Guilty Pleasure: The Doctor As Drug Rep
31 CommentsBy Ed Silverman // November 24th, 2007 // 9:14 am
In a first-person essay in The New York Times magazine, Danny Carlat, a psychiatrist and gadfly who publishes a newsletter about drug research and marketing, recounts how he was wooed by Wyeth to pitch Effexor to other docs. The tale is, basically, one man’s primer on how the process often works - how the reps schmooze, the drugmaker pays and the doc is seduced. For those unfamiliar with the routine, this is worthy reading. For those in the know, this is a reminder of the ceaseless tension between marketing and science. This is how Carlat opens his mea culpa…
“On a blustery fall New England day in 2001, a friendly representative from Wyeth Pharmaceuticals came into my office in Newburyport, Mass., and made me an offer I found hard to refuse. He asked me if I’d like to give talks to other doctors about using Effexor XR for treating depression. He told me that I would go around to doctors’ offices during lunchtime and talk about some of the features of Effexor. It would be pretty easy. Wyeth would provide a set of slides and even pay for me to attend a speaker’s training session, and he quickly floated some numbers. I would be paid $500 for one-hour “Lunch and Learn†talks at local doctors’ offices, or $750 if I had to drive an hour. I would be flown to New York for a “faculty-development program,†where I would be pampered in a Midtown hotel for two nights and would be paid an additional “honorarium.â€
I thought about his proposition. I had a busy private practice in psychiatry, specializing in psychopharmacology. I was quite familiar with Effexor, since I had read recent studies showing that it might be slightly more effective than S.S.R.I.’s, the most commonly prescribed antidepressants: the Prozacs, Paxils and Zolofts of the world. S.S.R.I. stands for selective serotonin reuptake inhibitor, referring to the fact that these drugs increase levels of the neurotransmitter serotonin, a chemical in the brain involved in regulating moods. Effexor, on the other hand, was being marketed as a dual reuptake inhibitor, meaning that it increases both serotonin and norepinephrine, another neurotransmitter. The theory promoted by Wyeth was that two neurotransmitters are better than one, and that Effexor was more powerful and effective than S.S.R.I.’s.
I had already prescribed Effexor to several patients, and it seemed to work as well as the S.S.R.I.’s. If I gave talks to primary-care doctors about Effexor, I reasoned, I would be doing nothing unethical. It was a perfectly effective treatment option, with some data to suggest advantages over its competitors. The Wyeth rep was simply suggesting that I discuss some of the data with other doctors. Sure, Wyeth would benefit, but so would other doctors, who would become more educated about a good medication….
Later, after realizing the limitations of the studies and the drug - a higher risk of hypertension and withdrawal symptoms, Carlat has an epiphany, and he doesn’t feel good about it…
“I realized that in my canned talks, I was blithely minimizing the hypertension risks, conveniently overlooking the fact that hypertension is a dangerous condition and not one to be trifled with. Why, I began to wonder, would anyone prescribe an antidepressant that could cause hypertension when there were many other alternatives? And why wasn’t I asking this obvious question out loud during my talks?
I felt rattled. That psychiatrist’s frown stayed with me — a mixture of skepticism and contempt. I wondered if he saw me for what I feared I had become — a drug rep with an M.D. I began to think that the money was affecting my critical judgement. I was willing to dance around the truth in order to make the drug reps happy. Receiving $750 checks for chatting with some doctors during a lunch break was such easy money that it left me giddy. Like an addiction, it was very hard to give up.
There was another problem: one of Effexor’s side effects. Patients who stopped the medication were calling their doctors and reporting symptoms like severe dizziness and lightheadedness, bizarre electric-shock sensations in their heads, insomnia, sadness and tearfulness. Some patients thought they were having strokes or nervous breakdowns and were showing up in emergency rooms. Gradually, however, it became clear that these were “withdrawal†symptoms. These were particularly common problems with Effexor because it has a short half-life, a measure of the time it takes the body to metabolize half of the total amount of a drug in the bloodstream. Paxil, another short half-life antidepressant, caused similar problems.
At the Wyeth meeting in New York, these withdrawal effects were mentioned in passing, though we were assured that Effexor withdrawal symptoms were uncommon and could usually be avoided by tapering down the dose very slowly. But in my practice, that strategy often did not work, and patients were having a very hard time coming off Effexor in order to start a trial of a different antidepressant.”
eDrugSearch Blog » Blog Archive » Pharma links for 11-24-07
[...] Guilty pleasure: the doctor as drug rep (Pharmalot) [...]
Laurie
Ed, the link to the article isn’t working.
Laurie
This link:
You can read the complete Times magazine article here.
The top link works fine!! :)
Dan
Dear Mr. Silverman,
Thanks for making me aware of this drug article authored by Mr. Carlat.
I’m a big pharma ex-pharmaceutical rep., and it’s worse than this situation so well illustrated in this soul-searching article by Mr. Carlat, in my opinion. With my previous pharmaceutical employers, pharmaceutical reps, possibly and likely, would simply generate speaking checks for ‘trained’ speakers within their organization and issue them to these select doctors for doing absolutely no work at all for the rep’s own employer or themselves, and likely, these trained speakers would accept these checks. At the same time, such a pharmaceutical representative would go to some top notch steakhouse, for example, and purchase thousands of dollars of gift certificates for a specified date in order to create an entirely fictitious speaking engagement, while documenting and annotating fictitious attendees afterwards. The etiology for this type of action, which many find hard to believe and digest, is due to the tremendous pressure put on many pharmaceutical reps. to develop speaking programs and speakers in thier assigned territories in order to spend thier organizations’ ’speaking budgets’, and this pressure, in my opinion, is and continues to be quite great and clearly corruptive. It’s because of my certainty of these occurences, and others of a similiar nature, which, by the way, I never did whatsoever when I was a pharmaceutical representative, that I divoriced myself from the very lucrative positions I had within the pharmaceutical industry and lack the ability to return to this industry as it exists today, yet I somehow tolerated such progressive activities described to you in this reply for over a decade.
So thank you again for your publication.
Hank
Thanks, Dan. I knew about “ghostwriters,” but I hadn’t heard of “ghost dinners” before.
Grief
This doctor, and the ex-rep whose letter is posted above, never mention the risks of the drugs they were pushing - let’s face it, they and the others are pushers. The only thing mentioned is effects people get trying to come off these drugs, particularly Effexor and Paxil. They do not mention homicide, suicide, diabetes, hyperglycemia, heart attacks, strokes, or death.
A good thing that they stopped this activity, but there are plenty of others in their place. There are no ethics in Pharma.
bob
Go ahead and keep attacking the industry that has saved 10’s of millions of lives including your children, parents, brothers and sisters. Go ahead and keep finding ways to attack an industry that gives free drugs to those who cannot afford them. All they have to do is ask, and they will get the drugs they need. Go ahead and attack the industry that has not only reduced mortality, but reduced operations and pain and suffering. What are you going to do when a new strain of virus develops and you need a drug to cure it? Who are you going to turn to when you need new treatment modalities for diseases? The generic industry? they don’t even conduct research, just leach on the pharmaceutical companies that continuously try to create new and more effective drugs. What industry continues to comply, happily, with affirmative action programs and supports the politically correct causes including HIV/AIDs, breast cancer, etc? Remember, if government continues to place undo restrictions on the pharmaceutical industry, prices will continue to rise and new, more effective drugs will be fewer and fewer. Who did we call when there was a bird flu epidemic scare? Not generic companies. Think hard before condemning an industry that has always pushed, by and large, for integrity in what it did and represented.
Your article misses a lot.
Bob
Ed Silverman
Hi Bob,
Just so we’re clear. The article was written by Dan Carlat and I posted an excerpt with a link to the complete article. I wasn’t the author of the article. You can visit Carlat at his site, and I’ve provided a link to that, as well. So if you want to let him know your views, I would write him directly. I hope this helps.
Regards
ed at Pharmalot
Pharma Giles
Great article, Ed. And I wonder what big pharma company or PR/political activist group “Bob” works for…?
The time of life-saving altruism in the pharmaceutical industry has long gone now, Bob. It’s all about money now, and Dr. Carlat’s article shows that quite nicely. Tell your masters to clean up their sleazy act rather than ask agency writers like you to shoot messengers (and with rather tired, uninformative and unoriginal copy, at that)…
Jamie
Thanks for the article Ed.
The power of Big Pharma over doctors, psychiatrists, and the FDA must stop.
Money can make anyone do almost anything.
Laurie
“All they have to do is ask, and they will get the drugs they need. ”
Bob…You really believe the stuff that you spout?? This is SO not true!!! I know thousands who have contacted GSK for liquid paxil(to wean off the drug) and have been told they don’t give away any drugs.
No one has said that all drugs are bad. But just as there are good drugs, there are bad ones. Sadly, both are marketed the same way.
Nathan
Laurie,
Do you really know “thousands” who have contacted GSK for Paxil? Obviously those are not personal acquaintances. Please enlighten the rest of us and let us know where you got this info from. Are you an insider at GSK?
As for Dr. Carlat’s story, there is pressure for success in all businesses, not just the pharmaceutical business. The problem for drug reps, it seems, is that the pressure to succeed can easily push them to do things that are illegal and unethical. That is a problem of personal character, not of the industry as a whole. Dr. Carlat is admitting to his own personal failings by succumbing to the pressures placed on him. It was HIS failing, not a failing of the pharma industry. The only fault of the industry that I see is that maybe Wyeth should have tried to hire people with a bit more moral character than Dr. Carlat and the Wyeth drug rep that paid him off.
Janet
Nathan,
The problem for drug reps AND pharma management and marketing people is that there are incentives ‘which can easily push them to do things that are illegal and unethical’. It goes beyond personal character to corporate culture. I would assume that it is not like this in all product groups or at all companies, however, it IS like this in some groups (although it has improved overall).
Stephany
Considering there is soon to be a multi-state lawsuit against drug companies for withholding data, and flat out lying about potentially deadly and harmful side effects, one can hardly use free meds as an example to make these companies appear as caring and innocent victims.
Zyprexa and Risperdal lawsuits forgotten already? Pharma flaunts its billion dollar industry by settling in court, at the expense of innocent victims./consumers
Anyone defending unethical practice of “Lunch and Learns” are as guilty as the ppl. who withheld data that killed or caused injury to innocent people.
I wonder why Eli Lilly didn’t want anyone to see the internal Zyprexa documents, now in public viewing on the Furious Seasons website listed on the blog roll here.
As far as Carlat not speaking about the psychiatric side effects of Effexor–it’s hard to find any psychiatrist to acknowledge that a psych med could be the reason for increased erratic behaviors. They’ve been taught to mask symptoms with add-on psych meds. Cogentin, Klonopin,Xanax,Ativan are commonly prescribed for agitation, aggression,and other side effects often resulting from anti psychotic or anti depressant use. Each of those medications has their own risk. Cogentin has a side effect of delusions. Zyprexa has a fine print side effect of “schizophrenic behavior”. Once on the medication cocktails, a patient and psychiatrist often never see a true baseline for a patient again.
The increased DCT marketing, and the re-packaging of anti psychotics being rx for depression is another fire that has been lit, and more reason for scrutiny. Lawsuits regarding innocent consumers are nothing in Pharma’s eyes, it’s the bottom line that counts.
Pill pushers indeed.
Jack
Laurie, isn’t Paxil generic?
Laurie
“Do you really know “thousands†who have contacted GSK for Paxil? Obviously those are not personal acquaintances. Please enlighten the rest of us and let us know where you got this info from. Are you an insider at GSK?”
I have an ssri withdrawal website that gets 3.1 million hits a month from posters all over the world going through antidepressant withdrawal…yes, I know thousands who have tried to get liquid paxil.
It is available generic, but the cost is prohibitive for most and insurance doesn’t cover it, in most cases.
“Dr. Carlat is admitting to his own personal failings by succumbing to the pressures placed on him”
And just who provided that pressure?? That would be those who provided him the information….that would be Wyeth. If it wasn’t Dr. Carlat, it would be someone else.
Prescription Project » Blog Archive » All the news that’s fit to print—or e-mail
[...] the Times Most-Blogged tab), and is yielding some interesting side stories, including a comment on Pharmalot from an ex drug rep who says that some pharmaceutical reps just go through the motions of setting [...]
Christopher
As is so often the case, people take to extreme positions, and it is not productive. While any visit to Dr. Carlat’s own blog would suggest that he has his own political agenda, his story is nevertheless compelling and I suspect largely true. As has been discussed before on this blog in various ways, the reality is that it has been a common practice in pharma for many years to pay hundreds if not thousands of doctors to perform speaking engagements on big brand-name drugs. Some of these doctors can make hundreds of thousands of dollars doing 20, 30, 40 or more speaking engagements over dinner, sometimes for multiple pharma companies. Indeed, some of these physicians speak so much for industry that you can’t tell anymore whether they were opinion leaders when they started or whether their speaking tours made them. Among the many other problems highlighted by Dr Carlat, the public has no access to information on pharmaceutical industry payments to individual physicians and therefore little means to identify potential physician conflicts of interest. It’s all very secret. However, with enough pressure there are solutions on the table. Disclosure laws would help the government and patients identify potential conflicts that may result from drug company marketing practices. For example, the Physician Payments Sunshine Act (S.2029) would require drug manufacturers to report all payments to physicians including compensation; food, entertainment or gifts; trips or travel; participation in conferences or continuing medical education; rebates or discounts; consulting fees; and any other economic benefit . . . And there are many state laws in the works if the federal government can’t get its act together. About a month ago, some of the major orthopedic device mfg’s were forced by a court settlement to disclose payments, and the impact of those reports in the paper seemed intense. It’s probably not a complete solution, but disclosure is a major step forward. Patients have a right to know whether their personal physician or surgeon is paid to speak for some of the products they might prescribe. And the physicians will think a lot harder about how much money they really want to take! So while it’s never very comfortable when the folks who benefitted from a bad practice suddenly turn around and criticize it, Carlat’s article sheds more light on a subject that needs some sunshine!
Nathan
“And just who provided that pressure?? That would be those who provided him the information….that would be Wyeth. If it wasn’t Dr. Carlat, it would be someone else.”
There is pressure in every industry out there to make things appear better than they are. Every company CFO out there is under extreme pressure to have the company get “in the black”, have positive earnings, and appear as valuable as possible so that investors will continue to push up the stock price. Every public relations person out there is under extreme pressure to give a positive impression of his/her company, regardless of all the negative events going on. Does this mean that the company is pressuring them to lie and do illegal things? Of course not. With some jobs, pressure for positive results is just a fact of life. If you can’t deal with it, then get another job. Evidently Dr. Carlat wasn’t cut out for the position he was recruited for. He neglected his oath as a physician and hopefully will loose his medical license as a result.
I agree there should be more openness in the whole process. But here’s where I disagree: the ultimate “bad guy†in this situation is not Wyeth, it’s Dr. Carlat.
Nathan
One other point: I work at a drug company and I can tell you that we generally don’t employ medical doctors. We are always going to need to work with doctors in order to know what treatments are needed, what are effective, and what not effective. We need doctors that are willing to HONESTLY tell other doctors about the new treatments we are developing. As Christopher said, full disclosure is important — BUT, there are always going to be conflicts of interest that come up. Doctors are not going to volunteer their time to tell other doctors about a new treatment the GSK developed for cancer. We have to PAY them for their time. Their time is valuable.
That said, drug companies should not be in the business of scripting what the doctor does and does not say about a particular drug.
Chris
Stephany -
> Considering there is soon to be a multi-state lawsuit against drug companies for withholding data, and flat out lying about potentially deadly and harmful side effects
Can you tell us more about this lawsuit?
CV MD
Nathan -
Honesty and Big Pharma are not compatible!! They need physicians on staff to sign off on their misinformation and hate it when the physician raises any questions. If they do, then they’re obstructive and disloyal.
The commercial people just can’t help themselves - they’re addicted to money and want to get the most that they can now in case it isn’t as free-flowing in the future.
Nathan
CV MD,
That’s silly — if that were the case we might as well admit defeat and not allow drug companies to sell their products anymore.
There are plenty of mechanisms that allow greed to coexist with honesty. Rather than just complaining about how bad the system is, maybe some people could come up with concrete ideas for improving what we have. Kudos to Christopher for coming up with a meaningful start.
Indecently, as I’ve pointed out repeatedly, this problem isn’t unique to the pharmaceutical industry — it just appears exceptionally bad in this industry because people’s health and lives are at stake.
CV MD
Nathan,
The difference is that the pharmaceutical industry involves taking care of people. Therefore, the standard should be higher. Read the news! Big Pharma is not capable of being honest. They are constantly dodging rules, regulations and laws. That’s why most of them have paid multi-millions in fines in the past 2-3 years.
I’ve worked in 2 Big Pharma companies and have been horrifed at what they’ll do to make a buck!
BP
CV MD is correct. Join Big Pharma and check your conscience at the door! It’s not welcome inside. If you try to do the right thing, they trash you. I’ve seen it happen too many times to good people.
Stephany
http://www.mindhacks.com/blog/2007/11/the_mother_of_all_dr.html
Stephany
http://www.furiousseasons.com/archives/2007/11/atypical_nation_will_states_lawsuits_lead_to_battle_over_drugs.html
CJ
As a current pharma rep I can tell you that much of this stuff still takes place fairly often (although there has been an enormous improvement over the last couple of years and not nearly as much of the most egregious activity occurs now). I can also tell you that there are plenty of reps and doctors that would absolutely never sell-out their peers and/or patients for any price. I find it disturbing that someone as distinguished (and probably relatively well-paid to begin with) as Dr. Carlat would be so easily bamboozled by a drug company. After all, it shouldn’t take a brain-surgeon (pun intended) to deduce that the quest for shareholder profits by a drug-company could lead to conflicts of interest with science. Doctors are trained to be skeptical and take an oath to protect their patients from harm. I am a sales rep with a fraction of their training, but I am proud of the way I conduct myself. I don’t need to take an oath. Many pharma companies are far from perfect, but they are certainly not the baneful, heartless organizations they’re portrayed as. The unfortunate thing about articles like this is that it probably just makes things worse. Sell-outs like Dr. Carlat learn about the opportunities to make quick-cash, while our most respected and principled doctors (that could provide a fair-and-balanced assessment of a therapy) are driven away. Just remember that for every Carlat there are 10 doctors that understand what it means to do the right thing.
Sean Stone
I just read a great new “fact-ional” book called “Pill Pushers: A Big Pharma Battle for Market Share” that highlights all of this and more!! Check it out at http://www.PillPushersTheBook.com... Very interesting read. Had no idea how corrupt the pharmaceutical marketing machine was and still is…
Michele Maret
As a former pharmaceutical rep, I was interested in checking out the book you recommended. The website is actually http://www.pillpushersthebook.com/ or you can access the book directly on Amazon. I already ordered a copy!
Is it Medical Education, or is it Pharmaceutical Marketing? - the Case of “Dr Drug Rep” | Etixet
[...] and Psychiatry Blog, the Health Care Organizational Ethics blog, the PharmaGossip blog, the PharmaLot blog, and the Retired Doc’s Thoughts blog. Share and Enjoy:These icons link to social bookmarking [...]