Going around the psychiatry blogosphere recently: this segment by John Oliver about doctors who take pharmaceutical company money:

I will resist the urge to geek out about its minor medical errors1 in favor of clarifying something more important.

The impression you’re supposed to get from this piece is a shady looking man handing you a briefcase full of cash and whispering “Hey, here’s $10,000 for you if you prescribe unnecessary medication.” The implication is the doctors who do this are awful and if you were in medicine you would have no trouble resisting this temptation.

In reality, pharma companies have figured out that some people have ethical qualms – “evil cannot possibly understand good” only works in movies – and adjusted their strategies accordingly.

We’ll start with a simple one. Imagine you’re a doctor, and your staff are complaining because the staff at every other doctor’s office has been getting these incredible free lunches every day – the video says drug companies aren’t supposed to give, like, Zagat-rated steakhouse lunches, but there’s still a lot of room between “Zagat-rated” and “Way better than the peanut butter and jelly sandwich you bring from home”. The nurses are grumbling and threatening to revolt and asking if you really appreciate them.

A drug company representative offers to provide your office with free lunches a couple of times a week.

You say “It would be really annoying to actually use the phrase ‘there’s no such thing as a free lunch’ here, so I will just ask what the catch is.”

They say “No catch. We don’t require you to ever prescribe any of our drugs. We don’t require you to listen to our presentation. We don’t even require you to read our promotional literature. Just accept our offer.”

You say “Why are you doing this?”

They say “Because every time you eat one of our lunches, you’ll associate the ice cold taste of Coca-Cola and the sweet warm chewy chocolate chip cookies with our company, and you’ll get positive feelings about it, and maybe those positive feelings will influence your prescription habits.”

You say “I think I’m a good enough doctor not to prescribe a drug solely because I get lunch from their company.”

They say “Look. We all know that most antidepressants are about equally effective. Sure, we split hairs and talk about how one has more anticholinergic side effects so it’s bad for patients with cholinergic sensitivity, and another has more chance of weird visual disturbances, but how often does someone come into your office and announce ‘Hey, I’m depressed, and also I have cholinergic sensitivity, but I LOVE weird visual disturbances!’? Although there are a few cases where one drug’s clearly a better choice than another, most of the time you’re about equally balanced between two or three options, and you just pick one at random. So maybe instead of picking one at random, you’ll pick the one you associate with delicious food. And if you do, so what? Nobody’s harmed. You would have just flipped a coin anyway.”

You say “I’d rather flip a coin than feel like I’m being pressured by what I had for lunch.”

They say “Look, you secretly worry anyway that you sometimes prescribe Effexor because the name makes it sound effective, or Paxil because the name makes it sound peaceful.”

You say “Wait, you can read my thoughts?”

They say “We’re a pharmaceutical company. Of course we can read your thoughts. Look. You already know that the mostly-meaningless choice of which of several equally effective drugs you prescribe is influenced by a bunch of silly marketing factors beyond your control. Why not add one more?”

“But -”

“Come to the Dark Side! We literally have cookies!”

Still not tempting enough for you?

Okay, imagine this. You’re a doctor and one of your patients comes in with incurable chronic pain that’s ruining their life. You try the normal medications on it and nothing works very well. There’s a high-tech next-generation medication available that you think is a good fit for your patient’s disease, but it’s not covered by their insurance and there’s no way the patient can afford it. You have to tell this guy that there’s nothing you can do for him.

Then a drug company representative comes to you bearing a big box of free samples. By “free samples” I mean hundreds of pills, enough to help the patient for the better part of a year – and maybe at the end of that time you’ll get another box of free samples. The drug rep doesn’t want you to sign your life away. She’s giving them for free, no obligation, maybe just listen to a sixty second speech on how to prescribe them safely and effectively (she wouldn’t want to give them to someone who won’t prescribe them effectively!) Are you really so fundamentalist in your approach to medical ethics that you won’t listen to a drug rep for sixty seconds in order to save a patient’s quality of life?

Most doctors – even the ethical ones who would refuse the briefcase full of cash – take the offer. This practice has come under increasing scrutiny recently. Some of the complaints are kind of dumb, but one very valid one is that a lot of the times what happens is you start off by giving the patient 100 days of free sample or something, then the free sample runs out, they’re fixated on that particular medication because it’s the one that worked for them, and they find some costly way to continue the (more expensive new) medication – instead of the two of you working harder to find some older less expensive medication that works equally well. A few drug companies have “fixed” this by giving out cards for “prescription programs” that solve some of the problems with free samples. These are even harder to resist, and they’re also given out by attractive drug reps who just want to tell you a few important facts about the drug before giving it to you.

Still not tempting enough for you?

Fine, then imagine this. You’re a doctor who really believes in a particular drug and is trying to convince the medical community to use more of it. For example, a couple weeks ago I wrote an article on suboxone saying it was one of the best medications for opiate abuse and I wish the medical community would pay more attention and prescribe it more often.

I wrote that article for free as a public service because I think that drug saves lives. But imagine that the company that makes suboxone approached me afterwards and said “Hey, you seem to have an important message to spread. Why don’t we sponsor you to go around the country for a week or two telling it to other doctors at medical conferences? We’ll get you first-class flights, put you up in five-star hotels, and give you a $10,000 stipend.”

I say “Wait a second, that sounds like taking pharmaceutical company money, and taking pharmaceutical company money is evil.”

They say “Look. You were trying to promote suboxone to people already. You were just doing a bad job because you were limited to one little blog. The more suboxone-promoting you do, the more doctors know about this drug – which you yourself have said is life-saving – and so the more lives get saved. If you’re willing to promote suboxone ineffectively for free, why not promote suboxone effectively for $10,000 plus nice hotels?”

I say “I’m still kind of uncomfortable with this.”

They say “Okay, well, it’s not our fault if hundreds of people die of drug overdoses because their doctors didn’t know suboxone was an option.”

You’re probably going to ask if I’ve ever accepted any of these offers. The boring truth is that I haven’t had to consider them because I’m a resident and residents are lower than dirt and the pharmaceutical companies know this and they don’t waste time trying to cozy up to us.

I have tasted the forbidden fruit only once, and it was my attending’s fault. She told us that there was a big dinner being planned for the entire psychiatric community of our city. The goal was to get doctors to meet nurses to meet therapists to meet social workers in one place so we could all get to know each other and talk about changes we could make to the system. It was very important that we attend, or else the nurses and therapists and social workers would think that the doctors were too snooty to interact with them and didn’t care about changing the system. Oh, and by the way the dinner was sponsored by PANEXA (here used in place of the real drug because I don’t want to get in trouble for calling them out) but there wouldn’t be any promotional material or pressure to prescribe PANEXA, honest, no sirree.

This was a tempting offer precisely because it was such a good idea. Everyone in the local psychiatric community deals with each other frequently, but we’d mostly never met before. I know them as the voice on the other side of the phone saying “No, no beds are available in our facility” or as the person who refuses to fax me my patient’s past medical history because the patient is too catatonic to sign a consent form. None of us are ever entirely sure what the others are doing, sometimes there are bad feelings, and it was reasonable to hope that maybe if we all met each other and socialized things would get a little smoother.

So we all meet at this restaurant, and immediately World War III breaks out. It’s like “Hi, I’m Mary, the clerk at Blue Sky Mental Health.” “MARY?! YOU’RE THE ONE WHO DIDN’T FAX ME THOSE RECORDS I NEEDED TWO MONTHS AGO! MY PATIENT WENT A WEEK ON THE WRONG DRUGS BECAUSE OF THAT!”

“Hi, I’m Dr. Alexander, I work at the inpatient unit in Our Lady Of An Undisclosed Location Hospital…” “WE HAD A PATIENT COME FROM THERE TWO WEEKS AGO AND HE ASSAULTED A STAFF MEMBER. IF YOU’RE A REAL HOSPITAL WHY CAN’T YOU DO PROPER VIOLENCE ASSESSMENTS?”

It turned out that the nurses hated the social workers for making them wait on the phone forever in order to get a straight answer. The social workers hated the nurses for always calling them up when they were busy about things and expecting an answer RIGHT NOW. The social workers hated the doctors for giving patients one measly prescription, then handing the case over to them to fix all of the impossible problems in the patient’s life. The doctors hated the social workers, because when we give patients one measly prescription and then hand the case over to the social workers to fix all of the patient’s impossible problems, sometimes the impossible problems don’t get fixed.

Anyway, in the midst of all of this, there was one guy who was staying completely calm, talking nicely to everybody, helping people see each other’s sides of the issue, just a really serene well-adjusted guy. I escaped over to his table and asked him who he was and why he was here.

“Oh,” he said “I’m a paranoid schizophrenic currently on PANEXA.”

Of course he was.

Then we all broke off into our own groups and got some incredible Italian food.2

What I’m saying is, pharmaceutical companies are sneaky.

Footnotes

1: By which I mean “succumb to the urge to geek out about its minor medical errors, but in the footnotes”.

The video says that a “horrifying example” of pharmaceutical company overreach was how AstraZeneca took Seroquel, “an antipsychotic with dangerous side effects” and marketed it to doctors for depression, sleep, and dementia, adding “You can’t just give people dangerous drugs and see what happens!”

But actually, lots of studies have shown Seroquel is effective for depression, lots of guidelines suggest Seroquel as a backup depression treatment, and doctors have been (correctly) prescribing it for such for a long time. Doctors also very commonly prescribe it for sleep and dementia; I think is less evidence-based, but it’d be a lie to say it wasn’t common as dirt or that it didn’t work for these things (safety is the problem).

So what was happening was that AstraZeneca was promoting Seroquel for the things it was actually being used for, as opposed to the thing the FDA said it was supposed to be used for. Doctors are allowed to use drugs for whatever they want based on their own analysis and their best judgment, but pharmaceutical companies are only allowed to promote it for the FDA-approved indication, which at that point was psychosis and bipolar depression.

The reason the FDA hadn’t approved Seroquel for depression wasn’t because it was a bad idea. It was because in order to get the FDA to approve anything for anything, you must perform the appropriate ritual of putting a zillion dollars into a big pile, then burning it as a sacrifice to the Bureaucracy Gods. AstraZeneca had performed the ritual for bipolar and psychosis, but was still in the process of performing it a third time for depression. Once they finished, the FDA approved it as an adjunctive medication for depression, but also fined them hundreds of millions of dollars because they had advertised it for depression – merely based on evidence and clinical practice – before the FDA had told them they were allowed to.

This is still not the whole story, because best clinical practice says to only use Seroquel as a third- or fourth-line antidepressant after some others have failed, and in conjunction with another medication. If AstraZeneca was advocating to use it for depression first-line on its own, this would have been a genuine overstep and something to get upset about.

(research and clinical practice say to use it for sleep and dementia approximately never, but there is enough wiggle room in that “approximately” for doctors to drive a bus through, and they do.)

This is still not the whole story, because The Last Psychiatrist thinks the way the FDA’s handled the Seroquel indication, and the subsequent culture of prescribing that grew up based on that indication, is stupid.

The other minor medical error in the video is much simpler. Oliver mocks Wellbutrin’s claim to be “the happy, healthy skinny drug” saying that “the only happy, healthy, skinny drug is amphetamine”. But Wellbutrin is actually amphetamine-based – its full chemical name is 3-chloro-N-tert-butyl-β-ketoamphetamine – and it shares a mechanism of action with amphetamines, which is why some of its effects are similar as well. So Oliver’s joke was a lot more accurate and a lot less funny then he thought.

2: Then later, and contrary to the promises I received, they gave us a presentation on PANEXA anyway.

The schizophrenic guy worked for one of the local psychiatric community services groups doing community outreach. I never did figure out whether he was there as a coincidence or whether the pharmaceutical company had arranged to have him there. I suspect the latter but I have no proof.