Pain Pills Withdrawn, Many Renew Search for Relief

By JOHN LELAND

Published: March 6, 2005

Barbara Birmingham faced a busy weekend recently, so she went into her medicine cabinet for a fix: a couple of doses of a medication that had been pulled from the market for safety reasons. Her leftover supply of the drug enabled her to get through the weekend. When she told her doctor what she had done, she says, he scolded her.

Mrs. Birmingham, 74, who lives in a retirement community outside Detroit, has arthritis pain that is so severe on some days that she cannot pull up the sheets on her bed. The pills she took were Vioxx, which were prescribed for her last year and were "a godsend," she said - at least until the drug's manufacturer, Merck & Company, withdrew it from the market in September because it appeared to double rates of heart attack and stroke.

Since then, Mrs. Birmingham has joined millions of former users and doctors scrambling to reinvent life after Vioxx, and often wondering which drug that they are taking or prescribing will be discovered to be unsafe next. After Merck pulled Vioxx, clinical trials linked a similar and likewise relatively new pain medication, Celebrex, to increased risk of heart disease, though the manufacturer, Pfizer Inc., did not withdraw it.

Many patients are trying alternative treatments, including acupuncture, herbal remedies, massage, exercise magnets and diet. Others have simply switched to older drugs. The withdrawal of Vioxx has led some, like Mrs. Birmingham, to consider how much risk they are willing to take to relieve their pain.

"One woman down the hall was on Vioxx since it first came out," she said. "The woman said: 'I haven't died of a heart attack yet. I would be willing to take my chances.' "

Last month a panel of advisers to the Food and Drug Administration concluded that Vioxx, Celebrex and a similar drug, Bextra, all posed significant heart risks. But the panel recommended against banning them, and a Merck executive said the company was considering returning Vioxx to the market.

In the meantime, patients and doctors are weighing the risks and benefits of this class of drugs - known as cox-2 inhibitors, or coxibs - which since 1999 has become enormously popular and profitable but has never been proved to be more effective than older drugs like ibuprofen, commonly sold as Advil or Motrin.

Some patients say they respond better to one drug than another, old or new. But the coxibs were developed as alternatives to older anti-inflammatory drugs, which can cause ulcers. Buffeted by the news media and by pharmaceutical companies' advertisements, patients often feel "fear both of the drugs and of the drugs' being taken away," said Dr. Joan M. Bathon, director of the Johns Hopkins Arthritis Center.

"A lot of our patients say they don't want to take drugs," Dr. Bathon said, but because of the advertisements, "if you offer them a new drug, they're eager to take it."

Some doctors and patients want to rethink the way the cox-2 drugs are used.

"The unexpected plus" of the coxib controversy "is that doctors and patients are more open to discussions about what were the benefits of coxibs anyway," said Dr. Daniel H. Solomon, an arthritis specialist at Brigham and Women's Hospital in Boston. "Many patients who are on coxibs don't need to be on coxibs. People are thinking more seriously about alternatives, such as nonpharmaceutical treatments."

For Mrs. Birmingham, life after Vioxx - her doctor refuses to prescribe her another coxib - includes a regimen that she says gives her only partial relief.

"I have water exercise twice a week," she said. "I work out in the weight room two or three times a week, do rubber band exercises, line dancing and tai chi."

She also takes ibuprofen. But she is eager for the cloud over Vioxx to be lifted.

"With Vioxx, I could bend my fingers in the morning and walk without problems," Mrs. Birmingham said. "I can't do that now."

She is also frustrated that she is not permitted to decide for herself whether to take the drug.