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Covid complications

What happens when your prescription drug becomes the center of covid misinformation

Ivermectin has been falsely promoted as a covid treatment—but for those who use the drug legitimately, seeing it become a piece of anti-vaccine misinformation is disconcerting.

September 8, 2021
Horses with ivermectin cream
Horses with ivermectin cream
Ms Tech | Unsplash

By the time Joe Rogan mentioned ivermectin as one ingredient in an experimental cocktail he was taking to treat his covid infection, the drug was a meme. In the days and weeks leading up to the hugely popular podcaster’s revelation, the drug had already become a flashpoint in the covid culture wars. Ivermectin isn’t some new or experimental drug: in addition to its use as an anti-parasite treatment for livestock, it’s commonly employed in humans to treat a form of rosacea, among other things. So for those of us who have been using it for years, its sudden infamy was unexpected and unwelcome.

Prescriptions for the oral form of ivermectin spiked in August as the drug was promoted widely across the conservative media landscape and championed by a group of pro-Trump doctors who are popular in anti-vaccine circles. Phil Valentine, an anti-vaccine, anti-mask radio host, posted on Facebook in July that people who turn down the vaccine should “have a doctor on speed dial who will write you a prescription for ivermectin.” (He later caught the virus and died.)

People without a prescription started buying it in the form of so-called horse paste from Amazon, from livestock suppliers—wherever they could find it. The CDC confirmed that the increased interest in ivermectin as a covid “treatment” coincided with a bump in calls to poison control centers for adverse effects of consuming the drug. Those callers included people who ate a topical cream and those who consumed veterinary formulations meant for large animals. This swell of interest in ivermectin attracted substantial, justified alarm. Headline after headline talked about the “livestock drug” that anti-vaxxers were relying on. Even the US Food and Drug Administration dunked on misinformation peddlers by tweeting, “You are not a horse. You are not a cow. Seriously, y'all. Stop it.” 

The viral posts and memes came as a surprise to some with rosacea, a common skin condition that is best known for causing redness on the face. I’m one: there are actually four varieties of rosacea, and several years ago, a dermatologist diagnosed me with three of them.  On and off for the past five years, I’ve used a topical cream containing ivermectin to treat it.

Watching “ivermectin” become a keyword for anti-vaccine misinformation has been pretty weird and infuriating for me. So as the memes spread, I wanted to know how all of this was going to affect those of us who use the drug legitimately. 

It’s become incredibly complicated, and even talking about it is tricky right now because the conversation is so easily weaponized: when I tweeted in late August that it kind of sucked to see the treatment you use for a skin condition go viral as a “livestock drug,” I was quoted by someone promoting ivermectin as a covid treatment. The argument was that because some people take the drug legitimately for completely unrelated conditions, it must also be safe for covid (it’s ... not: the FDA says that “taking large doses of ivermectin is dangerous”). 

I’ve watched this play out again and again online: misinformation evolves and adapts as it seeks attention. 

The fact is, the evidence that ivermectin can treat covid is slim, based largely on a preprint (i.e., not peer-reviewed) study that was posted early in the pandemic but later withdrawn after substantial questions about its data. But online, the fact that ivermectin has a history as a real drug with actual uses in humans and animals has become part of the script for those trying to promote its dubious and potentially dangerous use as a treatment for covid. And as ivermectin’s misuse has caught on, the response to that fact has itself become part of the story for anti-vaccine influencers.

Changing the script

Before ivermectin was hydroxychloroquine, an immunosuppressant that is often prescribed to prevent malaria and to treat some skin conditions, and was also falsely promoted as a covid-19 treatment. Its ensuing popularity led to shortages, hurting people who actually needed it—and made it harder to prescribe for legitimate uses, says Adam Friedman, a physician and chair of dermatology at George Washington University.

It’s a reminder that when drugs get caught up in viral health misinformation, it doesn’t affect just the people who ignore reliable experts and opt for ineffective, debunked, or dangerous treatments they read about online.

Friedman says has been forced to change how he talks to patients when he needs to prescribe hydroxychloroquine. “I’ve now worked into my scripting: ‘Hey, I want to start you on this medicine. You may have heard about it related to covid, that it was being used as a cure and it’s not,’” he says. “It got a lot of negative press. However, in dermatology we’ve been using it for decades for these different things.” 

To understand the extent to which this confusion might also be ivermectin’s future, I went to r/Rosacea, the subreddit for advice on dealing with the chronic condition. 

Categorically different

People with rosacea know ivermectin not as an unproven covid drug, but as a proven and effective treatment that helps some people with a type of rosacea that causes bumps on the skin. On the subreddit, one user was confused by the sudden influx of attention, asking: “Why are ivermectin memes popping up everywhere right now? And how does the mainstream know what it is?” 

For people on the subreddit, ivermectin is a pretty persistent topic of discussion. There’s an expensive topical cream called Soolantra that contains the drug, and a generic version was released this summer. But a subset of those users also knew that the same drug was in horse paste, because some people diagnosed with rosacea have also bought the veterinary form—usually because they can’t otherwise get access to the creams or can’t afford a prescription. 

This practice is controversial among people with rosacea, and dermatologists have raised concerns about experimenting with a product that contains an inappropriate dosage or untested ingredients with potentially adverse effects. However, Friedman says, a person with rosacea turning to horse paste for cost reasons is in a categorically different medical and ethical universe from the one in which people are eating horse paste to “cure” covid. For diagnosed rosacea patients who need ivermectin to control the condition, Friedman says, “unfortunately, the best medication is the one patients can get.” 

People who use Soolantra or the generic version of ivermectin topically are, as of right now, unlikely to be encountering shortages, says Friedman. There are reports of farm supply stores running short on horse paste, however. In addition to some practical issues of access—while reporting this story, I spoke to one person who had to purchase horse paste from the UK in order to treat his pet rats for mites a few weeks ago—there’s now an added layer of scrutiny and stigma. How do you explain that you use horse paste on yourself, but not like that?

“Attached to this oversimplified idea”

The subreddit’s moderators were already pretty familiar with misinformation about ivermectin. 

"We've seen some pretty crazy things, like people recommending wearing flea collars or using pesticides on their face."

Ryan, a moderator on the r/rosacea forum

People use the site, like many online communities, to discuss and trade information based on their experience: for example, discussing the best facial cleansers, asking how to avoid triggering a flare-up, or sharing how their treatment is progressing over time. But they can also incubate and promote misinformation, which moderators have to monitor and remove.

Although there are some Facebook groups that promote horse paste for those with rosacea, the r/Rosacea subreddit neither encourages nor bans discussion of its use. One moderator told me the biggest risk is that people will self-diagnose with rosacea and decide to treat themselves with a DIY version of a medication that, even in a form intended for use by humans, should only be used with the guidance of a physician. 

Not all rosacea is the same, however, and the reasons ivermectin might work for some is still a subject of scientific debate.

There is a connection between rosacea and demodex mites, which live in the hair follicles on more or less everyone’s face. in people with any form of rosacea, those mites are there in excess. But the exact relationship isn’t clear. “The question is chicken or egg,” Friedman says. Are people with rosacea ideal environments for demodex mites to live in excess, or “or is it this overgrowth that then exacerbates rosacea?” 

That uncertainty has led to some pretty dangerous suggestions online, said Ryan, a Reddit moderator who asked that I withhold his last name. 

“People get attracted and attached to this oversimplified idea that if they just kill the mites, their rosacea and their problems will go away,” he said. “We’ve even seen some pretty crazy things, like people recommending wearing flea collars or using pesticides on their face.” 

Data voids and poisoned wells

Online peddlers of misinformation often exploit a data void, telling people to search for specific terms that they know will lead to results that promote what they’re trying to say. At worst, as the misinformation researcher Renee DiResta has written in the past, the top results can end up coming entirely from people who believe in and promote the misinformation. 

And as searches for “ivermectin” soared in August, according to Google Trends, the search results themselves were more or less completely overtaken by discussions of the people who use ivermectin to treat covid. 

Platforms and vendors have started promising to address the problem: Amazon’s results for horse paste, which had been filled with reviews promoting the product as a covid treatment, were removed after a Washington Post reporter asked for comment. Searches for “ivermectin” on Amazon now carry a warning from the FDA. But in subreddits and private Facebook groups, in Amazon reviews, and in YouTube videos, bad information still awaits those searching for it.

The second result on a Google search for “ivermectin” run on September 7 was a study in the American Journal of Therapeutics promoting the drug’s use to treat covid. The study, a meta-analysis of other trials of using ivermectin, was authored by researchers who are trying to get the drug approved as a covid treatment, Politifact noted. Outside experts said the studies the paper relied on were not high enough quality to warrant the conclusions. 

Another top result? A clip of Joe Rogan’s podcast in which he jokes about the media’s coverage of his use of ivermectin.

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