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Pharmaceutical Payola -- Drug Marketing to Doctors

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Last week, a Congressional committee properly raked Big Pharma over the coals for misleading advertising of pharmaceuticals.

A hearing of the House Energy and Commerce Committee's oversight subcommittee focused on advertising campaigns for three drugs, including the remarkable case of Robert Jarvik. Jarvik is featured in endlessly re-run ads for Pfizer's blockbuster cholesterol drug Lipitor. Known as the inventor of the Jarvik artificial heart, he is not a cardiologist, not a licensed medical doctor and not authorized to prescribe pharmaceuticals. He's shown in the ads engaged in vigorous rowing activity, but in fact he doesn't row. Pfizer pulled the ads in February after controversy started brewing.

Among industrialized countries, only the United States and New Zealand permit drug companies to market directly to consumers. It's a bad idea, it drives bad medicine, and it should be banned.

But although it has the highest profile, direct-to-consumer advertising is a small part of Pharma's marketing machine.

Researchers Marc-André Gagnon and Joel Lexchin conclude in a recent issue of the journal PLOS Medicine that direct-to-consumer ads make up less than a tenth of industry marketing expenditures ($4 billion of $57.5 billion in 2004). And Gagnon and Lexchin's estimate of $57.5 billion on marketing excludes many industry expenditures that are really driven by marketing, including clinical trials conducted for marketing purposes.

The bulk of the industry marketing effort -- more than 70 percent by Gagnon and Lexchin's calculation -- is directed at doctors.

Why?

Because it works.

The companies spend huge amounts paying firms that carefully track what doctors prescribe, and then they use the information to tailor messages to doctors, distribute samples and develop continuing medical education programs.

Gagnon and Lexchin report that Pharma spends more than $20 billion a year on "detailers" -- the pharma reps that knock on doctor doors, ply the staff with free coffee and lunches, distribute samples ($16 billion worth), and prod docs to prescribe their drugs.

This is complemented by a host of tactics that in other circumstances might be called bribes.

"Virtually all physicians in America take cash or gifts from the drug companies," says Melody Petersen, author of Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs, and a former New York Times reporter. "A recent survey said 94 percent of physicians took something of value from the drug companies. Some doctors take hundreds of thousands of dollars a year from these companies, and there's no law that says they can't."

Petersen says she "had no idea this was so extensive until one day I was writing a story about Celebrex and Vioxx -- this was before Vioxx was taken off the market. The story was about the marketing battle between these two pain drugs. I called one of the large societies of rheumatologists and asked for an expert on arthritis. I specifically said I needed an expert who was not being paid as a consultant to one of the manufacturers of these drugs. A staff person said, 'We have lots of people you can talk to, but all of these doctors are consultants to one or both of the drug companies.'"

Drug companies hire doctors to give lectures, and they hire other doctors as "consultants" to go to fancy dinners and listen to the lectures. "There are more than 500,000 of these dinners or events in America every year," Petersen says.

The drug companies weave these diverse strategems into an elaborate tapestry -- not infrequently to push drugs for inappropriate purposes. One eye-opening case that Petersen details in Our Daily Meds concerns Neurontin, a mediocre drug for epilepsy that Warner-Lambert illegally peddled as an unapproved treatment for bipolar disorder, migraines, attention deficit disorder in children and other conditions. The drug does not work for most of these conditions. Many persons were injured by taking excessive doses of Neurontin, and many others wasted money and emotional energy on hopeless Neurontin treatment strategies. Warner-Lambert ultimately paid $430 million to settle criminal and civil charges related to Neurontin marketing, but Petersen says that, even so, the illegal marketing scheme was clearly profitable for Warner-Lambert (and Pfizer, which acquired Warner-Lambert in 2000).

Petersen's account of the Neurontin nightmare draws heavily on a whistleblower, David Franklin. She summarizes the central theme of the story Franklin revealed: "The company got doctors to prescribe the drug for all these experimental uses by paying them. They paid physicians to give speeches to other physicians at restaurants or hotels or resorts. The doctors not only enjoyed a nice meal or a weekend vacation, they often also received a $500 check for attending. The physicians giving lectures at these parties were often trained by the drug company's ad firm to describe how Neurontin could work for conditions like bipolar. ... The company tracked the doctors' prescriptions before and after these dinners or weekend retreats. The executives saw how well it worked."

Which raises an interesting question: How is that the industry can so effectively manipulate highly trained doctors?

Answers Adriane Fugh-Berman, a doctor and Georgetown University professor who runs PharmedOut, a project that focuses on how pharmaceutical companies influence prescribing decisions and encourages physicians to educate themselves from non-industry sources: "Physicians are trained in medicine, not psychological manipulation. Every bit of flattery, friendship and information offered by reps is aimed at selling drugs."

There is no simple solution to these problems, though ending patent-based marketing monopolies would transform pharmaceutical marketing practices and likely eliminate most abuses.

In the meantime, a ban on Pharma gifts to doctors would be a modest step forward. In the United States, notes Petersen, "radio disc jockeys can't take cash from music companies. But when it comes to something like medicines -- which mean life or death for people -- doctors can take as much money as they want from the drug companies. We need a law to stop that."

Note: I serve as managing director for Commercial Alert, which advocates for elimination of direct-to-consumer pharmaceutical advertising.