Moderated Web Chat: Washingtonpost.com

Books: Selling Sickness
Alan Cassels
Author
Wednesday, September 21, 2005; 12:00 PM
In the new book, "Selling Sickness: Pharmaceutical Companies Are Turning Us All Into Patients," authors Ray Moynihan and Alan Cassels explore the aggressive marketing campaigns used by large drug companies and how more and more healthy people are turning into patients.

Cassels, a pharmaceutical policy researcher at the University of Victoria, British Columbia studying how clinical research information and experience on prescription drugs is communicated, will be online Wednesday, Sept. 21 at Noon ET to discuss his book.

Washington, D.C.: I think that one of the biggest problems with drug companies is the excessive (and often misleading) advertising with a laundry list of common symptoms and a convincing pitch for an expensive drug. Do you think these ads should be regulated? I think this is part of what is causing the over-medication of many people and spiraling health care costs.

Alan Cassels: They are regulated. Some would argue they aren't regulated well enough. I agree that this is leading to over-medication.
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Gaithersburg, Md.: Do you think that the "disease" idiopathic short stature was invented in order to sell genetically engineered human growth hormone?
Alan Cassels: Good question which I don't know the answer to. But I will tell you this, if you are trying to sell a treatment for short kid-syndrome, or whatever it's called now, you've got an incredible challenge convincing the parents that their kid is sick and needs a pill. This won't be easy and I imagine many parents wouldn't fall for it. That is not to say some kids won't benefit from a treatment--some will. But does that mean every kid not reaching a certain height by a certain age is sick and needs treatment?
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Bethesda, Md.: Do drug companies have any kind of industry ethical standards when it comes to advertising their drugs aside from whatever Federal regulations they're bound to?
Alan Cassels: yes they do. But like any industry if those standards are not enforced then they can be conveniently ignored, without penalty. What bothers me is not the advertising of the drug, but rather the advertising of the disease, which has no standards at all (ie: companies standing to gain from your disease being treated with your drug can exaggerate the heck out of the disease. That's what Selling Sickness is about).
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Arlington, Va.: Mr. Cassels,
Do you think that pharmaceutical companies are focused more on treating illnesses, more profitable, rather than curing them. For years I have heard debates on the subject and I was wondering what your opinion is.
Alan Cassels: In their own words it's more profitable to make drugs for chronic, long term illnesses that have no 'cure' per se. I'd like to see even a small portion of that money keeping people on drugs for such a long time, towards real 'cures' in the classic sense. What we see happening with diabetes is a classic example where long term maintenance therapy is a lot more profitable than a 'cure'.
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Harrisburg, Pa.: Do we need all these medications? I keep seeing an ad for curing a yellow toenail and then the side effects are mentioned. If I had the side effects, I would rather take medication to get rid of them with a yellow toenail being the side effect. Isn't advertising just creating new things to be fearful of that probably aren't urgent needs for medication?
Alan Cassels: there are more than 20,000 drugs on the market in the US. The World Health Organization keeps a list of "Essential drugs" that any nation needs to provide to its people. Guess how many drugs are on the WHO Essential Drugs List? 306.
As for the toenail thing, my mother took that drug and when I explained the rare but serious side effects she still chose to take it. At the end of the day people need to be fully informed as to a drug's risks and benefits and when they have that information, whether or not they take the drug is up to them.
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Dayton, Ohio: There was another chat a few weeks ago that's the corollary to this, about anxiety. So many people are searching for a magic bullet that can make them live forever: whether they turn to pharmaceuticals, fad diets, or 'alternative medicine', it's all the same thing. I'm not going to blame the manufacturers too much for seeking to capitalize on demand. I will criticize them for taking prescription medications and lobbying to get them over-the-counter.
Alan Cassels: OTC (over the counter) changes to drug is very complicated. Some might say, why not put a drug over the counter because it is relatively 'safe'? Others say, that a doctor should be mediating your drug treatment. I don't know where I stand.
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Arlington, Va.: Alan:
Thanks for the discussion and taking my question.
Initially, switching costs from inpatient hospital stays to pharmaceuticals seemed like a surefire way to reduce healthcare spending. Now, it looks like pharmaceutical costs are a major component of health care inflation. Do we need more federally funded studies, like the one released the other day on anti-psychotic drugs, to determine which drugs are wasting money and which drugs are medically effective? If so, what part of the federal government would be most adept at administering the studies?
Alan Cassels: Yes, and we have such federally funded studies. Some of which I work on as well. I know the US government is very interested in funding 'effectiveness' studies. I think it is the AHRQ--the Agency for Research and Quality that is administering such studies and in my opinion, this is a very good use of tax dollars.
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Anonymous: My impression of the drug business is that it's very hard to be a critic (I'll admit pharma's no different from anything else in this way). Should the government do more to encourage "robust discussions" of drug risks and benefits, etc...?
Thanks.
Alan Cassels: It's hard to be a critic because there are so few of us. Many of those who could stand to be critical of pharma's practices work within the companies, on studies funded by pharma, and so on. They are probably critical in their own, but non-public ways. One thing I will say, because public criticism is often so muted, whenever someone does say something very harsh against the industry, it attracts a lot of attention. Witness David Graham who wanted to blow the whistle on Vioxx but was stifled by his FDA bosses. Yes we need more 'robust' discussions of the properties of drugs, but also properties of diseases...
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Arlington, Va.: I think I take a more active role in my healthcare due to drug marketing -- I ask my doctor more questions about options. Or is that what the pharmaceutical companies want me to think?
Alan Cassels: Good point. Maybe one of the side effects of drug marketing is that it forces thoughtful people to question their options. I do know, however that in research done on direct-to-consumer advertising (BTCA) of pharmaceuticals, people more exposed to such ads will go and ask for those drugs, by name. And they are more likely to get them, even when their physician thinks that the advertised drug may not be the best choice of treatment. By the way, DTCA is only allowed in two industrialized countries in the world--the US and New Zealand. Every other country has regulated against DTCA because fears that it is not in the public interest to be advertising drugs that your doctor has to mediate.
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Arlington, Va.: It's easy for drug companies to maximize profits with commercials that play to consumers fears (fear of balding or bedroom performance issues) instead of playing to consumer’s health. The public then gobbles up their pills in order to remain sexy instead of healthy. Meanwhile, real research and funds are not being devoted to meds that will help folks with real long-term health issues. My wife, who has Lupus, is taking medication designed for rheumatoid arthritis. And these drugs have not been improved upon in 40 years. Quite a disparity I would say.
Alan Cassels: agree, those rarer diseases that aren't a real big market for manufacturers get short shrift when pharmaceutical research money is being doled out. What you say about Lupus could be applied to many other 'orphan' diseases. Pity. On the bright side, for even very minor minor complaints, let's say "Sleep disturbances" which are shaping up to be a market of gargantuan proportions--there's tons of drugs you could take to help you sleep. Pharma would argue it's all about consumer choice.
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Fairfax, Va.: What role does the media play in this? How have mainstream media advertising guidelines changed in this area?
Alan Cassels: Both Ray Moynihan and myself have published in peer reviewed journals (he in the New England journal in 2000 and I in the Canadian Medical Associaion Journal in 2003) on this very topic. We analyzed the media's reporting of drugs in Canada and the US and found some very surprising things, particularly the use of misleading statistics, the lack of coverage of adverse effects or side effects, and the lack of exposure of potential conflicts of interest. As for mainstream media advertising guidelines changing, I don't know. What I can say is that the quality of news coverage of pharmaceuticals is improving because journalists are becoming a bit more savvy on how they are being manipulated.
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Washington, D.C.: How often do pharmaceutical companies fund disease advocacy groups? Are there any guidelines for focusing their marketing dollars to traditional advertising?
Alan Cassels: How often? the question you need to ask is how often do disease advocacy groups REFUSE funding from pharma companies? The answer to that is "almost never". If you have a disease and want to be out there you need money. And if a manufacturer asks to 'partner' with you and wants to hand over a few hundred thousand, that would surely capture your attention. Having said that there are some very good advocacy groups in the US that are pharma-free, and they provide an incredible public service.
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Re: critics: I'm writing to follow up on my comment about critics. Something that clued me into this was Marcia Angell's critical book "The Truth about the Drug Companies," which was very good. I don't think there was a single endorsement on the cover, despite her being the former editor of the New England Journal of Medicine. My conclusion was that everyone is bought off or scared within the industry.
Why can't someone who has some relationship with the industry still be critical in a public way?
Alan Cassels: there are some critics within pharma. Look at Dr. Peter Rost, an executive with Pfizer. He has gone very public about the industry's appalling defence of high drug prices and restriction of free trade in pharmaceuticals. But you raise a very good question: why can't people with a relationship to industry be critical? it takes good old fashioned courage to challenge the very industry that may be providing you with a job. In our book you will meet Dr. Michael Oldani, a former drug rep who became an anthropologist, studying the gifting cycle of drug reps and doctors. His thesis is that you can only be really critical once you have severed your ties to the industry.
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Rockville, Md.: Can you give any historical perspective to this kind of marketing? have they always been this aggressive or was there something in the industry that changed opening the floodgates?
Alan Cassels: Hmmm, there has always been people and companies selling snake oil, with various levels of aggressive tactics and so on. What has contributed to the presence of the current marketing tsunami, in other words, the "perfect storm" has been media concentration (less critical voices on our airwaves), pharma success (billions of new dollars to fund new ways to turn you into a patient plus a pathological need to provide blockbuster profits for investors) and cultural acceptance (at one level we WANT a pill for every ill, and seek instant gratification and immediate solutions to our health problems). What has changed? Primarily the volume and tempo of the marketing.
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Washington, D.C.: The debate over hormone replacement therapy seems to be a great example of this. Clearly there are women with extreme symptoms of menopause who are helped by HRT, but that's not the way it's marketed. For a long time it was a "birthday drug" -- you reached a certain age and your doctor automatically prescribed it, whether you had bad symptoms or not.
I am glad to see that there is more discussion now of the risks vs. the benefits, but I still think that the pharmaceutical companies have made sure that every woman over 50 is inherently diseased.
Alan Cassels: We have a whole chapter devoted to the marketing of menopause in our book. It was a mark of marketing brilliance to redefine every woman who lives long enough as "estrogen deficient". Watch what is happening to men now. We are growing "testosterone deficient" as we age, and luckily there is pharmaceutical treatment to help us...
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Alexandria, VA: Part of the problem is how commercials are regulated. From my understanding, as long as an advertisement does not specifically mention what the drug does, they do not have to mention any side effects. Consequently, drug companies can dress up their commercials to look as appealing as possible without ever mentioning what their product does. Am I correct about this regulation?
Alan Cassels: Absolutely correct. I know anecdotally that a lot of people, even very intelligent and educated people, are very confused by drug ads that don't mention what the drug does. Perhaps that too is marketing brilliance: you'll be driven by your innate curiousity to find out, and in the course of your search you may start down the road to becoming a patient...
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New York City: I think the strongest validation for Selling Sickness is the announcement this week, that the most profitable class of drugs in America, the atypical antipsychotics, are no more effective than the old cheap drugs that psychiatry had disowned because of their side effects.
Isn't it appalling that antipsychotics are racking in $10 billion in sales annually --even though they are, at best, ineffective--at worst cause potentially fatal metabolic abnormalities--such as, diabetes and cardiac arrest?
Alan Cassels: I agree. We've been studying the anti-psychotics for some time now and what is amazing is how frequently they get used in long term care facilities (ie: old folks homes). The statistics, quite frankly, are appalling. These drugs are effectively sedating our grandparents so that maybe the facility can save on not having more nurses and so on looking after them. I think more and more we are spending on expensive drugs and seeing no net benefit, and furthermore as you mention, actually buying more illness.
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Alan Cassels: These have been very interesting questions and I am glad I got asked to participate. I would say in closing that asking questions is about the best thing you can do to keep yourself healthy. Our book gives a list of suggested places you can go for 'evidence-based' information about diseases and drugs and suggests the kinds of questions you need to be asking your doctor before you accept a diagnosis and a drug. So I wish the best of "Healthy Skepticism" to all the participants today.
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