Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients (34 page)

All of this is built on the back of a published academic evidence base that drug companies have carefully nurtured, through selective publication of flattering results and judicious use of design flaws, to give a flattering picture of their product. But those aren’t the only tools available to companies for influencing what appears in journals. They pay professional writers to produce academic papers, following their own commercial specifications, and then get academics to put their names to them. This acts as covert advertising, and will get more academic publications on their drug, more rapidly. It also aggrandises the favoured experts’ CVs, and helps doctors friendly to the company get the kudos and veneer of independence that comes from a university post.

The company can also give money to patient groups, if those groups’ views and values help it sell more drugs, and so give them greater prominence, power and platform. On top of all this, it can then pay academic journals to accept papers, with advertising revenue and ‘reprint’ orders, and with these academic papers it can foreground the evidence showing that its treatment works, and even expand the market for its drug, by producing work that helpfully shows that the problem it treats is actually much more widespread than people realise.

All of this sounds very expensive, and it is: in fact, the pharmaceutical industry overall spends about twice as much on marketing and promotion as it does on research and development. At first glimpse, this seems extraordinary, and it’s worth mulling over in various contexts. For example, when a drug company refuses to let a developing country have affordable access to a new AIDS drug it’s because – the company says – it needs the money from sales to fund research and development on other new AIDS drugs for the future. If R&D is a fraction of the company’s outgoings, and it spends twice as much on promotion, this moral and practical argument fails to hold water.

The scale of this spend is fascinating in itself, when you put it in the context of what we all expect from evidence-based medicine, which is that people will simply use the best treatment for the patient. Because when you pull away from the industry’s carefully fostered belief that this marketing activity is all completely normal, and stop thinking of drugs as being a consumer product like clothes or cosmetics, you suddenly realise that medicines marketing only exists for one reason. In medicine, brand identities are irrelevant, and there’s a factual, objective answer to whether one drug is the most likely to improve a patient’s pain, suffering and longevity. Marketing, therefore, exists for no reason other than to pervert evidence-based decision-making in medicine.

This is a very powerful machine: tens of billions of pounds are spent each year, $60 billion in the US alone, on medicines marketing.
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And, most impressively, this money isn’t plucked from the air: it is paid for by patients, funded entirely from the public purse, or patients’ payments into medical insurance companies. About a quarter of the money taken by pharmaceutical companies for the drugs they sell is turned around into promotional activity which has, as we will see, a provable impact on doctors’ prescribing. So we pay for products, with a huge uplift in price to cover their marketing budget, and that money is then spent on distorting evidence-based practice, which in turn makes our decisions unnecessarily expensive, and less effective.

All of this comes on top of a system for evidence-based medicine that is already gravely wounded, with poor-quality trials that are poorly communicated to doctors at the best of times.

It’s magnificent. Now, on to the details.

Adverts to patients

It is doctors who make the final decision about signing a prescription, but in reality the decision on which treatment to choose – and whether to bother with treatment at all – is made between them and their patients. This is entirely how you would want things to be; but it does make patients another lever to be leaned on, by an industry keen to increase sales.

We will see in this chapter that the techniques used by drug companies to do this are many and varied: the invention of whole new diseases and explanatory models; funding patient groups; running star patients who fight (with professional PR assistance) against governments that have refused them expensive drugs; and more. But we will start with advertising, because there is an ongoing battle to bring it to the UK, and compared to the more covert strategies, it seems positively transparent.

Direct-to-consumer drug advertising has been banned in almost all industrialised countries since the 1940s, for the simple reason that it works: adverts distort doctors’ prescribing behaviour – by design – and increase costs unnecessarily. The USA and New Zealand (along with Pakistan and South Korea) changed their minds in the early 1980s, and permitted a resurgence of this open marketing. That doesn’t, however, mean that these ads are someone else’s problem. There is a constant battle to reopen new territories, and these adverts leak through national borders in the age of the internet; but more than anything, they expose some clear truths about the industry’s thinking.

Let’s take a look at this mysterious world. When adverts were first made legal again in the US, they could only appear in print, because of a requirement to include all the side-effect information from the drug label. Since 1997 the rules have been relaxed, and now the side effects can be abbreviated (they are read out at jabbering speed over the end of the TV adverts). After this change the pharmaceutical industry’s annual advertising budget rose from $200 million to $3 billion in the space of just a few years. Notable single spends include Vioxx, at $161 million, which was taken off the market because of serious concerns over hidden data; and Celebrex, at $78 million, also later taken off the market because it was harming patients.

Various approaches have been used to try to evaluate the impact of these adverts in the real world.
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One study observed patients visiting their doctors in Canada, where direct-to-consumer drug advertising is still banned, and the US. It found that those in the US were more likely to believe they needed medication, more likely to request specific drugs that were advertised on television, and more likely to receive a prescription for that drug. In other words: the adverts worked. The doctors in the US, meanwhile, were more likely to report being worried about whether the drugs requested by their patients were appropriate.

Another study took a more proactive, experimental approach. Trained actors, posing as depressed patients, were sent to visit doctors in three American cities (three hundred visits in all).
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They all gave the same background story, about the problems they were having with low mood, and then were randomly assigned to act in one of three ways at the end of the consultation: to ask for a specific named drug; to ask for ‘medicine that might help’; or to make no specific request. Those who did what adverts drive patients to do – ask for a specific drug, or ‘medicine’ – were twice as likely to receive a prescription for an antidepressant pill. Whether you think that’s a good thing might depend partly on whether you think these drugs are actually worth using (the evidence overall shows that they’re pretty ineffective for mild and moderate depression). But whatever your view on antidepressants, the evidence very clearly shows that what patients say to their doctor, and what they request, has a significant impact on what is prescribed. Engaged and informed patients are something most doctors would want to see, but here the question is whether the information the patients have received is truly helpful, and whether doctors can resist inappropriate requests for pills.

So the same study sent more actor-patients to see doctors, but this time they gave a clear history of ‘adjustment disorder’, a term used by some people to describe the simple human phenomenon of feeling bad in the immediate aftermath of a very bad thing happening in your life. This is a normal and appropriate thing for your feelings to do, though it’s unpleasant, as any normal feeling person will know, and pills to treat it aren’t a good idea. But patients presenting with ‘adjustment disorder’ who demanded a specific named drug still got it, in 50 per cent of cases, compared with 10 per cent of those who didn’t request any medicine. This is the dark side of these adverts, and as a doctor, I’ve always been surprised by people who say that it’s doctors who force pills on patients. Doctors are generally nice people, and eager to please. They will get bounced into giving people what they want, and a lot of patients have been persuaded, through whatever social processes are at play in their world, that pills fix things. I’ll rephrase that for something that’s coming later in this chapter: a lot of
people
have been convinced that they’re
patients
.

So the evidence shows that adverts change behaviour, and they change it for the worse. This becomes much more worrying when you look at which drugs get advertised. One study gathered data on 169 drugs on the market, and looked for patterns in their promotion.
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Firstly, drugs are advertised more when the number of potential patients, rather than current patients, is large. This is an interesting finding, because it means that people are turned into patients, which is good news if they’re sick, but bad news if they’re not. Secondly, drugs get advertised more when they are new. That may seem inevitable, but it can be very problematic. As we’ve already seen, new drugs are often not a good idea: they’re the drugs we know least about, because they haven’t been around long; they’ve often been shown only to be better than nothing, rather than the best treatments we already have; and lastly, even if they’re equally effective when compared with older drugs, they will be more expensive.

We’ve already seen how AstraZeneca managed the transition from omeprazole to esomeprazole, the ‘me again’ drug, and we can also see it in their advertising strategy. The company spent $100 million on omeprazole in 2000, the second-highest advert spend that year. Then in 2001, as it was shortly to come off patent, AstraZeneca dumped the drug, and put $500 million into advertising esomeprazole instead, the ‘me again’ drug. But as we’ve already seen, these two drugs are almost identical, and esomeprazole is basically no better than omeprazole, just much more expensive.
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The advertising campaign was highly effective, so we waste money on drugs that are no better than those that already exist.

As I’ve previously argued, when you take a step back from pharmaceutical industry marketing, it is simply a process whereby patients pay money to drug companies, in order for them to produce biased information, which then distorts treatment decisions, making them less effective. This is not simply my view, or an interpretation from the basic principles of economics: we can also watch the phenomenon in real time, by tracking the cost of drugs, and their advertising budget. One study looked at clopidogrel, an ‘anti-platelet’ drug that can help prevent blood clotting, and is given to people at high risk of various heart problems.
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It’s popular, and expensive – in 2005 it was the world’s second-biggest-selling drug, at $6 billion. Clopidogrel came to market in 1999 with no advertising, and was used widely, with no advertising, until 2001. Then the drug company introduced television advertising, spending $350 million in total. Oddly, this had no impact on the number of people taking the drug, which continued to increase at exactly the same rate. So nothing changed, except for one thing: the price of clopidrogel went up by 40c per tablet. As a result, Medicaid alone paid out an extra $207 million. For me this episode is strong evidence – if it wasn’t already obvious – that it’s patients and the public who pay for the industry’s expensive marketing campaigns.

That would be fine if we were paying for reliable information, cautiously explained, but the reality is that even if the adverts are adequately policed (I will review the endless to-andfro on this later) they are still focusing only on pills and commercial products, which in turn distorts our whole outlook on medical interventions. Any sensible public-health campaign to inform people about reducing the risk or the consequences of a disease would look at prescription drugs, of course. But it might also inform patients with equal vigour about things like exercise, alcohol, smoking, diet, recreational drug use, social engagement, and perhaps even social inequality. A public education and engagement programme costing $350 million – the amount we have just seen spent on clopidrogel alone – would achieve a great deal for all of those goals, but instead, using money from patients and public, it is spent on TV adverts for one pill.

This is a theme that we will see recurring: one of priorities being distorted, alongside individual treatments being sold. But first, we must note that adverts are not the only way in which drugs are advertised.

Celebrity endorsement

In the 1952 Hollywood movie
Singin’ in the Rain
, Debbie Reynolds plays Kathy Selden, a talented singer who hides behind a curtain, and covertly provides the sweet singing voice for an on-stage starlet who merely mimes the words. In a recent interview, Debbie Reynolds suddenly starts explaining that ‘Overactive bladder
affects
you because it
defects
you…effective treatment is available.’
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The interview didn’t mention that she was working for Pharmacia, a company pushing a new treatment for overactive bladder. In another recent interview, Lauren Bacall encourages readers to get tested for macular degeneration, which she says can be helped with Visudyne. Neither she nor the interviewer mentions that she is being paid by Novartis to promote the drug.
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The mom from
Serial Mom
(seriously) drops references in interviews to arthritis drugs, and is paid to do so by Wyeth and Amgen.
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