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Pharmaceutical companies are ingenious in all the different ways they pump drugs into the system.The best known techniques include buying medical experts to put their names on articles written by the drug companies which can then be placed in medical journals; or hosting small casual dinners of docs to tell them about supposedly new and proven but still off-label uses for drugs. Docs get asked to come along for wonderful vacations with the dealers. They get great money making speeches.

Adriane Fugh-Berman, a Georgetown University doctor and colleague of mine on Pharmedout.org, drives the pushers nuts with her research and writing exposing their underworld. She has published a new article in the Boston Review setting out a basically unknown and genius way that Big Pharma makes a killing. In addition to buying docs, the drugsters invent or exaggerate diseases. They then pump knowledge about the creepy new condition into the medical world through a process known as Continuing Medical Education, or CME. This is how docs and health care professionals are supposed to keep abreast of new developments in their field. It works like this:

CME is the pharmaceutical industry’s most important marketing tool. Through a largely unnoticed process that plays out over a course of years, the pharmaceutical industry uses CME—which, unlike other forms of drug promotion, is not regulated by the Food and Drug Administration (FDA)—to prepare the market for new drugs, expand existing markets, position products against competitors, and promote unproven uses of treatments.

Here’s how it works. Pharmaceutical-company employees, or specialized vendor services, identify opinion leaders—influential (or up-and-coming) health-care professionals at academic medical centers. Physicians are the primary target, but as nurse-practitioners and physician assistants become increasingly important in primary care, these hidden prescribers are also being targeted. Industry’s influence on NPs and PAs has not received enough attention; for example, the recently passed Physician Payments Sunshine Act requires that pharmaceutical companies disclose payments made to physicians, but not those made to other prescribers. Selected opinion leaders are wooed, perhaps over an expensive one-on-one meal with a company researcher or executive—not someone identified with marketing. In the course of discussing the opinion leader’s work, the industry representative will elicit his or her opinions on a variety of topics, including the “disease state” of interest. Opinion leaders whose perspectives align with a company’s marketing goals are then courted. A company may nurture relationships with targeted health-care professionals over many years and will pay them to educate their peers at CME events and other settings. Industry-paid speakers frequently deny espousing marketing messages. I’ve heard many physicians justify their pharma-funded speaking gigs by saying, “I never emphasize their product” or, triumphantly, “I don’t even mention their drug!” But these comments only highlight their sales skills. Pharma doesn’t hire doctors to sell drugs; that’s a drug rep’s job. Pharma hires physicians to sell diseases.

Read the entire article in the Boston Review, and then, if you want to follow the ups and downs of the industry, take a look at pharmedout.org. It provides recent developments in the drug business, a lengthy bibliography of blogs and sources of information as well as a few videos of drug reps spilling the beans and telling how the business works inside out.

This post originally appeared on “Unsilent Generation,” James Ridgeway’s blog about the politics of aging.