The pill pushers
By Alex Roslin
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