One pill makes you larger
And one pill makes you small
And the ones that mother gives you
Don't do anything at all
It’s pretty easy to imagine the millions of dollars pharma companies spend on the advertisements we watch on television, hear on the radio, see on the Internet, in magazines, newspapers, and so forth. However, some of the advertisements, referred to as stealth ads, are harder to recognize; infomercials can fool consumers by resembling newscasts rather than commercials (Angell 117). In an even stealthier strategy, celebrities have been used to sell drugs during what appears to be an ordinary interview. Dr. Marcia Angell provides a particularly startling example in her book, The Truth about the Drug Companies
Lauren Bacall, for instance, in conversation with Matt Lauer on the Today show, spoke about a friend who had become blind from macular degeneration. She urged the audience to get tested for it and mentioned the Novartis drug Visudyne. What she did not reveal is that she was being paid by Novartis. (117)
With advertising techniques as stealthy as those evident in the Lauren Bacall example, even an alert consumer can be duped. However, what is less apparent to the general public, is the far, far greater amount of money pharma companies spend to sway doctors’ prescribing habits through gifts, drug samples, grants, trips, consultant fees, blatant drug endorsements camouflaged as medical education, and their increasing control over major medical journals. The amount of money pharma companies spend in an effort to control doctors and medical education is staggering, figures like $54 billion per year have been cited, and this estimate, made a number of years ago (Angell 122), may be far too low. Given that pharma companies are required to disclose the amount they spend on marketing, why is this figure so hard to track down? For starters, pharma companies lump “administration and marketing,” into one category. Then, pharma companies define marketing very narrowly: 1) Direct-to-consumer (DTC) advertising (mainly TV ads); 2) Sales pitches to doctors in their offices; 3) Free samples for doctors; and 4) Advertising in medical journals (Angell 121). Pharma companies thus hide billions of dollars in annual costs by categorizing many of its activities as education.
For example, detailing is “a marketing tactic that involves individual sales representatives (detailers) meeting with doctors in their offices to promote specific medications” (Horner et al 1). Typically, detailers are young and attractive. A New York Times’ study describes how many detailers are being recruited from college cheerleading squads. A detailer works in a highly competitive field where, in 2004, there were just over 100,000 drug reps for the “roughly 884,000 licensed doctors in the nation” or “at least 1 sales rep for every eight doctors” (Homer et al 8).
To learn more about the doctors they target, detailers study physicians’ prescriber reports. Prescriber reports provide a breakdown of every drug a doctor prescribes so that a detailer can “deliver a tailored marketing pitch” based on the doctor’s prescribing habits. In addition, detailers can track doctors’ weekly prescribing habits so that they know whether the particular type of sales pitch they used was effective. In the report, they can see the name of each doctor, his DEA number, and precisely what medications he/she has been prescribing. Pharmaceutical companies buy this information from pharmacy chains (Angell 129-130). Although the pharmacies do not provide the doctors’ name, the reports do contain physician identifiers which pharma companies can decode by purchasing a “comprehensive database of U.S. physicians from the American Medical Association,” which earns over 20 million dollars annually to provide this service. I have yet to talk to one doctor who knew his/her prescribing habits were available and being tracked by pharmaceutical companies. The common response I’ve received is outrage. Doctors, quite rightly, consider this an invasion of privacy and none of the pharma companies’ business. On the flipside, though, the prescriber reports, which have been studied in conjunction with drug rep visits and incentives, demonstrate that many doctors are swayed by the pharma companies’ sales techniques.
Detailers are often eager to educate doctors on the “off-label” uses of a drug. For example, the drug Neurontin has FDA approval for treating epilepsy, but as Marcia Angell has noted, there is not much money in that (158). Consequently, pharmaceutical companies work to demonstrate that a drug can be used “off-label” to treat a variety of conditions, even if the data is based on biased and inadequate research (112). The off-label uses of Neurontin are very broad and very lucrative. In addition to its FDA-approved use for epilepsy, the drug became a huge money-maker by being recommended for non-FDA-approved or “off-label” uses that included “bipolar disorder, post-traumatic stress disorder, insomnia, restless legs syndrome, hot flashes, migraines…tension headaches” (160), fibromyalgia, multiple sclerosis, and peripheral neuropathy to name just a few. Although some off-label uses of drugs may be beneficial, many are not and, again, the off-label uses can take a drug with a limited market and turn it into a multi-billion dollar success.
In addition to the off-label uses for a particular drug, pharma companies promote “Me, too” drugs to boost sales. For example, Nexium was developed when Prilosec’s patent was about to expire. Although there is no proof that Nexium works any better than Prilosec, both of which are used for acid reflux (or heartburn), AstraZeneca launched a particularly aggressive sales campaign. Nexium, the “little purple pill,” which is advertised everywhere, was developed in 2001, and by 2003, was already earning profits of 3.1 billion dollars (Angell 76-78) per year. Although Nexium is no better than Prilosec, the monthly cost for Nexium is $400 (without insurance) compared to $40 for Prilosec.
The line between pharmaceutical marketing and medical education is blurred further by the increased influence of pharma companies on established medical journals. In the January 2008 issue of The New England Journal of Medicine
(NEJM), possibly the most respected medical journal in the world, there were fewer than one hundred pages of medical articles vs. 39 full-color glossies of pharmaceutical advertisements. Anyone who’s kept up with academic publishing knows that both academic presses and academic journals are in financial crisis. Medical journals receive a hefty economic boost from pharma company advertising – estimated to be as much 21% or higher of their total revenue (Sepkowitz). In addition, some medical journals publish supplements, which are “typically a one-topic, free-standing volume that shares font and layout with the present magazine—but not serious peer review” (Sepkowitz 1). More importantly, the production and publications costs are often covered generously by pharma companies. Pharma companies also provide another source of revenue. When an article is published favoring a particular drug, thousands and thousands of reprints are purchased to “sprinkle around in the good name of education” (Spitzer). Even more alarming, however, is the lack of educational rigor and the overt agenda some articles evince.
Angell, a former chief editor of the NEJM, explains how doctors are required to list all possible conflicts of interest (i.e. primarily “research” funding received by pharma companies). In one instance, while Angell was still editing the journal, all the authors’ conflicts of interest for a particular article were so extensive they could not fit in the journal and needed to be listed on a website. The article presented a study—favorable, of course—of an antidepressant agent. Clearly, the “peer-reviewed” article had been bought and paid for by a pharmaceutical company. Angell, in a trenchant footnote she appended to the article, wrote the following:
Our policy requires authors of Original Articles to disclose all financial ties with companies that make the products under study or competing products. In this case, the large number of authors and their varied and extensive financial associations with relevant companies make a detailed listing here impractical. Readers should know, however, that all but one of the twelve principal authors have had financial associations with Bristol-Myers Squibb—which also sponsored the study—and in most cases, with many other companies producing psychoactive pharmaceutical agents. The associations include consultancies, receipt of research grants and honorariums, and participation on advisory boards.” (143)
Clearly, the ubiquitous drug advertisements that dot our cultural landscape are merely a fraction of the money pharma companies spend on marketing. The implications are serious:
* All marketing costs, whether they’ve tucked away under categories such as administration or education matter because these costs are passed on to the patients, who pay higher and higher prices (Angell, Chapter 3).
* “Me, too” drugs and “off-label” uses of drugs result in patients paying much higher prices for a new drug that offers no appreciable benefits or using a drug, for a non-FDA approved purpose, that may accomplish nothing at all (Angell, chapter 5).
* The decreased amount of rigor in some clinical trials and evident in some medical articles help to keep drugs on the market – such as Vioxx, which was shown to cause heart attacks and strokes – that are dangerous (Angell 270).
* Pharma companies often divert research money to create useless or duplicate drugs when this money could be spent finding cures for serious diseases. However, if a useless drug can bring in billions of dollars, what is the incentive for pharma companies to create drugs that provide smaller revenues?
In short, Angell asks that the pharmeceutical industry (and those in the medical profession complicit with these practices) undergo complete reform. I agree.