It's a multi-million dollar marketing strategy which, according to Dr. Daniel Carlat, writing in today's edition of the New York Times, 25 per cent of all doctors in the United States receive 'drug money' from sponsoring pharmaceutical companies in exchange for lecturing to other physicians on behalf of the company, or helping to promote drugs in other ways.
That figure represents at least 200,000 of the nation's physicians who are on the payroll of major drug manufacturers, to promote their products.
In a detailed, revealing and folksy essay appearing in the November 25th edition of The Times, Dr. Daniel Carlat articulates how Wyeth Pharmaceuticals recruited him in 2001 to promote the virtues of Effexor, an anti-depressant drug. His essay takes us through the process—from the initial invitation to present on behalf of Effexor, to his attendance at a lavish conference complete with perks paid for by the sponsoring drug company, and the day-to-day dynamics of extolling the virtues of a drug to his colleagues, for a fee.He also tells us the fee—quality coin, by any standard.
But even more revealing, are the tools drug companies have at their disposal to track and market drugs in ways we could never imagine, let alone be revealed as the status quo.
And finally, what happens when a doctor on the drug payroll doesn't toe the pharma line? It's a telling response.
The so-called art of drug detailing is the process whereby representatives of drug companies make regular presentations to doctors and others in the medical community. In other words, a sales rep peddling his wares. It's a sales call, and both sides are aware that there isn't anything more to it than that.
However, along the way someone realized the value of having expert opinion and professional credentials on your side. To wit, a sales associate with a medical degree, but someone at arm's length from the company. Someone who could exude confidence in the product, and impartiality at the same time.
Daniel Carlat is an assistant clinical professor of psychiatry at Tufts University School of Medicine, and the publisher of an independent newsletter known as the Carlat Psychiatry Report.
And so it was, in the fall of 2001 that Dr. Carlat was approached by a representative from Wyeth Pharmaceuticals with an offer to talk to other doctors about using Effexor XR for the treatment of depression. Wyeth would fly him and his spouse to New York for a conference, described by Dr. Carlat as a 'faculty-development program' that included comfortable accommodations in a Midtown hotel for two nights, theatre tickets and other comforts.
For taking his lunch hours to present to his colleagues, Carlat would be paid $500 for the hour, plus an additional $250 if he had to drive an hour and back to reach his destination.
That's the potential for $750 per session, just to talk about Effexor.
Carlat weighed the issues and, flattered, decided to give it a try. As a doctor of psychiatry specializing in psychopharmacology with a busy private practice, Carlat was familiar with Effexor, and that which set it apart from selective serotonin reuptake inhibitors. Commonly referred to as SSRIs, drugs such as Prozac, Paxil and Zoloft increase the levels of serotonin, a neurotransmitter in the brain that is identified as having a role in the regulation of mood. Effexor, on the other hand, presented an added advantage of increasing both serotonin and norepinephrine. With two neurotransmitters targeted, Wyeth was promoting Effexor as being more powerful, and more effective than the others.
Up to that point Dr. Carlat's experience prescribing Effexor had been largely positive.
At the conference in New York, sponsored by Wyeth, attendees were wined and dined for two days. Leaders in their field offered expert, if not completely unbiased, opinion and data surrounding Effexor. A hundred or so other psychiatrists from various pockets of the United States were in attendance, including one former acquaintance of Dr. Carlat who had moved to a different part of the country and was making a lucrative income, although Dr. Carlat had no knowledge as to how that income was being earned.
He was about to find out.
As the doctor embarked on his new and lucrative part-time career of drug detailing on behalf of Wyeth, he knew that he was fluffing the positive pillow and playing down side-effects, which included a risk for hypertension. However, any spin Dr. Carlat was putting on his comments were, in his view, not harming anyone. Plus he was flattered to be asked, and the extra income was welcome. While the perception exists that doctors make a pile of money, those in private practice have expenses and overhead we can't begin to fathom.
As Dr. Carlat continued with his presentations, confidence in him by Wyeth grew. Soon faxes and other communiqués would start arriving from Wyeth, advising Carlat that a particular doctor was a 'decile 6' in terms of prescription volume. The higher the decile factor, from 1-10, the higher the prescription volume and the more potential Wyeth might have need for a lucrative relationship with a doctor with a busy pen, as well as a busy practice.
Other doctors were identified to Dr. Carlat as 'targets'—in one case, an internist prescribing Wyeth's competitors at various levels over and above the six percent he was prescribing Effexor. Carlat's task was to somehow persuade the internist to write more prescriptions for Effexor than he had been writing.
Herein lay another sensational practice employed by drug companies to increase their revenue.
The term is called prescription data mining. Drug reps receive printouts once per week that track prescriptions. A pharmacy information company, acting as a middleman, will buy prescription data from local pharmacies, re-package the data, and sell it to the big pharmaceuticals.
But how are doctors individually identified? This is where the American Medical Association (AMA) comes in. According to Dr. Carlat, pharmacies will not typically release doctors names to the data-mining enterprises—however, they will release their Drug Enforcement Agency numbers. The AMA licenses its data file of US physicians to the data miners, which in turn match up the names with DEA numbers, to identify specific doctors and glean valued information as to their prescribing habits.
Carlat claims the AMA makes millions licensing their doc database in this way, and the big pharma companies have valuable information at their disposal.
In the meantime, Carlat listened increasingly to an inner voice that began to whisper in his ear that very first weekend in New York; a feeling that something was not quite right. The gnawing in his gut just wouldn't leave him alone, a feeling compounded by one presentation to a group of psychiatrists, and one in particular who questioned the data Carlat was presenting. Hypertension was the issue, and Carlat came away from that meeting feeling uncomfortable. He began to wonder how much of the negativity surrounding Effexor was he downplaying, in his responsibility to Wyeth, to accentuate the positive, and the glee with which he was collecting $750 in fees for little more than an hours' work.
There was the issue of patients experiencing dizziness, insomnia and bizarre, electric-shock sensations in their heads, the result of trying to stop the medication. In short, the patients were going through withdrawal. The symptoms were only mentioned in passing during the initial conference in New York, Carlat writes. Tapering off the drug slowly could mitigate withdrawal symptoms, the attendees were told. But Carlat, in his own practice, did not have the same experience.
This issue he was also downplaying, and he wrestled for some time about whether or not he was communicating untruths to his colleagues. In the end, he determined that he wasn't, given the absence of published data, and the reality that some patients, indeed, had no problem coming off Effexor.
But he agreed that, in his view he was 'tweaking and pruning' the truth. After taking into account the relatively short clinical trial window for Effexor, he was beginning to doubt just what benefit Effexor really held over SSRI drugs, when weighed against the Effexor link to high blood pressure and prolonged withdrawal symptoms.
In the end, he decided to tell it like it was. At his next 'drug lunch' talk, Dr. Carlat suggested the data supporting Effexor was short-term at best, and offered up the possibility that SSRI drugs were just as effective.
Within days the friendly rep from Wyeth was on his doorstep, suggesting that he wasn't quite the enthusiastic cheerleader for Effexor he had been prior, and wondered if he was ill?
That was the end of the line for Dr. Carlat. The incident spelled out to him quite clearly that he was being paid to endorse Effexor by Wyeth. If he was unwilling to do so, then he was of little value to them.
Dr. Carlat's newsletter directed at the psychiatric community is not funded by pharmaceuticals, so his findings are not unduly influenced. The Carlat Psychiatry Report therefore reflects an unbiased assessment of drug research and marketing. He maintains a practice and continues to prescribe Effexor, but not as often as he once did. And he has found Effexor to be useful and effective with some patients.
His days as a spin Doctor are over. But judging from the swell of participants at the New York conference in 2001, there are many others like him extolling the virtues of various drugs at the best of major pharmaceutical companies...
And depositing a tidy little sum into the bank, on their way back to work...