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Tuesday, February 6, 2024


Good medicine? or a pipe dream?







GUEST BLOG / By Rachael Bedaral for The New York Magazine.--FDA approved Suboxone, a new medication to treat opioid use disorder. Suboxone is a compound of two drugs that decreases one’s cravings for opioids while blocking their effects. It is safer and less cumbersome than methadone, which requires daily or weekly visits to a clinic, and more effective than any abstinence-based treatment, which requires people to withstand cravings and suppress physical discomfort. In clinical trials, Suboxone was shown to help opioid users avoid jail time and to decrease their mortality by over 50 percent. 

“You’d think that anything that can help save a heroin addict’s life would be seen as a good thing,” the writer and academic Michael Clune wrote in 2014, a year that marked an inflection point in an epidemic of fentanyl-related deaths. “So why, then, when I touted Suboxone at a Narcotics Anonymous meeting with a bunch of regulars did they look at me as if I’d gone insane?” Clune has a history of heroin addiction (he wrote, to my mind, one of the great heroin-addiction memoirs) but successfully wrestled his demons into submission through a stay in rehab, diligent attendance at Narcotics Anonymous, exercise, and an enigmatic, epiphanic experience of grace. 

He knows how lucky he is to have overcome his addiction through struggle and also knows how rarely his strategy works for others. But when he proposed to friends in the recovery community that Suboxone is a worthy tool, they were upset; they were skeptical of a fix so expedient, so simple, so biological. “That’s like telling someone that smoking crack will get their mind off booze,” one NA longtimer argued. “Your recovery is based on a spiritual awakening,” another explained to Clune angrily. To this friend, Suboxone — a magic pill that changes the brain — would foreclose a person’s chance of personal transformation. 

I thought of Clune’s essay often as I followed last year’s media coverage of Ozempic, Wegovy, Mounjaro, and other new medications that cause weight loss (from here, I’ll just use “Ozempic” as a shorthand for the whole class). Like Suboxone, Ozempic is a startlingly effective pharmacological intervention for a problem — obesity — that is common, stigmatized, complicated, and deadly. Helping people lose weight is only one of its benefits. At the homeless clinic in Brooklyn where I work as a doctor, most of the patients suffer from long-standing, intersecting chronic illnesses that doom them to trajectories of debility and decline: uncontrolled diabetes that hastens kidney disease, kidney disease that worsens high blood pressure, high blood pressure that increases the risk of heart attacks and strokes. 

Until recently, this was a Gordian knot that was impossible to cut with medication alone; my patients routinely take a full pharmacopeia a day and yet their conditions progress. 

But now, suddenly, I’m hopeful. 

Ozempic seems to be something of a miracle. It’s a very effective treatment for diabetes as well as high blood pressure, heart failure, and kidney disease. 

New evidence suggests that it improves depression and reduces suicidality, and it also seems, unexpectedly, to reduce non-food-related addictive behaviors, like gambling. 

Studies are underway to see if it prevents cancer and Alzheimer’s disease. There’s much more to learn, and we don’t understand how these drugs work so well. It isn’t just a matter of shedding fat and getting glucose under control; as a side effect of Ozempic’s potency, we’re gaining new insight into the relationship between mind and metabolism. 

2023 was year one of the Ozempic Revolution, and the revolution has been televised, TikTok’d, Instagrammed, tweeted, and written about everywhere. 

Some of the coverage has been about the medications’ startling efficacy, but most of the big juicy deep dives into what the medications are, what they do, and what they mean have focused not on their astounding clinical effects but on what Ozempic reveals about our morals and values, about identity and our obsession with thinness. 

In magazine features, opinion pieces, and essays across prestige media, the medicines have been written about almost exclusively as a double-edged sword, a reflection of our vanities and insecurities, or an expensive, overhyped pharmaceutical ploy. The drugs have been treated as an existential threat to the still-new body-positivity movement or a shortcut primarily for the rich and already thin. 

Stories that have considered what the drugs could mean for the not-rich offer dour arguments that Ozempic will exacerbate health inequalities or break the health-care bank. Having emerged at the same time as AI assistants like ChatGPT, these drugs have been assessed during a broad reckoning with what it means to take the effort out of hard things. 

The overarching implication is that even if the medicines are as amazing as the studies claim, we can’t afford them, and even if we can afford them, we probably want them for the wrong reasons. 

The media class has turned Ozempic into a mirror for our cultural shortcomings, but when we stare at it primarily in search of our reflection, we miss the chance to recognize its true significance. 

In October, the sociologist and writer Tressie McMillan Cottom wrote an essay for the New York Times “Opinion” section in which she says, “If GLP-1 drugs only treated diabetes and did not promote weight loss, they would still be medically groundbreaking. 

But Ozempic, Wegovy and Mounjaro probably would not have social media hashtags. These drugs are blockbusters because they promise to solve a medical problem that is also a cultural problem — how to cure the moral crisis of fat bodies that refuse to get and stay thin.” 

In her piece, McMillan Cottom makes mention of diabetes and the murky category of prediabetes, but her discussion dwells primarily on what she sees as the drugs’ cultural implications: the way they function as “a shorthand for our coded language of shame, stigma, status and bias around fatness.” McMillan Cottom’s distinction between the “medical problem” and “cultural problem” of obesity is a common theme of the Ozempic coverage; most pieces offer an obligatory nod toward the drug’s therapeutic effects but then are most eager to discuss its implications for body politics. 

The first wave of Ozempic coverage was largely about celebrities — were Julia Fox and Kim Kardashian taking it? — which set the themes that would define the Ozempic discourse that followed: vanity, beauty standards, and class.

In February 2023, in this magazine, Matthew Schneier wrote a cover story in which he profiled actresses, artists, and fashion employees who were taking the medication to shed ten pounds. “Weren’t we supposed to have moved on from this?” Schneier wondered — “this” referring to the tale as old as time of women chasing trends to look more svelte. 

In March, The New Yorker writer Jia Tolentino ordered bootleg Ozempic through a pill-mill-type service to prove its ready availability to anyone with a credit card. Once the drug seemed to be everywhere, some writers struggled with whether taking it might mean abandoning their commitment to body positivity. 

In the Cut, Samhita Mukhopadhyay wrote a vulnerable essay about her reluctance to take Mounjaro. “I was too ashamed to say it out loud,” she wrote, “but the drug was working, and I wasn’t sure how I felt about it.” 

In August, Emma Specter wrote in Vogue about how she would have wanted the drug five years ago but was now at a more radical place of self-acceptance. “What would we do — who would we be — if we let our bodies and lives exist more or less as they are, without looking to drugs like Ozempic to free us from the eternal trap of bodily perfection?” Specter asked. 

The cultural and emotional implications of the drug’s weight-loss effects, especially shame, became a recurrent theme. 

In the New York Times, Aaron Carroll, a physician, wrote about overcoming his own resistance to trying the medicine for weight loss, and in the Washington Post, Ruth Marcus published a long reported essay about her initially ambivalent experience taking Ozempic in which she confessed, “As my weight loss began to show … I realized that I had internalized the sense that being heavy was a failing for which I was personally responsible.” 

In early summer, the New York Times published a story with the headline “New Obesity Drugs Come With a Side Effect of Shaming” and then reprised the topic during the holidays: “Plates are full. Families may be quick to judge. What happens when weight-loss drugs collide with Thanksgiving?” As the year drew to a close, Ozempic’s implications for “the eternal trap of bodily perfection” remained a focus: In late December, Jennifer Weiner wrote in the New York Times about Oprah Winfrey’s choice to take one of these medications, claiming that Winfrey’s public weight struggles had reinforced the idea that “every woman’s body is a battleground … and that thinness is a woman’s true life’s work.” 

Meanwhile, new information about Ozempic was emerging in the medical literature. By December, the results of the SELECT trial had been announced: It turns out that Ozempic reduces heart attacks, strokes, and cardiovascular mortality for people who are overweight, even if they don’t have diabetes. We also had initial results from the FLOW trial, suggesting that Ozempic prevents diabetics with kidney disease from needing dialysis. 

Forty percent of Americans are obese, and 12 percent have diabetes. These results suggest that Ozempic might change the shape and length of their lives more than anything we’ve previously had to offer. In my job, I regularly encounter the type of story that I wish we were telling about Ozempic. 

Recently, I met a woman I’ll call Arlene. Arlene has bad diabetes and is about 80 pounds overweight. Diabetes is a hard condition to manage; injecting insulin causes weight gain, so treating it often causes a person’s obesity to worsen. Arlene lives in a shelter where she eats what the shelter serves her, which is basically shit, and she’s in a wheelchair, which prevents her from exercising. 

We had a hard, tearful visit because a lot is going wrong in her life and she’s under significant stress. But one thing was going well. A few weeks before I met her, a specialist had started Arlene on Ozempic. 

In four weeks, Arlene had lost almost ten pounds. Her blood sugar was already in much better control, and she thought her back pain had improved. Arlene used the word “miracle” to describe the effects; the medication was the first thing in a long time to make her feel hopeful. 

People like Arlene remain curiously absent from the Ozempic discourse, and they don’t seem to be anyone’s imagined reader, either. Not one of the first-person essays and opinion pieces that I read last year was written by a person with serious chronic illness. Never hearing this perspective means we don’t actually understand the experiences of the people who most stand to gain from Ozempic’s arrival. 

All medical problems are cultural problems — all illnesses exacerbate structural inequalities and provoke identity questions and elicit stigma — but by now, the cultural implications of struggling with one’s weight are so well covered that they have spawned a kind of genre writing. 

In all of the stories I’ve mentioned — and in similar coverage in The Atlantic, Slate, and elsewhere — “Ozempic” plays the same role that “Weight Watchers” or “diet culture” or “plastic surgery” have played in stories written over the past 30 years. 

Despite everything we now know about Ozempic’s radical therapeutic potential, we’re still calling it a “weight-loss drug,” which allows us to keep it in a zone of moral ambivalence and interpret it using familiar conventions. 

Conversely, we don’t have popular, well-developed narratives about the chronic diseases that result from glucose derangement and excess fat tissue, which disproportionately debilitate people who are poor and racialized. 

We have the cultural elite’s obsession with Susan Sontag’s Illness As Metaphor, we have cancer memoirs, and we have an emerging post-pandemic literature about the vagaries and difficulties of living with long COVID. We have no canon of great writing about struggling with cirrhosis or the decision to get a diabetic amputation. 

“There aren’t breathless profiles of a pharmaceutical drug because it will help a diabetic manage her blood glucose level,” McMillan Cottom observed in her essay. 

She’s right. 

America’s silent majority of chronic-disease sufferers — dying prematurely, disabled, or on dialysis — desperately need this drug. For them, taking this medication and losing weight isn’t a question of succumbing to vanity or vanquishing one’s inner critic. 

Elite media discourse around Ozempic can meaningfully influence public opinion and health-care policy. 

Right now, the most urgent concern about Ozempic is the fact that everyone who needs and wants it cannot get it. Recently, the state of North Carolina had to rescind its policy of paying for the drugs for people who do not have diabetes — in other words, people prescribed the medications primarily for weight loss — because it could no longer afford the ballooning costs. 

The drugs can cost up to $16,000 a year (depending on the one prescribed), an out-of-pocket cost few people can bear. So far, the public discussion of Ozempic’s daunting economics have been consistently fatalistic. 

At the end of the summer, the columnist Megan McArdle and the physician Leana Wen wrote op-eds in the Washington Post within two months of each other saying the cost benefit for the drugs may not pencil out. Nearly every story I’ve read has used the current access challenges as reason to doubt the drug’s miracle status: If it’s only going to be available to the luckiest few, what makes it any better than Botox? Jia Tolentino, in The New Yorker, wrote, “It is possible to imagine a different universe in which the discovery of semaglutide was an unalloyed good … 

In the actual universe that we inhabit, the people who most need semaglutide often struggle to get it, and its arrival seems to have prompted less a public consideration of what it means to be fat than a renewed fixation on being thin.” 

As long as we talk about these medications primarily as “weight-loss drugs” — as medications that have prompted “a renewed fixation on being thin” — insurance companies and policymakers will remain incentivized to treat them as a luxury good. 

We’ll never ask the questions that need to be asked: If such a large percentage of the country wants Ozempic, and if we now have good-quality evidence that it helps with a variety of serious conditions beyond diabetes, what is our cutoff for determining who truly needs it? 

And how do we make it available to them? 

Price is not an inherent feature of most pharmaceuticals. Ozempic already costs less in other countries, and in the U.S., the president recently took the extraordinary step of lowering drug costs for some of the most commonly prescribed medications by using his executive authority. 

Ozempic presents a radical opportunity to change the chronic-disease landscape in this country. It may require radical policy to make it accessible, and what that policy looks like is the conversation I want to have. In a culture where we so powerfully associate wealth, beauty, and thinness, I wonder if we simply can’t envision recategorizing a medicine like Ozempic, something rich people want, as an intervention for the non-rich. 

We are comparing Ozempic to the wrong precedents — fen-phen in the 1990s gets mentioned a lot; McMillan Cottom compares the hype it’s received to Botox and Viagra — and missing the analogies that would be most helpful. 

In a hopeful end-of-year story in The New Yorker, Dhruv Khullar compares Ozempic to COVID therapies and the COVID vaccine: interventions that made an overwhelming, seemingly intractable public-health crisis suddenly much less so. 

The comparison is a useful one, because it also points toward how Ozempic’s initial access issues do not mean that it cannot, ultimately, play a powerful role in reducing health disparities. Initial coverage of the COVID vaccine focused a lot on the equity concerns surrounding who would get it first. And yet, because the vaccine was disproportionately beneficial to the populations most vulnerable to serious COVID outcomes, the poor, sick, and elderly were ultimately most helped by it, even if they got it two months later than they should have. 

Suboxone is the other medication that might help us make sense of how we should understand Ozempic’s potential. Over the past 20 years, Suboxone’s cost — initially prohibitive to many who needed it — has decreased, and it’s gradually achieved greater acceptance in the recovery community. Regulatory barriers that prevented physicians from prescribing Suboxone have fallen, and “harm reduction,” a framework for managing addiction that tries to mitigate its worst impacts rather than require people to conform to certain behaviors, is increasingly recognized as the standard of care in addiction medicine. 

And yet, Suboxone remains a heavily stigmatized, underutilized therapy largely because of its cultural associations rather than its medical risks. The persistent dogma that people who use it aren’t really “clean” prevents people who use drugs from asking for it, and most doctors are reluctant to make it part of their practice and take on a patient population they’d rather not deal with. 

Like any medication, it also comes with a host of complications: It doesn’t work for everyone, it carries a risk of side effects, it often requires a daily out-of-pocket co-pay, and people usually have to take it for the rest of their lives. It’s a very good medicine, but it doesn’t magically address all the reasons people become addicted to opioids in the first place: trauma, untreated mental-health issues, bodily pain, existential distress. 

It doesn’t fix a broken culture. 

But it does give a lot of struggling people a better chance of waking up each day to face that culture and work through everything else that ails them. 

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