Pill Pushers: Pharmaceutical Marketing in an Overmedicated Nation

An interview with Melody Petersen

Melody Petersen covered the pharmaceutical beat for The New York Times for four years. In 1997, her investigative reporting won a Gerald Loeb Award, one of the highest honors in business journalism. She is the author of Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs  (2008).

Multinational Monitor: There is a long history of pharmaceutical companies hawking remedies to the broad population. What’s different about the current era?

Melody Petersen: It’s much more aggressive. Many companies have even put their marketers in charge of their laboratories. At Pfizer, there was a program called CRAM, which stood for Central Research Assists Marketing. The name made it clear that the marketers were in charge.

The whole focus of the industry has changed. The drug companies center their efforts on medicines for chronic conditions that affect large portions of the American public — and therefore have vast potential markets — things like heartburn, depression, allergies, blood pressure. Even inside the labs, the scientists are told to focus only on drugs that could become billion-dollar sellers. That’s why we have six drugs to lower cholesterol that all work in the same way. And yet millions of very sick patients have no treatments.

MM: What are the key themes of drug company marketing campaigns to consumers?

Petersen: There are two different ways the companies use the ads to get you to go to the doctor. One way is to trade in fear about a disease. These ads have taglines like, “What you don’t know could kill you” or the ominous, “All it may take is the formation of one clot.” Those are attempts to make you fearful that, if you don’t take a pill, you could die.

The second way they use the ads is to show wonderful scenes of people running on the beach, hiking in the woods, dancing at a party. In those ads, they’re not really selling medicines, they’re selling things like youth and happiness and friends and beauty and sex. This is how marketers sell a whole host of different products. The underlying message is that this medicine will bring you a sort of personal transformation. You’ll be envied, you’ll be more lovable, if you take the advertised medicine.

MM: Besides overt ads, what do the companies do to market to consumers?

Petersen: The companies do most of their promotion from behind the scenes. If a company needs a group of patients or doctors to stand up and be advocates for its drugs, it may simply create a group that looks like a cancer society or a heart association, but is really nothing more than the creation of a PR firm working for the drug company.

If they want a news story about their medicine, a PR firm calls up reporters and works to get stories placed, often successfully.

When I was at the New York Times, I would get calls from the public relations staff of a drug company offering me what they called “an exclusive” story. They had one of the best doctors in the country ready to talk to me about a new medicine that was going to be on the market. They had patients who wanted to tell me how this drug had changed their lives. They even had a survey that said a large percentage of the American public suffered from this particular disease. It was clear I wouldn’t have to do much work for this story. It was all written out in the press release.

I could never get myself to do these stories, but if you read the newspaper, you will find stories like this that have come from a public relations person. They describe what sounds like a wonder drug.

The drug companies are experts at knowing how to put their words in the mouth of someone who appears to be independent, so the public accepts their promotional message as the truth.

MM: One noteworthy phenomenon you document is the marketing of pharmaceuticals to children.

Petersen: The companies are creating cartoon characters and giving kids free gifts. They’re trying to reach young consumers who may go on to take their medicines for decades.

For instance, AstraZeneca has created a creature named Pulmi. He kind of looks like a frog. He’s animated. He looks like he could be a character in a Disney movie. And the kids can go online and watch funny videos of Pulmi dancing and blowing his horn. He’s advertising a drug for asthma called Pulmicort. He’s also making drugs fun for kids.

  This type of promotion is very dangerous because it can mislead children and their parents into believing these drugs are safer than they actually are.

  Kids don’t buy drugs, but they’re very persistent. If the child has asthma and the doctor thinks a drug other than Pulmicort might be better for the child, the doctor might be up for a fight.

MM: The industry has also created or expanded markets for drugs for kids, notably to treat Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD).

Petersen: ADHD is a condition defined by certain behavioral symptoms a child displays.

What the drug companies have been able to do is sell more of their medicines by marketing the disease. They’ve promoted the disease to parents, taught parents about it through their websites and by handing out brochures in schools and through doctors.

At the same time, they now aggressively advertise drugs like Concerta and Adderall for ADHD. You can open up Ladies Home Journal and see ads for these drugs tucked in amongst the ads for cold cuts and cereals.

MM: How important are industry efforts to create or dramatically expand the population understood to have diseases, or redefine problems to be perceived as diseases needing treatment?

Petersen: I was very surprised about this. One day I was at a conference where drug executives were giving speeches. I looked down the agenda, and there was an executive from one of the biggest drug companies planning to give a speech about how he and his drug company had “created a disease.” At the time I didn’t understand that the drug companies could do this. But, indeed, he got up on stage and through his slide presentation went point by point how he and his company had created the disease of “overactive bladder.”

In essence, they went to some of the top urologists in the world, put them on their payroll as consultants, and gathered these doctors together in meetings where the expenses were paid by the drug company. At these meetings, the company and its physician consultants laid out how they thought the disease of overactive bladder should be defined. The company then paid some of these doctors to write articles about this new disease and how the company’s drug Detrol worked to remedy it. The company then paid to publish those articles in a medical journal. It’s as simple as that.

MM: What do you mean they paid to publish those articles in a medical journal?

Petersen: In this case, the company paid a journal called “Urology.” The journal published a supplement, and the manufacturer, Pharmacia, paid Urology to publish these articles. It said at the beginning of the supplement that these articles were generated from a meeting Pharmacia had sponsored in London where a group of urologists had gathered to talk about overactive bladder. It sounds, and it actually was, simple.

These first articles were then used as the source of even more articles in other medical journals. And the company paid some of its physician consultants to give lectures to other physicians about this new “disease.”

The company then taught consumers about this new disease through millions of dollars of TV ads. It also hired celebrities like Debbie Reynolds to talk to women about why they should be worried about their overactive bladders.

Today, Detrol, the company’s drug for overactive bladder, is a billion-dollar seller.

MM: Most people in the United States are much more aware of drug company marketing directed to consumers than the marketing directed to doctors. What’s the relative importance of those two things for the industry?

Petersen: Most of the drug companies’ marketing dollars actually go to physicians. The drug companies do this because once physicians played a very important role in our drug safety system.

In 1951, Congress decided that we must get a prescription for certain drugs. Before that law, we could go into the pharmacy and get whatever we wanted. Congress wanted the physician, who was independent and well educated and had the best interests of the patient at heart, to make sure we didn’t take drugs that could harm us more than help us.

But now, virtually all physicians in America take cash or gifts from the drug companies. A recent survey said 94 percent of physicians took something of value from the drug companies. Some doctors take hundreds of thousands of dollars a year from these companies, and there’s no law that says they can’t. So we’ve lost a key part of our drug safety system: the independent physician. This safeguard has disappeared.

MM: What are the ways the industry can transfer such significant sums to doctors?

Petersen: The drug companies hire thousands of physicians to be their consultants or advisors. They hire doctors to give lectures to other groups of doctors. Some doctors take money from two dozen drug companies at the same time.

I had no idea this was so extensive until one day I was writing a story about Celebrex and Vioxx — this was before Vioxx was taken off the market. The story was about the marketing battle between these two pain drugs. I called one of the large societies of rheumatologists and asked for an expert on arthritis. I specifically said I needed an expert who was not being paid as a consultant to one of the manufacturers of these drugs. A staff person said, “We have lots of people you can talk to, but all of these doctors are consultants to one or both of the drug companies.”

MM: What kind of “consulting” can so many doctors be doing?

Petersen: The drug companies will invite physicians to a dinner or a weekend retreat where they hear a lecture from another doctor. That lecture is being paid for by the drug companies. The physicians who are invited will get a nice meal, but they’ll also be paid for serving as a consultant.

I’ve read agreements that these doctors sign and it’ll often say that “For your work as a consultant, we will pay you $500 for this evening.” There’s also a confidentiality agreement. This is why so few patients understand that this is going on. The doctor signs an agreement where he agrees not to tell others what went on at this dinner.

There are more than 500,000 of these dinners or events in America every year. This is a huge part of how drug companies market their drugs.

MM: Could you say more about how the marketing push affects the science that the companies are doing?

Petersen: This is one of the most frightening things about the way drugs are marketed in America today. The drug companies have learned to use science as a marketing tool. They have a standard marketing technique that they call “publication planning.” They want to saturate the medical literature with articles about their new drug that will get doctors to prescribe it. They will hire a Madison Avenue ad agency, or a smaller marketing firm, to draft these articles. But the name of the ad firm rarely appears in the article. Instead, they hire a physician or a group of physicians to put their names on as “authors,” although these doctors may do little or none of the work.

Our medical literature has become so distorted by the industry’s influence that some scientists say it is little more than corporate propaganda. This is frightening. It means that even if you have one of the few doctors who ignore the sales reps and read medical journals to find what is best for patients, that physician is still getting little more than an advertisement.

MM: What is Neurontin?

Petersen: Neurontin is a drug for epilepsy. It’s not a very good drug for epilepsy. It was a drug that Wall Street wasn’t excited about because it really didn’t have much of a future.

Warner-Lambert, which sold Neurontin, decided they were going to change that. They decided to sell the drug for more than a dozen other medical conditions for which it wasn’t approved. They had little or no science to back the use of Neurontin for these conditions. They sold it for things like bipolar disorder, migraines, attention deficit disorder in children.

It is illegal for a drug company to sell a drug for indications that the FDA hasn’t approved. But doctors can prescribe a drug for whatever they see fit, and that’s the loophole that this company set out to exploit.

MM: Was there some basis or intuitive reason to believe that it would be helpful for these varied conditions, or did Warner-Lambert just make this stuff up?

Petersen: In some cases they had some limited research where they believed it might help. Neurontin was eventually approved to treat certain types of pain. But for some other conditions, like bipolar disorder, the company actually had studies that showed it didn’t work. That didn’t stop doctors from prescribing Neurontin to hundreds of patients suffering from that mental illness.

MM: Based largely on whistleblower efforts, you have a rich account of what the company was doing internally and how it was marketing. Ultimately, Warner-Lambert paid $430 million in a criminal and civil settlement over its off-label promotion.

Petersen: It’s really a story about a scientist, David Franklin, who went to work for a big drug company believing that he could help people get the medicines they needed. He was quickly horrified by what he found going on inside that company.

The company got doctors to prescribe the drug for all these experimental uses by paying them. They paid physicians to give speeches to other physicians at restaurants or hotels or resorts. The doctors not only enjoyed a nice meal or a weekend vacation, they often also received a $500 check for attending. The physicians giving lectures at these parties were often trained by the drug company’s ad firm to describe how Neurontin could work for conditions like bipolar. The whistleblower, David Franklin, told me that he was saddened by how many doctors seemed eager to help the company succeed with this deception. 

The company tracked the doctors’ prescriptions before and after these dinners or weekend retreats. The executives saw how well it worked.

MM: One thing that’s very striking about this story was how the deceptive marketing scheme was a central part of the company’s business model.

Petersen: The plan for selling Neurontin was actually approved by the highest level of management. I’ve looked at thousands of internal documents that became public as part of the lawsuit and you can see how top level executives were involved. They were excited by the enormous sales potential of what was really a mediocre drug for epilepsy.

MM: The pharmaceutical industry is very much on the defensive politically. Do you see meaningful reforms likely in the near future?

Petersen: The drug industry has enormous political power in Washington. The companies have been able to defeat proposed reforms again and again. Then, add the power of the American Medical Association and physicians and you can see how hard it is to get new laws to protect patients. Americans need to rise up and say they’ve had enough. They really need to start a revolution. So many people are needlessly dying because of the industry’s relentless marketing tactics.

MM: You are very critical of pharmaceutical marketing. The industry says it is providing information to consumers and doctors and that people are better off for knowing about treatments that can help them. How do you respond?

Petersen: The bottom-line point of my book is that it’s not the medicines that are the problem. Medicines can help you if you get the right drug at the right time. The problem is the marketing.

The marketing is distorting the information that we, as patients, read and understand. The marketing makes these drugs appear to be much more helpful and a lot less risky than they actually are. There really isn’t any place for marketing in medicine. Patients need honest and objective information about these products and they simply can’t get that today.

MM: Should drug companies be prohibited from advertising to patients?

Petersen: I wish we could prohibit them from advertising to patients, but I don’t think that we can. They have a First Amendment right to get their information out there. But, at the same time, they don’t have a right to hurt patients with their ads.

We should go back to the rules before 1997, when ads weren’t allowed on television. Let the drug companies publish print ads in black and white with basic, truthful information about drugs. The ads should include the price of the drug and also information on how patients could find relief through changes that do not involve taking a prescription drug. For instance, if the drug is for Type II diabetes, the ad should describe how many patients can cure themselves through diet and exercise. We need to get away from the images of people having a good time on the beach or at a party. That shouldn’t be allowed in the ads.

MM: What about drug company payments to doctors?

Petersen: We have a law in America that says radio disc jockeys can’t take cash from music companies. But when it comes to something like medicines — which mean life or death for people — doctors can take as much money as they want from the drug companies. We need a law to stop that.

MM: One of your book’s recommendations that may surprise people is a call for more autopsies. Why is there a need for more autopsies?

Petersen: We really have no idea how many people are dying from prescription drugs in America. It’s clear that most of these deaths are not being attributed to the medicines on the death certificate. One reason for that is that doctors and hospitals no longer do autopsies. The autopsy rate has fallen to less than 10 percent of all deaths in the country. Doctors are guessing at what people actually died from. If there were more autopsies, we could learn which drugs were excessively dangerous and which ones were beneficial. Doctors would stop making the same deadly mistakes.

MM: You suggest that one hidden toll of taking “Our Daily Meds” is a massive, underappreciated impact of drug-induced injury and death.

Petersen: We only have estimates of how many people are dying from prescription drugs. The study that the FDA often cites estimated that more than 100,000 Americans die every year from prescription drugs they took just as their doctor recommended. These aren’t situations where a doctor made a mistake, or a pharmacist made a mistake, or the patient accidentally took too much. This is where, supposedly, everything went right.

There’s been disaster after disaster caused by aggressively-promoted medicines. Just look at Vioxx. More than 20 million Americans took Vioxx before it was taken off the market in 2004 because it doubled the risk of heart attack or stroke. A government scientist estimated that this single drug might have led to the deaths of 40,000 Americans. This was a devastating tragedy.

Far too many physicians are ignoring the deaths caused by the prescriptions they write. It’s as if they read about cases like Vioxx, shrug their shoulders, and think, “Oh well.” They like the current profit-driven system that puts money in their pocket. They don’t want anything to change.