snake-oil.jpgTwo fascinating papers in the open-access journal PLoS Medicine turn a spotlight on the practice of “detailing” — the office visits that drug-industry salespeople use to flatter and manipulate their way into the good graces of the doctors they want to influence.

The first and most eye-opening paper is co-authored by Shahram Ahari, a former Eli Lilly sales rep, and Adriane Fugh-Berman, a Georgetown University professor who researches drug marketing. Together, the two outline a variety of tactics that sales reps use on detail visits to disarm doctors and to indirectly — sometimes all but imperceptibly — nudge them into prescribing their company’s drugs more freely. This is one of those papers that best speaks for itself, so I’ve excerpted some key passages below. For the full effect, though, read the whole paper; Table 1 alone is worth the price of admission.

Good details are dynamic; the best reps tailor their messages constantly according to their client’s reaction. A friendly physician makes the rep’s job easy, because the rep can use the “friendship” to request favors, in the form of prescriptions. Physicians who view the relationship as a straightforward goods-for-prescriptions exchange are dealt with in a businesslike manner. Skeptical doctors who favor evidence over charm are approached respectfully, supplied with reprints from the medical literature, and wooed as teachers. Physicians who refuse to see reps are detailed by proxy; their staff is dined and flattered in hopes that they will act as emissaries for a rep’s messages. (See Table 1 for specific tactics used to manipulate physicians.) […]

The purpose of supplying drug samples is to gain entry into doctors’ offices, and to habituate physicians to prescribing targeted drugs. Physicians appreciate samples, which can be used to start therapy immediately, test tolerance to a new drug, or reduce the total cost of a prescription. Even physicians who refuse to see drug reps usually want samples (these docs are denigrated as “samplegrabbers”). Patients like samples too; it’s nice to get a little present from the doctor. Samples also double as unacknowledged gifts to physicians and their staff. The convenience of an in-house pharmacy increases loyalty to both the reps and the drugs they represent….

Pharmaceutical companies spend billions of dollars annually to ensure that physicians most susceptible to marketing prescribe the most expensive, most promoted drugs to the most people possible. The foundation of this influence is a sales force of 100,000 drug reps that
provides rationed doses of samples, gifts, services, and flattery to a subset of physicians. If detailing were an educational service, it would be provided to all physicians, not just those who affect market share…. Physicians are susceptible to corporate influence because they are overworked, overwhelmed with information and paperwork, and feel underappreciated. Cheerful and charming, bearing food and gifts, drug reps provide respite and sympathy; they appreciate how hard doctor’s lives are, and seem only to want to ease their burdens.

The second paper isn’t anywhere near so colorful, but compensates with depth of analysis. A research team at the University of California, San Francisco, studied market-research forms for the anti-seizure drug Neurontin (generically known as gabapentin), which became public as the result of a whistleblower lawsuit against Neurontin’s maker, Pfizer. That lawsuit contended that the former Parke-Davis — later acquired by Pfizer — had violated federal rules by promoting Neurontin outside its FDA-approved uses, and concluded with a $430 million out-of-court settlement.

By studying 116 of the market-research forms filled out by selected doctors following a sales rep visit — here’s an example:
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— the researchers built a detailed picture of the way Neurontin detailing worked. In 44 percent of the visits, physicians reported at least one “off-label” message related to Neurontin use in an unapproved fashion — exactly the sort of thing sales reps are forbidden to introduce in such conversations. Almost a full quarter of the visits involved only discussion of unapproved uses of the drug. (The researchers acknowledge that they have no way to know if the sales reps initiated such conversations.) Ultimately, almost half of the doctors involved said they planned to increase their prescription of the drug following the visits, while none reported plans to decrease Neurontin use.

Interestingly enough, former Pfizer exec Peter Rost is now closely tracking what may be a similar scandal related to AstraZeneca’s promotion of its chemotherapy drug Arimidex. The story, which began with the firing of an AstraZeneca regional sales manager who compared doctors’ offices to “a big bucket of money” in an internal newsletter, then mushoomed to include a cabal of alleged whisteblowers and leaked audio recordings — supposedly of AstraZeneca sales-rep training sessions — is detailed at his sometimes quirky blog Question Authority. If you don’t mind working backward, start here and keep scrolling down. Way, way down if you want to get all the way to the beginning — Rost is nothing if not prolific.