The Pill Pushers
- From: rpautrey2 <rpautrey2@xxxxxxxxx>
- Date: Mon, 8 Sep 2008 11:44:20 -0700 (PDT)
The pill pushers
By Alex Roslin
Publish Date: September 4, 2008
When Shahram Ahari went to work at pharmaceutical giant Eli Lilly
straight out of college in New Jersey, he was hired to do a job that
few people know exists. Even the job title would be a mystery to most
people. Ahari was going to be a “detailer”.
His job was to schmooze with doctors in order to get them to prescribe
Lilly’s drugs. He was really a salesman, but he was also much more.
His tools included everything from free drugs to offers of lucrative
speaking engagements, even trips. He’d bring medical residents pizza
for lunch or invite a doctor to dinner at an exclusive restaurant.
He’d do anything to improve sales in his New York City district, which
meant a bigger bonus.
The first hint of the strange world Ahari had entered came when he was
brought to Indianapolis for Lilly’s intensive, six-week boot camp for
detailers. There, he met his fellow trainees. They were hundreds of
fellow college grads, mostly in their mid-20s, perhaps two-thirds of
them women, the vast majority beautiful.
“They were 200 or 300 of the most attractive people I had ever seen,”
he said in a phone interview. “The physical appeal was only part of
it. They were vivacious, well-coiffured, well-dressed, engaging
people.”
Ahari soon learned that charisma was more important in his new job
than, say, medical or scientific knowledge. He was the only one in his
class of 22 trainees with a science degree, he said.
The training was part CIA, part Freud. He learned to immediately spot
items in a doctor’s office that could be used to strike up a personal
conversation and, ultimately, friendship: golf paraphernalia, photos
of trips or kids, religious items. The information would later be
entered into the company’s file on the doctor and analyzed for future
approaches.
“It was analogous to training in spy agencies,” said Ahari, who ended
up working for Lilly for a year and a half in New York City. “You
instantly suss up the person’s personality and look for points of
entry. You capitalize on sexual appeal. My more attractive colleagues
would say, ‘I’m going to wear my short skirt today,’ or ‘I’m going to
wear my low-cleavage top. He [the doctor] seems to get a kick out of
that.’ ”
The practice of detailing has come under growing scrutiny in B.C. Two-
thirds of doctors in the province say drug reps visit them at least
once a month, according to a 2006 survey by the B.C. Medical
Association. Forty-two percent of general practitioners are visited
several times a week.
The association and provincial Health Ministry deny there is any
reason for concern about the visits and benefits to doctors. But a
raft of studies shows interactions with sales reps cause doctors to
prescribe costlier drugs that aren’t necessarily the best ones for
their patients. Doctors in some cases are influenced to prescribe
drugs for so-called off-label uses: treating ailments for which the
drug has not been approved by health regulators.
The lobbying of doctors is poorly regulated and is also seen as a
major reason behind skyrocketing prescription-drug costs in B.C.,
where drug spending by the province’s PharmaCare drug-subsidy program
more than doubled between 1996 and 2005. According to the office of
the B.C. auditor general in 2006, costs ballooned from $372 million to
$801 million during that period. (The B.C. Ministry of Health predicts
that figure to further rise for 2008–2009, to $1.016 billion.)
“The explosion in drug costs is directly proportional to marketing,”
said Alan Cassels, a University of Victoria researcher who studies
drug-company marketing and is a director of Drug Policy Futures, a
team of researchers studying pharmaceutical issues.
“The industry knows what it’s worth,” Cassels said of detailing.
“Pharmacists have told me they can tell when a certain company’s drug
rep has been in town because of a spike in that company’s
prescriptions.”
Pushing pills involves fantastic amounts of money. In a study in
January in the journal Public Library of Science Medicine, two
Canadian academics, Joel Lexchin and Marc-André Gagnon, calculated
that pharmaceutical companies spent $57.5 billion on marketing in the
U.S. in 2004. That was nearly double the $32 billion spent on
researching and developing drugs.
The marketing budget included $20.4 billion for an army of 100,000
detailers—one for every eight doctors. This sales force has almost
tripled, from 38,000 in 1995.
Another $2 billion was spent on 371,000 pharma-sponsored lunch and
dinner meetings, conferences, and other events for U.S. doctors.
According to a 2006 study by Cassels’s Drug Policy Futures, Canada is
similar. The number of detailers here jumped from 3,990 to 5,190
between 1998 and 2002, working out to one rep for each 11.4 doctors.
But the numbers don’t tell the whole story. In fact, a very large
portion of all that lucre goes to the secret weapon of the detailer:
food. “Food is a pretty powerful catalyst for sales,” Ahari said from
Berkeley, California, where he now works as a consultant to
PharmedOut.org, a group of doctors working to counter pharmaceutical
marketing. “I sometimes saw myself as a glorified caterer.”
While at Lilly, Ahari cozied up to doctors with invitations to dinner
at Manhattan’s hottest eateries. “I knew the maître d’s of all the
finest restaurants. I could get reservations the same week at places
where the wait could be a month,” he said.
Food would often have a greater impact than his best arguments about a
drug’s merits. “I would argue with doctors until I was blue in the
face [about a drug]. Then I’d take them out to dinner and see their
[prescription] numbers rise,” he said.
Ahari also didn’t neglect staff at doctors’ offices; they could be
useful for scheduling appointments with doctors and putting in a good
word about Lilly’s drugs. “I took great pains to make sure the staff
were happy with my lunches,” he explained. “There’s almost a sub-art
to figuring out which food people will like. How successful and
delicious your lunch is has a sway in terms of how quickly you can get
meetings [with the doctor].”
Many offices counted on him for lunch on a specific day each week.
Ahari could threaten to cut off the free food if he thought a doctor
wasn’t prescribing enough of his product. Such a threat could be a
powerful weapon. “The staff would be up in arms. I would be fomenting
rebellion in the [doctor’s] practice.”
Lunch was so important, Ahari said, that competition often flared
among drug reps from rival companies over getting a slot. “You had to
compete to bring food in. They [some offices] have free lunch from a
different company every day of the week. You have to talk to their
receptionist and say, ‘When’s the next time I can bring lunch in?’ You
have to not blanch when she says the next available lunch date is in
two months,” Ahari said.
Occasionally, he said, someone would call from a doctor’s office and
say, “A lunch slot has opened up. Another company has fallen through.
Do you want to take it?” He always jumped at the chance. “I’d be
grateful for the opportunity for more face time.”
Food was just one in an array of tactics Ahari was taught to employ.
“If the doctor was academically driven, I’d bring in an article and
say, ‘I just got this new study but I don’t understand the science.
Can you teach me?’”
Ahari said that if a doctor raised concerns about possible side
effects, like the rapid weight gain sometimes associated with Lilly’s
top-selling antipsychotic drug, Zyprexa, he’d be ready with a quick
response: “Would you rather have a thin, psychotic patient or a fat,
stable patient?”
He rewarded high prescribers with an invitation to join the company’s
“speaker’s bureau”. That meant lucrative gigs addressing other doctors
at Lilly-sponsored lunch and dinner meetings and medical symposiums.
Speakers typically earned $100 to $500 for a lunch or dinner
presentation and up to $10,000 for a major conference talk.
Ahari’s tactics aren’t unique. The activities of detailers have been
subject to growing scrutiny in recent court cases involving pharma
giants. One involved a drug called Neurontin (generic name
gabapentin). Neurontin was developed by pharmaceutical company Warner-
Lambert, now a subsidiary of Pfizer, to control epileptic seizures.
In 2004, Warner-Lambert agreed to pay $430 million in fines and civil
damages after it admitted it illegally promoted Neurontin for off-
label uses, such as treating pain, migraines, attention deficit
disorder, amyotrophic lateral sclerosis, and psychiatric disorders,
that weren’t backed by scientific evidence or approved by the U.S.
Food and Drug Administration.
The settlement didn’t include extra sums sought in patient lawsuits,
including some claiming wrongful death due to off-label uses. A lawyer
for one of the patients submitted records to the FDA saying 258 people
had committed suicide while on the drug, the Washington Post reported
last year.
One-half to two-thirds of Warner-Lambert’s marketing budget for
Neurontin went to “professional education” for doctors, according to a
2006 study on the company’s documents in the Annals of Internal
Medicine. That included company-sponsored dinners and paying for
continuing-education courses that specialists have to take to maintain
their credentials. Large amounts also went to honorariums for doctors
who wrote journal articles, joined company advisory boards, and spoke
at company-sponsored meetings.
The study also showed that one of Warner-Lambert’s best marketing
tools was recruiting prominent medical professors to act as “thought
leaders” for hundreds of company-sponsored teleconference calls with
doctors, dinner meetings, and conferences. In many cases, the
company’s sponsorship wasn’t disclosed. These advocates, some of whom
were paid up to $150,000 over several years, helped promote the drug’s
“emerging uses”, the off-label uses not approved by the FDA.
The campaign was a stunning success. While prescriptions of Neurontin
for epilepsy remained flat at 400,000 per year through the 1990s, off-
label use exploded from virtually nil in the mid-1990s to more than
three million prescriptions annually in 2000. By 2002, according to
court documents, those unauthorized prescriptions were 94 percent of
the total.
In B.C., some doctors insist they are immune to this kind of
marketing. Shelley Ross, a Burnaby family doctor, is chair of the B.C.
Medical Association’s council on health economics and policy.
“I see drug reps every day, and I don’t feel any pressure,” said Ross,
who is also an alternate rep from B.C. on the Canadian Medical
Association’s board. “I would say by far the majority of reps are
professional and we develop a relationship of trust.”
Ross said drug reps bring her free drug samples, leave printed
information, and invite her to company-sponsored dinners and
symposiums. “I do appreciate hearing from pharmaceutical drug reps in
a busy practice. It helps keep me up-to-date [on new drugs],” she said
in a phone interview.
“Yes, we go to dinners put on by companies, and I believe I’m
representative of my colleagues. But are we swayed? Not on your life.
I pick what’s best for my patients.”
The B.C. Health Ministry also doesn’t see any problem with the
interactions. “We have faith in the professional capacity of the
physicians,” spokesman Stephen May said on the phone from Victoria.
May said the province has, nonetheless, taken away one tool from drug
companies. In 1996, it prohibited pharmacies from selling doctors’
prescription data to pharmaceutical-research firms, or data miners,
that then provided the information to detailers to help them target
doctors.
Although B.C.’s ban was widely applauded by public-health advocates
and members of the medical community, some critics say the province,
Ottawa, and the medical community do little else to counter the
marketing and ensure that doctors are free of conflict of interest.
“The medical associations are largely MIA when it comes to monitoring
and trying to improve prescribing,” Cassels said in a phone interview
from Victoria. “They [doctors] oppose restrictions because of the
close ties a lot of them have with the companies. A lot of doctors
don’t want to bite the hands that feed them.”
“There actually is no active monitoring of promotional activities by
pharmaceutical companies,” said Barbara Mintzes, an epidemiologist at
the University of British Columbia’s Centre for Health Services and
Policy Research.
“It’s a key problem. Nobody actually is watching what sales reps are
telling physicians or the gifts and hospitality. There is considerable
evidence those benefits have massive influence on doctors’
prescribing.”
In fact, the province is now threatening to turn back the clock as
worries grow it will gut UBC’s Therapeutics Initiative, one of the
province’s few efforts to counter drug-company marketing. The
internationally acclaimed initiative is funded by the B.C. Health
Ministry to independently evaluate drugs at arm’s length from drug
companies. It issues bulletins to doctors that act as a counterweight
to detailers and advises the PharmaCare program on which drugs to
cover.
In 2006, in a review of PharmaCare, B.C. auditor general Wayne
Strelioff praised the Therapeutics Initiative for saving the province
money and said that B.C. had “missed an opportunity” by not expanding
the program. Strelioff called on the Health Ministry to “significantly
increase support” for the initiative.
UVic’s Alan Cassels has linked rising public drug costs to more
marketing.
Instead, Health Minister George Abbott appears poised to do the
opposite. He formed a pharmaceutical task force that included
prominent pharmaceutical lobbyists who could be expected to be
antagonistic to the initiative. Their conclusion: the Therapeutics
Initiative should be scrapped or completely overhauled to improve its
“accountability”. Abbott has said he accepts the task force’s
recommendations. His response is expected this fall.
Mintzes, who is a drug assessor at the Therapeutics Initiative, said
the task force mirrored the complaints of drug companies. “They think
the Therapeutics Initiative isn’t inclusive enough. That’s because it
has a policy against conflict of interest involving evaluators.”
The auditor general also took the province to task for failing to
expand its minuscule program of “academic detailing”. This 15-year-old
program, the first in North America, hired a government-paid detailer
to visit doctors on Vancouver’s North Shore with independent
scientific info on drugs in an effort to counter the detailers’
message. Last March, the province finally expanded the number of
academic detailers from one to 10.
That’s still far from enough, Cassels said. “We’ve got 600 or 700 drug
reps in B.C. versus 10 academic detailers. You tell me if that’s going
to have much impact.”
Meanwhile, some U.S. states are taking much tougher steps. Minnesota
has banned drug-rep gifts of more than a $50 value to doctors, and
Vermont requires drug companies to disclose gifts worth more than $25.
The Massachusetts legislature is now considering going a step further
with a bill that includes a ban on any pharma gifts to doctors.
Cutting off the pharma gravy train isn’t popular with most doctors,
but a backlash against drug reps appears to be growing in the medical
community. “I don’t think doctors should see them [drug reps] at all,”
said Joel Lexchin, a Toronto physician and a professor of health
policy and management at York University. “Doctors should be looking
out for the interests of patients and should not be seeing sales reps,
because that will lead to misprescribing.”
Doug Brown had his first brush with drug marketing in his second year
as a medical student at UBC. Students all got a free textbook that had
been funded and donated by pharmaceutical giant AstraZeneca. Brown and
three other med students decided to investigate drug marketing and
produced a 30-minute documentary titled “Bedfellows”.
Now a medical resident, he said drug reps have many opportunities to
ingratiate themselves with doctors and residents at regular
professional-development meetings organized through many B.C.
hospitals.
Each hospital department holds a weekly “lunch round”, a meeting over
lunch featuring a talk by a doctor or resident on a medical topic. A
drug rep often supplies the food. Some departments do daily rounds.
According to Brown, there are also monthly “grand rounds” involving
staff from several hospitals and monthly “journal clubs”—dinners for
staff at restaurants or a department member’s home at which medical
papers are discussed. Drug reps, again, frequently pick up the tab.
Ahari said he also supplied meals for hospital “rounds” and journal
clubs. In addition, he said, he contributed money for bringing in
speakers and suggested pro-Lilly doctors for the talks. “They used my
speaker more often than not,” he said.
“Most physicians I’ve interacted with are comfortable accepting meals
and don’t think it influences them,” Brown said in a phone interview.
“That goes against all the literature, obviously.”
Indeed, one of the most comprehensive reviews of this question found
that drug rep interactions with doctors have a significant impact on
which drugs doctors prescribe. Ashley Wazana, a doctor and psychiatry
resident at McGill University, reviewed 29 studies of the effects of
gifts on doctors’ prescribing behaviour in the U.S., Canada, Holland,
New Zealand, and Australia.
In a 2000 study published in the Journal of the American Medical
Association, he found that free samples, honorariums, and research
grants led doctors to be significantly more likely to prescribe that
drug or to request it for formularies, hospitals’ official lists of
drugs that can be prescribed there.
The study also noted that hearing a drug salesman at a talk led
doctors to recommend “inappropriate treatment” more often than other
doctors, including treatment that cost more and was more invasive.
Residents who heard detailers speak at lunch rounds were more likely
to have inaccurate information about drugs on the market.
As well, accepting a free trip to a company-sponsored conference led
doctors to increase prescriptions of that company’s drugs by 80 to 190
percent. Doctors who “occasionally” attended pharma-sponsored meals
were 2.3 times more likely than other doctors to request that the
sponsor’s drug be added to a hospital formulary.
Doctors who “often” ate the meals were 14 times more likely to do so.
Wazana’s study also reported that most doctors and residents are in
some way interacting with drug companies. Four in five residents
attended industry-paid meals, with the average resident eating on the
corporate dime 14 to 15 times a year. Interns did so 31 times a year.
Residents got an average of six gifts per year worth $60 each.
As for doctors, 85 to 87 percent said they had some interaction with
detailers, with an average of three to four encounters a month. Eighty-
six percent accepted free drug samples, and half got research grants.
Two in five attended company-sponsored meals, and a similar proportion
accepted funding for travel or lodging to attend company-backed
conferences.
Yet despite all this, just one in five doctors agreed that pharma reps
“fairly portray their product”, and three-quarters of residents said
detailers “may use unethical practices”; 44 percent said they “provide
misleading information”.
Paradoxically, many doctors still rely on detailers more than any
other source for information about new drugs—and not just in North
America. One-third of U.K. doctors said pharmaceutical-industry reps
were their most important source of initial information on new drugs,
and pharmaceutical ads accounted for another 15 percent, according to
a 2002 survey in the British journal Family Practice.
The study also reviewed 616 prescriptions the doctors had written. The
doctors cited pharma reps more often than any other factor in
influencing their prescription choice. The reps were cited 39 percent
of the time, far more than concern about the drug’s side effects (17
percent) or prescribing guidelines developed by the medical community
(15 percent).
“I think if you see a rep who you know well…it’s the same rep who
you’ve seen for several years, they don’t try and pull the wool over
your eyes,” one doctor in the study explained.
Ahari, for his part, said that’s a grave misconception. “There’s no
such thing as a free lunch. It’s the patient who pays,” he said.
Ahari said he eventually began to have serious qualms about his work
at Lilly. “Not only are you fooling your [doctor] clients, you’re
fooling yourself that you’re doing something good,” he explained. “I
felt I had become such a calculating social manipulator I would be
thinking like a chess game in every social encounter with my
girlfriend and family. It was horribly disconcerting.”
In 2000, Ahari said, he quit Lilly after a year and a half as a
detailer. He volunteered helping the mentally ill and homeless in New
York and eventually started to talk publicly about what he had done.
He has spoken before Congress, at medical schools, and to the American
Medical Association about detailing and conflict of interest.
Now he’s decided on a new career for himself. He is applying to med
school. If he succeeds, no doubt a detailer will be knocking on his
door one day soon. And she might not get quite the response she
expects.
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