The best medical research money can buy

The New York Times opined July 23 on our conflicted medical journals. Too many researchers are on the payroll of the companies pushing the treatments being studied.

"Two disturbing cases were described in detail by The Wall Street Journal in recent weeks. One involved The Journal of the American Medical Association, or JAMA; the other an obscure journal known as Neuropsychopharmacology, which is published by a leading professional society in the field.

"The article in JAMA must surely have pleased all makers of antidepressant drugs. It warned pregnant women that if they stopped taking antidepressant medication they would increase their risk of falling back into depression. Hidden from view was the fact that most of the 13 authors had been paid as consultants or lecturers by the makers of antidepressants. Their financial ties were not disclosed to JAMA on the preposterous grounds that the authors did not
deem them relevant.

"An even more egregious set of events occurred at Neuropsychopharmacology, which recently published a favorable assessment of a controversial new treatment for depression resistant to conventional therapies. Left unmentioned was that eight of the nine authors serve as consultants to the company that makes the device used in the therapy. The ninth works directly for the company. Just to make things particularly incestuous, the lead author of the study is the journal's editor and a consultant to the company. He has been accused in the past of promoting therapies in which he had a financial stake."

This is par for the course. The new breed of "reps" -- those hired by pharmaceutical companies to pitch their products (drugs) to prescribing doctors -- are actually doctors themselves. But the main workforce of ordinary drug salesmen is a great investment for drug companies.

"Drug reps have been calling on doctors since the mid-nineteenth century, but during the past decade or so their numbers have increased dramatically. From 1996 to 2001 the pharmaceutical sales force in America doubled, to a total of 90,000 reps. One reason is simple: good reps move product. Detailing is expensive, but almost all practicing doctors see reps at least occasionally, and many doctors say they find reps useful. One study found that for drugs introduced after 1997 with revenues exceeding $200 million a year, the average return for each dollar spent on detailing was $10.29. That is an impressive figure. It is almost twice the return on investment in medical-journal advertising, and more than seven times the return on direct-to-consumer advertising. " (The Drug Pushers, The Atlantic, April 2006)

Drug reps are usually ordinary salesmen, not doctors, who call on doctors to give sales pitches and free samples. Sometimes they buy lunch for the doctor's staff. And at times they will spend exhorbitant sums to get the doctors to prescribe more of their companies' products. The finesse involves giving gifts that aren't perceived as bribes.

Increasingly, doctors themselves are being co-opted by industry to pitch drugs to their peers.

"Doctors are often the best people to market a drug to other doctors. Merck discovered this when it was developing a campaign for Vioxx, before the drug was taken off the market because of its association with heart attacks and strokes. According to an internal study by Merck, reported in The Wall Street Journal, doctors who attended a lecture by another doctor subsequently wrote nearly four times more prescriptions for Vioxx than doctors who attended an event led by a rep. The return on investment for doctor-led events was nearly twice that of rep-led events, even after subtracting the generous fees Merck paid to the doctors who spoke."

But it is a slippery slope.

"These speaking invitations work much like gifts. While reps hope, of course, that a doctor who is speaking on behalf of their company will give their drugs good PR, they also know that such a doctor is more likely to write prescriptions for their drugs. 'If he didn't write, he wouldn't speak,' a rep who has worked for four pharmaceutical companies told me. The semi-official industry term for these speakers and consultants is 'thought leaders,' or 'key opinion leaders.'

"Some thought leaders do not stay loyal to one company but rather generate a tidy supplemental income by speaking and consulting for a number of different companies. Reps refer to these doctors as 'drug whores.'

"The seduction, whether by one company or several, is often quite gradual. My brother Hal explained to me how he wound up on the speakers' bureau of a major pharmaceutical company. It started when a company rep asked him if he'd be interested in giving a talk about clinical depression to a community group. The honorarium was $1,000. Hal thought, Why not? It seemed almost a public service. The next time, the company asked him to talk not to the public but to practitioners at a community hospital. Soon company reps were making suggestions about content. 'Why don't you mention the side-effect profiles of the different antidepressants?' they asked. Uneasy, Hal tried to ignore these suggestions. Still, the more talks he gave, the more the reps became focused on antidepressants rather than depression. The company began giving him PowerPoint slides to use, which he also ignored. The reps started telling him, 'You know, we have you on the local circuit giving these talks, but you're medical-school faculty; we could get you on the national circuit. That's where the real money is.' The mention of big money made him even more uneasy. Eventually the reps asked him to lecture about a new version of their antidepressant drug. Soon after that, Hal told them, 'I can't do this anymore.'"

And so it goes.

Costly eye drug challenged by cheap alternative

"Wet" macular degeneration is a serious eye disease that can lead to loss of a great deal of vision. New treatments may be able to halt the vision loss and in some cases even improve vision.

NPR offered a news item this week about Lucentis, an FDA-approved treatment for "wet" macular degeneration that is being overshadowed by a drug that is chemically almost the same, and has the same effect (it prevents the proliferation of new blood vessels).

The second drug, Avastin, is not FDA-approved for this particular use, but it may cost as little as $50 for treatment, compared to $2000 for the first drug. Doctors often prescribe drugs for things other than their FDA-approved purpose. It is called an "off-label" use.

You can listen to the story here: http://www.npr.org/templates/story/story.php?storyId=5596931

The representative for the expensive drug is questioned about the pricing. He cites the cost of other drugs to treat wet macular degeneration, claims his drug is superior, and thinks $1950 per dose (with possibly multiple doses needed) is a cost the patient can afford, since most insurance companies will cover most of the cost. Additionally, the drug company, Genentec, set up a foundation to help poor patients with the exhorbitant price. The subtext of all this is that the drug company picks the highest price they think they can get away with.

In the NPR story, we listen in on a doctor consulting with a patient. Even when the more expensive option is covered by insurance, the patient chooses the cheaper alternative, because she would have to pay first, and be reimbursed by insurance later. She doesn't want to part with her 2 grand. Smart lady! "Clearly, Avastin is a better value," the doctor says.

Ya think so?