action (for example, soothing or activating) the drug under study (or placebo) may have. In our experiments (Nuller Y. L., Lapin I. P., 1971), we encoded placebo with the abbreviation “Kos”. In different series of experiments, there were placebos called “Kos-5”, “Kos-11″, “Kos-33″. Many subjects associated such names with the word “Cosmos”. Thus, with advanced technologies, privileges, and systematic selection of the best, including medicines, the expectation of meaningful action was overestimated. However, it was impossible to guess its orientation from the name. Familiarization with the methodology of a number of recent works on placebo psychology has revealed that the prerequisite — the indifference of the placebo code name — is not always respected. Hence the obvious inaccuracies in the results and conclusions. Half of the subjects who received caffeine, a typical stimulant drug, had a decrease in pulse and a decrease in systolic and diastolic blood pressure, while without naming the drug, it caused the opposite effects (Hamburg A. L., 1956). Some of the medical students (5 out of 92) who took the tranquilizer meprobamate, encoded as “stimulin”, noted its stimulating effect in self-reports, and those who took placebo, codenamed “sedatan” or “tranquilan”, indicated a significantly greater number of sedative effects than subjects who received placebo with an indifferent orientation. The actions of the instruction are 17 out of 92 and 8 out of 88, respectively (Nuller Yu. L., Lapin I. P., 1971). The novelty of the name often plays an important role in patients’ assessment of the effectiveness of the drug. When the tranquilizer meprobamate was given to patients with neurosis under a new, previously unknown name, a more pronounced therapeutic effect was observed than after the same drug prescribed under its usual name (Bojanovsky J., Chloupkova K., 1966). There are cases of deterioration of self-esteem after the patient found out that he was taking a drug previously known to him by another name. It cannot be ruled out that it is precisely a change in attitude and expectation due to the loss of novelty by the drug and its name that may become the leading reason why, as Professor N. Koper (1985) writes, “really effective drugs really become ineffective.” The novelty of the name is, as is well known, of great importance in many areas. It increases attention to the subject, arouses interest — at least due to the universal orientation reflex, called by Ivan Petrovich Pavlov the reflex “What is it?” This effect of novelty is widely used in advertising. So, in St. Petersburg at the end of the 90s, you could find colorful advertisements for wallpapers and tiles, entitled “Oh, how I want novelty!”.

The text of the inserts on the package

The text on the inserts in the medicine package contains information that immediately precedes taking the drug and significantly shapes the patient’s attitude to the expected effect. Patients often have considerable concerns or even refusal to take medications due to the information about side effects and contraindications contained in the supplement. I have repeatedly had to dissuade patients who refused to take absolutely necessary medications due to fright due to overestimation of the warnings indicated on the leaflet. Since the patient always has his own ideas about the picture of his illness and the state of his health, he may well mistakenly assess the likelihood of complications when using this medication. This assessment is more typical for hypochondriac and suggestible personalities, for people with a tendency to hypochondriac reactions. Therefore, one cannot but agree with the opinion (Walluf-Blume D., 1994) that the insert often scares away rather than informs the patient, that, according to a special survey, patients complain about the incomprehensibility of the text of the inserts, an excessively long list of side effects causing confusion. Therefore, an international commission of representatives from 16 countries concluded that it is necessary to provide only a minimum of information in the inserts of medicines, especially those obtained in pharmacies without a prescription (therefore, without a preliminary conversation with a doctor) (Working-Group, 1977). I can’t count how many times patients and their relatives have contacted me by phone, frightened by the warnings they read in the inserts. Examples. “The doctor said that I really need this particular drug. I finally got him. At home, I read in the leaflet that there may be complications from the liver. And I had something about twenty, no, thirty, no, maybe even forty years ago, it seems (my italics. — I. L.) there was something with the liver (my italics. — I. L.). I haven’t started taking it yet. Maybe I won’t…” Another patient is frightened by the fact that the insert mentions “some kind of allergic reaction”, “and I had something allergic when I was a child” (italics are mine. — I. L.). There were also patients who confessed to me that they did not take their prescribed medications, fearing possible side effects in the text of the insert — “out of harm’s way.” They did not tell the attending physician about this, because they were afraid of “spoiling relations with him.” At the end of 1997, I was approached by a well-known Moscow writer who had many years of experience taking various cardiovascular medications, and therefore was well acquainted with medical terminology, with a request to help her out: — I’m at a complete loss. In a panic. I have been prescribed the drug enap for my hypertension. Bought. I take out the insert. And I can’t understand a single word. Not a single one. Translate it, please. I thought that the text was not in Russian. That’s why I asked: — From what language? Russian Russian, yes. But it’s full of terminology, and I can’t understand anything at all. What did I have to read? It was not good, of course, to laugh in the presence of a person who was at a dead end, but I couldn’t help laughing as I read the text of the insert through the patient’s eyes, translating it into “normal language” as the patient requested. Soon we were laughing at every line. How could she, poor thing, know and understand all these words (I quote in a row, from the beginning of the text of the insert): “prodrug” (why not explain?), “inhibits (why not “slows down”?) angiotensin-converting enzyme that catalyzes the conversion of angiotensin I to angiotensin II”, “improves coronary hemodynamics (why not “blood circulation through the coronary vessels of the heart”?), “reduces the mortality rate”, “the drug does not affect metabolism (why not “metabolism in the body”?) glucose and lipoproteins”. The writer was puzzled by both “after oral administration” (why not “oral administration” or “oral administration”?) and “after 4 days of treatment, the half-life of enalapril to enalapril stabilizes at 11 hours.” Just half a page of four pages of the insert text! And should this be written for the patient? — Well, why couldn’t they write like that, how do you translate? — the writer asked through laughter. — Who needs these complicated words and phrases? Here I was once again convinced that, right, separate inserts are needed for patients and doctors. Their text should be different: for patients — in simple literary language (the bard writer Yuli Kim once asked in the press for all those who write to follow the “principle” of HRE – explain to the common man), understandable to any literate reader, for doctors – in professional language using modern medical terminology. But even with the insert for doctors, with medical terminology, that is, the language of doctors for doctors, not everything could be expected to be successful. Why? This is because both in medical publications and in scientific classrooms there are words and terms that unnecessarily complicate speech, “memorize” and clog it with tracing paper from foreign languages, most often English. Example. At a scientific and practical conference at the Academy of Medical Sciences in Moscow a couple of years ago, I felt literally poisoned by high concentrations of pollutants – in words like “aerobatic” or “pilot” studies (tracing paper from the English “pilot”, which corresponds to the exact name in Russian — “trial” or “exploratory” studies), “interaction” (why not “interaction”?) cardiac drugs and antidepressants, “transmission” (referring to the transmission of a nerve impulse), “opposition groups” (referring to groups with the opposite type of behavior), “treatment complications” (why not “treatment complications”?), “definition” (why not “definition”?), “prediction(why not “prediction”? — after all, the exact match!). I wrote down many more similar “terms” on the conference program. What are they for? For what? To give yourself, your writings and speeches a more “learned” look? In fact, it is “scientific”, revealing an inferiority complex and defects in style. So the inserts for doctors may not be of high quality if they are written by doctors who prefer a vocabulary littered with scientific words. It is not by chance that the question of what should and should not be reported in the patient’s supplement has become the subject of special consideration in the scientific literature (Sammons J. H., 1982). It is impossible not to add what language the insert should be written in. Source: Lapin I. P. “Placebo and therapy” Photo: okeydoc.ru