The 9 Ps of Prescriptions, Potions and Pills

“One has to swallow a bitter pill to get cured.”

~ Sharad Pawar

Open most medicine cabinets and you’ll find a portfolio no investor should hold: two dozen positions, no thesis, no exit plan, auto-delivery and a monthly bill.

You shouldn’t buy a junior miner because a stranger said it tripled for his brother-in-law. Yet that’s the standard of evidence behind a lot of the capsules people swallow every day.

So let’s borrow the discipline we apply to mining stocks and point it at the pill bottle.

Proof: the Bitter Truth

Proving that a treatment works is hard. Proving it works for you can be harder.

In resource exploration, the drill is considered the truth machine. But it’s not. It’s one tool. It can mislead on the high side. It can miss on the low side. In evidence-based medicine (which is what standard medicine has strangely morphed into), the truth machine is the randomized, double-blind placebo-controlled trial. It can mislead too, and in my experience is often used for the very purpose of misleading.

Importantly, a controlled clinical trial at most can tell you the pill might work for you, not that it will. Because none of those people in that study are you. You are not even the average person in that study.

Alternative medicine sells its remedies with highly selected testimonials. You know how a junior explorer’s press release highlights the best gold concentrations from their drill cores? Same thing.

The testimonies pass through filters before they reach you. It turns out that most diseases get better on their own, and chronic disease symptoms wax and wane. People tend to start a remedy when they feel worst, so next week they are likely to feel better no matter what they swallowed. Statisticians call this regression to the mean. The people who improve on the pill talk it up and keep taking it. The people who didn’t? They say nothing and move on to the next. The seller picks the best stories to show to you.

I call alternative medicine Anecdotal Medicine because it offers as proof only anecdotes about people the pill seemed to help. Highly selected anecdotes. This is not proof that it works. And it is not proof it works in you. Thus, Anecdotal Medicine.

A bit better

If you measure a lab value in yourself that responds to a pill, that’s a bit better, but a lab value is not a disease. Statins in low-risk people are an example: decades of treating a lab number, for a fractional chance of benefit against actual disease. Lots of benefit for Big Pharma though!

The best proof is a one-person, blinded placebo-controlled trial in yourself of a therapeutic that has a rational mechanism of action and has been well-proven to be highly effective in other people. Preferably you would track a measurable objective outcome that is more than a lab test. It’s a doable thing. But only a rare, superb doctor will help you do it. Call your nearest compounding pharmacist. He may be willing to assist you.

One caution. A personal experiment works for things you can measure or assess in a short period of time. It cannot assess successful prevention of rare events nor outcomes that take more than a month or so to reveal themselves. It won’t work for purported life extension therapies. For those, we are stuck with choosing between evidence-based medicine or total guesswork.

Proof is never perfect. Not remotely.

Hornswoggling

Drug companies hornswoggle doctors and patients with data more often than either suspects. Don’t underestimate how complicit many physicians are as they become mouthpieces for big pharma marketing departments. One of my early novels—Assume the Physician—relates how the doctors get recruited while oblivious that it’s happening. Purveyors of alternative medicine can hornswoggle patients too, just by different methods.

The 9Ps of pills and potions, plus more Ps

Crisis Investing subscribers know our 9Ps framework for evaluating resource stocks. Here is a parallel idea for evaluating your medicine cabinet.

1. Problem. Identify the problem before popping pills. First, do you have a confident diagnosis? Throwing a pill at a symptom, a lab number, or a vague worry are three different speculations, whereas purchasing a therapeutic that is well-proven to treat a clearly identified diagnosis is more of an investment. Popping pills to prophylax against a phantom problem is pointless and potentially perilous.

2. Plausibility. Is there a credible mechanism that would make it likely that the pill you are considering will work for you? Is the biochemistry understood? Is effective dosing known? True homeopathy (the stuff with 30C and 100C dilutions) dilutes its ingredient until not one molecule remains. That’s like mining sand you know holds no gold while claiming the sand receives gold energy from long ago and far away. It’s a waste of money. But there is lots of stuff that is labeled as homeopathic that actually has real ingredients in it. This fake homeopathy is just using the term to sell stuff, yet it is more likely to work than true homeopathy, simply because it has something in it.

3. Placebo effect. Be aware. It’s real. It’s powerful, and it’s relevant. Both in Big Pharma medicine and Anecdotal Medicine.

4. Proof. What is the proof you are relying on? Is it clinical studies performed scientifically in other people (not you) that are selected for the purpose of marketing the pill? Is it anecdotal testimonies of other people (not you) that are selected, likewise, for the purpose of marketing the pill? Is it no proof at all? Or have you found a way to assess in yourself whether the pill is working and made some effort to rule out placebo effect and spontaneous improvement?

5. Personal. Do you resemble the people in the clinical trials? Do you have the same disease as the trial participants, or is your disease different while just sharing overlapping symptoms? Asthma medications help people with asthma, not people with COPD. Also, is the doctor treating you as an individual person, or is he treating you as a statistic? Standard evidence-based medicine has moved increasingly to being collectivist, some even focusing on “population medicine.” Your medical choices should be personalized.

6. Pushers and Promotion. Who profits? Is the pill sold with emotional music and people blowing bubbles while dancing in fields of wildflowers while the announcer races through explosive diarrhea and 60 other side effects? That’s the drug-company way. Is it sold by a doctor who charges you for the visit and then also profits off the pills he prescribes? That’s a common functional-medicine way. Social media testimonials are likely lies. A friend or family member pushing a pill wants you well, which is nice. But taking their medical advice is like buying a junior miner on a tip from your Uber driver.

7. Product. Does the bottle contain what it claims, at the dose studied? Independent testing has found supplements with too little, too much, or something else entirely. Who knows what’s in a pill manufactured in China. Remember, a gold mine is a hole in the ground with a liar at the entrance. That same hyperbole is well applied to any pill promoted by a guy who plays a doctor on TV.

8. Pitfalls. Harms, drug interactions, and opportunity cost. Supplements are often active medications. Natural does not equate to safe. Prescriptions have side effects. Don’t forget the effective treatment you delayed taking while the heavily-promoted bullcrap failed.

9. Price and Probability. Cost divided by realistic benefit. If 100 people must pop the pills for a year for one to benefit minimally, 99 people will be disappointed. And the hundredth is not likely to be you. These sorts of numbers are common, by the way.

10. Phat Lady Exit. Our mining framework ends with the exit, and so does this one. Before you open the bottle, write down the date you’ll judge it and the result that justifies continuing. If you reach that date without the result, cut your losses.

Consider all the Ps before speculating on your next pharmaceutical or supplement. It’s not easy to do.

~ John Hunt, MD
Doug Casey’s Crisis Investing & Grey Swan