A former pharma rep explains how the industry pushes doctors to overprescribe

The pharma industry spends $2 on marketing for every $1 it spends on R&D: Shahram Ahari was a rep for Eli Lilly, so he knows how the money was spent: in a tell-all op-ed in the Washington Post, Ahari describes how he lavished spending over doctors, everything from dinners at "so many fancy Manhattan restaurants that the maitre d's greeted me by name" to free ballgames and Broadway musical tickets to offering hundreds of thousands of dollars in speaking fees to top prescribers.

What's more, Ahari was able to access expensively assembled prescribing data — purchased from pharmacies across the country — to both identify doctors with a lot of chronic pain patients (or those who were "freer with their prescription pads") and to give him ammo for "guilt tripping" doctors who had taken freebies from him but hadn't rewarded him by writing a ton of prescriptions for his employers' drugs.

In the years since Ahari left the industry (he's an MD now), it has adopted modest restrictions on how its reps deal with doctors, but as Ahari points out, any amount of freebies (or even plain sales calls) leads to increased prescribing. In part, that's down to the powerful arsenal of manipulation techniques that the salesforce is schooled in, including flat-out lying about the research on their products' efficacy and safety (this was endemic among opioid marketers like the Sackler family's Purdue Pharma, makers of Oxycontin).

An unspoken bedrock principle guided my actions when I was in the pharmaceutical industry: It was not enough to grow our market share — we had to grow the market, too. This dynamic played out during the early 2000s, when the American Pain Society and the Joint Commission started calling pain the "fifth vital sign." Such organizations, whose boards included doctors who received consulting fees and honoraria from opioid-makers, circulated teaching materials designed by drug companies. Medical students and doctors didn't just learn how to assess and pay attention to patients' pain — they also internalized the idea that prescribing opioids was a professional, even an ethical, obligation. Exaggerating the clinical significance of pain drastically expanded the market for opioids, bringing them to populations with a high risk for addiction, like adolescents. From 2005 to 2015, nearly 15 percent of teens and young adults who went to the emergency room received an opioid prescription, according to a study in the journal Pediatrics. The prescribing rate was 38 percent for ankle fractures; for dental issues, the rate was 60 percent.

Physicians and sales reps are locked in a double delusion. When I was a drug rep, I really believed my pitch for our products — and I believed that by exerting influence over doctors, I helped patients access medicine they needed. As a doctor, I now have colleagues — colleagues with sharp, clinically trained minds and only the best of intentions — who think they write prescriptions on a wholly rational basis.

They don't know what I know: that people are paid six figures and armed with fat expense accounts to make them feel confident that they're acting without bias. In the case of opioids, this delusion has exacted a terrible human cost.

Perspective | I was a drug rep. I know how pharma companies pushed opioids. [Shahram Ahari/Washington Post]

(via Naked Capitalism)