Money for nothing (and the drugs for free)

By Rob Wipond, September 2013

Doctors’ relationships with drug company representatives have changed, say knowledgeable readers. But for better or worse?

A recently-unemployed friend of mine went into a Victoria walk-in clinic in June complaining about unease he couldn’t explain, and walked out with enough free packets of the antidepressant Cipralex and the stimulant Ritalin to last for weeks. If he liked these drugs, the doctor said, he should come back and get prescriptions for more. “It all happened so fast, in less than five minutes,” my friend said with both fascination and wariness. 

I was working at the time on last issue’s article about the drug company sales representatives who fill our doctors’ shelves with free drug samples (“Meet Your Doctor’s Generous Friend,” Focus July/August 2013). My friend showed me his packets, each prominently stamped “Sample.” It seemed very coincidental. However, over the next several months coincidental encounters with Cipralex kept occurring, and I started to wonder how coincidental it really was. 

Meanwhile, as damning as my article was of the relationships between drug companies, their sales representatives, and local medical doctors, Focus and I received only a few critical responses. That silence started making me feel like the reality was even worse than the article portrayed. Where were all the doctors declaring their independence from drug company money? Where were all the drug companies and reps declaring, “We’d never engage in those kinds of manipulative, corrupt activities”?

This month’s letter to the editor from a drug sales rep reflects one criticism we did hear: Bill’s and Sam’s stories of working as drug reps in Victoria and Vancouver from 1997-2009 were dated and things today are different. As some folks told it, today many local doctors know drug reps as responsible professionals who deliver samples and, if there’s any interaction, it’s a collaboration in patients’ best interests, period. However, my response was, even if practices in Victoria have changed, most doctors practising today will have been influenced by activities going on here as recently as four years ago, and going on elsewhere still today, and therefore Bill’s and Sam’s stories are still relevant. 

This point would soon be even more robustly illustrated to me as I gradually learned about the corrupt international history of Cipralex and its enduring local legacy (see below).

Furthermore, all of my expert sources in the article admitted it was difficult for anyone to definitively ascertain the “big picture” of what’s really going on locally or nationwide because, despite many lawsuits detailing widespread bribery and kickbacks in the US involving doctors and the same pharmaceutical companies active here, Canadian governments do virtually no monitoring and regulating of these relationships. And unfortunately, starting with this month’s letter writer who declined my subsequent request to interview her, getting the current story isn’t easy: doctors and drug reps are not clamouring to get media attention around this issue. 

Nevertheless, one younger physician currently practising at a large medical institution in a major Canadian city read the article and provided some interesting new insights, and consented to be quoted anonymously. 

“Dr Smith” explained why he thought doctors and drug reps rarely speak to media on these topics. Many, he said, have seen the scientific studies, US lawsuits, and news coverage critical of physician relationships with drug reps, and they feel insulted. “Most of these are very decent people,” Smith said. “It’s just that they have worked in medicine since before these things have become so prominent… People who have been already involved in pharma for 30-plus years, it’s a hard pill for them to swallow, to say you’ve been wrong all along, and you’re benefiting, and this is corrupt.” 

Consequently, many doctors aren’t “proud” that they’ve taken drug company gifts, trips, or money, he said, and therefore don’t want to discuss it publicly. Even critical or questioning physicians are reluctant to speak out, Smith said, because they don’t want to appear to be insulting doctors and sales rep colleagues and friends. Speaking out can also be a precarious career move when so many physicians, scientists, organizations and institutions are so deeply intertwined with the drug industry—which was the main reason Smith himself requested anonymity. 

Smith agreed with those who believe drug companies are behaving similarly in Canada as in the US. “There’s absolutely no difference,” he said. “It’s the same companies. It’s the same behaviours.” 

However, he also agreed with those who argue drug rep practices have changed in recent years due to growing critical awareness. So while drug-company sponsored meals in the best local restaurants continue, he said the gifts and sunbelt vacations are much less common. “That has changed, definitely.”

Smith commended such changes, but called them “a first few baby steps” that are “nothing to celebrate.” He said drug companies and doctors are still engaged in ethically dubious relationships, and inappropriate prescribing continues. “The problems are just as rampant.” For example, Smith said he has witnessed an increase in drug companies giving cash to doctors. “[A drug rep] will say, ‘We want you to come for a consultants’ meeting, and we’ll pay you for your time as a consultant.’ But really it’s a drug talk again.”

And indeed, I’ve been learning of cases of Canadian doctors being paid from $200 to $2000 by drug reps just for attending meetings of one to several hours in length. For example, a current Meda Valeant Pharma Canada solicitation offered physicians a $200 “honorarium” to join a 1.5 hour online webinar. “We look forward to your contribution, as we value your expertise,” said the ad. In the presentation preview comparing sleep aids, guess whose drug looked best? 

What’s a proper comparison for this practice? If a drug company dropped $1000 on my MLA to “consult” with her about provincial drug policy for an hour, would I consider it acceptable for her to take the money? And if a drug company gave me $1000 to meet ahead of my writing an article about drug and non-drug approaches to depression, should I disclose that? Actually, I would disclose it, and I imagine Focus readers would expect that (and still question my taking the money). So why do we seemingly expect a higher standard of disclosure and avoiding conflict of interest from our journalists and politicians than from our doctors? Do we imagine, against all the evidence, that doctors are less susceptible to such influences? 

In the US, new legislation is forcing more doctors to disclose drug company payments, and it’s clear that payments are frequent and substantial for giving presentations, chairing meetings, participating in studies, consulting, and other “services.” It’ll be interesting to see the impacts, although critics caution that disclosure alone doesn’t remove conflicts of interest and bias.

In any case, personally, I can’t think of any practice that looks more explicitly like blatant bribery of doctors than paying them cash just for coming to meetings. So I contacted the Canadian offices of various pharmaceutical companies, asking if they paid and, if so, how much did they pay Canadian doctors simply to meet with them.

No company said they never did it. Some companies didn’t respond, like AstraZeneca. Some asked for more information and then didn’t respond, like Johnson & Johnson. In brief emails, GlaxoSmithKline said they had “rigorous” policies on the issue (which they didn’t share), while Bristol Myers Squibb directed me to Rx&D, the Canadian drug industry’s voluntary self-regulating body for sales reps, and added, “BMS will not provide further comment regarding this topic.” A Pfizer Canada official confirmed via email that they’d sometimes “retain the services” of healthcare professionals, individually or in groups, and compensate them for, amongst other things, “participation in market research” or “other” services. She said the amount paid was “proprietary” information, but added that Rx&D’s guidelines indicate payments “must be reasonable and reflect the fair market value of the services provided.” She said Pfizer adhered to US anti-bribery and anti-corruption laws. 

What seemed apparent from reading the Meda Valeant ad, though, was that in drug industry parlance, a doctor is contributing to a company’s “market research” if he merely shows up at a meeting. And notably, just since 2009, Pfizer has paid over $3 billion in penalties in the US for improper and misleading drug marketing activities, which included, according to government allegations, “illegal remuneration to health care professionals.” In fact, it’s difficult to find any major pharmaceutical company that hasn’t paid massive penalties in the US, repeatedly, for engaging in such activities—including all the companies I just named.

In Canada, meanwhile, Rx&D dispenses on average two tiny fines per year against drug companies—I found none involving direct payments to physicians. 

I sent the Meda Valeant ad to Rx&D, and asked if this money-for-meeting solicitation contravened their ethical standards.

Media liaison Isabelle Robillard explained via email that “The Rx&D Code of Ethical Practices only applies to member companies. In this case, the company is not a member.”

Okay, I responded, but if the company were a member, would this be an ethical breach? 

She said a complaint about a member would have to go through official adjudication. 

I asked her to treat it like a hypothetical, then: “I write to you and say, ‘Hi, I’m a member pharmaceutical company and I’m planning on paying doctors $50, $200, or $2000 to meet with me to discuss my drug. Can you tell me, would I be breaching the code? What factors would you consider in deciding whether I was breaching the code?’”

Robillard responded, “We don’t work with hypotheticals.”

When I expressed frustration that the much ballyhooed self-regulating body for drug company ethics in Canada was refusing to answer a simple, relevant question around their policies, Robillard asked for more time. She eventually sent an excerpt from Rx&D’s code, which indicated that it would be improper to pay someone specifically “as an incentive or reward” for prescribing, administering, recommending or purchasing etc a particular drug. There was no indication that it would be a contravention to give doctors wads of cash in exchange for simply showing up at meetings or listening to an online “webinar.” And the ethical guideline itself looked inherently preposterous, anyway—why would any drug company give doctors money under any scenario except if the result were that doctors more often recommended or prescribed its drug?

One company that didn’t respond to my repeated queries was Lundbeck, the sellers of Cipralex in Canada. I’d heard they were also paying doctors handsomely for attending meetings. I investigated further, and soon discovered this drug’s marketing history was very instructive.

 

CIPRALEX IS AN INTERNATIONAL joint venture of Forest Pharmaceuticals and Lundbeck, and is called Lexapro in the US. Lexapro/Cipralex became famous in 2002 after the New York Times reported on an extravagant drug company-funded event in which students and their partners were flown in from virtually every medical school in Canada and the U.S. for a “conference” including Broadway plays, all-expenses-paid stays at the Plaza overlooking Central Park, and presentations about Lexapro/Cipralex.

The New York Times was later leaked documents from 2004, revealing that the relatively small company Forest was outspending all but the world’s biggest drug companies in its marketing of Lexapro/Cipralex.

In 2007, a lawsuit stripped the patent on Lexapro/Cipralex in the UK because it wasn’t actually a new drug. What had happened was, when Forest’s Celexa patent expired and Celexa’s price had to be dropped to compete with cheaper generics, Celexa was tinkered with, re-patented, and re-marketed as the more expensive “new, improved” Lexapro/Cipralex. But the functional identicalness of the old drug and the new drug was so transparent that at least one Celexa study was used to gain US FDA approvals for Lexapro/Cipralex. Nevertheless, thanks to intense marketing to doctors, sales of Lexapro/Cipralex rapidly surpassed those of the similar, cheaper Celexa and generics.

In March of 2009, Lexapro/Cipralex was approved in the US for use in adolescents, ostensibly because it did not increase suicides in youth like other SSRIs do. Huge financial windfalls resulted. But three months later it was conclusively revealed in a lawsuit and medical journal statement that the main study upon which that particular approval was based had been misleadingly and secretly crafted in part by drug company marketing reps; most people, including doctors, have never heard about that.

In 2010, Forest pled guilty to a US Department of Justice lawsuit and paid a $313 million fine. The drug company, the official settlement stated in part, “used illegal kickbacks to induce physicians and others to prescribe Celexa and Lexapro. Kickbacks allegedly included cash payments disguised as grants or consulting fees…” 

Forest now faces many lawsuits in the US over birth defects caused by Lexapro/Cipralex, knowledge of which it allegedly hid during its marketing efforts.

There’ve been no such lawsuits here. Today in Canada, Cipralex has become our most popular depression drug, holding 23 percent of the Canadian market, and is one of our top ten most-prescribed and most-costly drugs.

 

THE CIPRALEX STORY ILLUSTRATES how some Victoria doctors might currently have strictly professional, limited contacts with drug reps, and yet still be naïve victims of years of sophisticated global propaganda efforts. But some local doctors might also be taking kickbacks—we only learned about the US practices because, in most cases, there were drug company whistleblowers who got cuts of the massive financial settlements. Canada has no similar whistleblower laws.

In Dr Smith’s opinion, however, we get false impressions of how doctor-drug rep relationships actually work from those more “scandalous” cases. “It’s much more fundamental and pervasive,” Smith said. “The influence is much more subtle than that. Involvement with pharma is not just about financial transactions, it’s about relationships.”

Smith said many drug reps and doctors he sees are well-meaning people who have good, respectful, sometimes “intimate” friendships or working relationships with each other over years. He once suggested that a get-well gift from a drug rep to a clinical staff member was inappropriate, and the staff member became irate at him for mischaracterizing a genuine friendship. “These are the influences we’re talking about,” Smith commented.

Therefore, said Smith, we need more than just better monitoring. “It’s not about little rules and regulations.” In our increasingly overmedicated culture, as individuals, we need to be more “proactive” in educating ourselves and critically questioning our doctors about drug benefits and risks, he said. Systemically, short of eliminating the profession of drug sales reps, Smith suggested bringing drug development under public control, so “the focus would be on the best health benefit and not the best profit.” He also proposed firewalls between different sectors; for example, silo drug developers, manufacturers, evaluators, and sellers from each other, to ensure independence and lack of conflicts of interest in each sector.

Interesting ideas, I thought, hanging up from Smith, and shortly thereafter “coincidentally” learning of yet another Victoria friend who’d been newly prescribed Cipralex.

Rob Wipond’s research on this article was paid for by Focus magazine. Contact him at rob(at)robwipond.com.