Most Americans think of doctors as healers, not salespeople. When patients visit a doctor, a reasonable expectation exists that the physician acts in an unbiased manner as to the diagnosis of signs and symptoms and the treatments prescribed. Patients tend to think of the doctor like a scientist dispassionately evaluating data or as a detective following the clues wherever they may lead. The scientist seeks only understanding. The detective seeks only the truth. Likewise, we expect our doctors to seek only the cure.
Enter the influence of big pharma, and this image of the good doctor in the white coat becomes tainted with the cloak of greed for financial gain. Many patients remain unaware that doctors are provided with financial incentives by drug makers. These incentives often occur under the table. Prescribing a certain medication becomes to the doctor’s financial benefit, or to the benefit of the practice, hospital, or clinic that employs him.
Doctors, like most of us, either work for ourselves or have a boss. When their boss sets an expectation to prescribe certain drugs, doctors are beholden to follow. When doctors work for themselves, they have more of a choice. They can prescribe according to what they judge is the patient’s benefit or blur the lines between the patient’s benefit and their pocketbook’s benefit; however, even if a doctor tries to prescribe ethically, the pharmaceutical sales system still works overtime to push doctors to prescribe certain drugs. This pushing has nothing to do with patient outcomes and everything to do with profits.
Big pharma runs promotional campaigns, advertising campaigns, and sales campaigns that serve to increase the sales of certain pills. Pharma invests money in either developing or purchasing the rights to sell a drug. They have sales goals that must be met to make these investments pay off. They also have pressure to increase profits to satisfy boards and investors. This system has resulted in many familiar scandals, such as the EpiPen scandal. Obviously, big profits were placed ahead of patient outcomes.
Price gouging is just one of the problems that besets the pharmaceutical sales system. Others include big pharma misleading doctors about certain drug’s efficacy and doctors being paid to prescribe or promote certain drugs. The case of doctors being paid to promote drugs is particularly troublesome because it puts them in the position of endorsing a drug for money. Most patients don’t like to think that doctors act like celebrities paid to extol the benefits of a product in an infomercial. Unfortunately, a recent investigation by CNN shows this is exactly what is happening.
CNN revealed that California-based drug maker Avanir Pharmaceuticals paid 500 doctors to endorse and promote its drug Nuedexta between 2013 and 2016. During this time period, Nuedexta paid doctors over $14 million for consulting and public speaking efforts to promote Nuedexta. Michael Santoro, a Santa Clara University professor and expert on pharmaceutical industry ethics, called the Avanir program a scheme and sees doctors were “basically being signed up as a sales force.”
Santoro also noted that Avanir signed up doctors who had shady histories. Some of these doctors have been in trouble with medical ethics boards and been placed under federal investigation for drug and prescription-based crimes. Three of the doctors in Avanir’s Nuedexta promotional program have even been convicted of illegal prescribing.
Avanir claims it uses a rigorous screening process for doctors and pharmacists that it accepts into its program. Despite Avanir’s assertion, CNN reported that doctors in its Nuedexta program had verifiable disciplinary and criminal records for misconduct involving prescriptions. One such Doctor, Michael Friedman, a Florida psychiatrist, was charged with felony grand theft for Medicare and Medicaid fraud totaling over $1 million. His license was suspended as a result. His license has since been reinstated, and he signed up for the Nuedexta program. Between 2013 and 2016, Avanir paid him $200,000 for speaking in promotion of Nuedexta.
In further investigation of the Nuedexta program, Fierce Healthcare notes that Neudexta is indicated for the treatment of just one rare disorder, Pseudobulbar affect(PBA). Though the condition is very rare and only occurs in conjunction with certain neurological disorders, sales of Nuedexta jumped 400 percent in four years to $400 million in 2016. The CNN investigation shows that some of this sales increase was due to heavy prescribing by doctors who had accepted payment from Avanir.
The Mayo Clinic describes Pseudobulbar affect as a condition where the patient experiences prolonged bouts of crying or laughing that has no relation to the patient’s emotional state. A PBA patient may break out crying for no reason or laugh when they actually do not find anything funny. PBA also causes extreme laughing and crying in response to mild events. For example, someone afflicted with PBA may laugh uncontrollably for minutes after hearing a mildly amusing comment. PSA often occurs as part of a broader neurological issues. Common comorbidities include PBA and Amyotrophic Lateral Sclerosis (ALS), Parkinson’s disease, Alzheimer’s, and stroke.
Doctors usually diagnose PBA in an informal manner during a neurological examination. Drug therapy is used to manage PBA symptoms. Currently, the two prescription options at doctor’s disposal are antidepressants and Nuedexta.
Though PBA patients may have no symptoms of depression, the antidepressant drugs are proven to reduce symptoms when taken at doses lower than those given to patients with clinical depression. Both tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) have proven effective.
Nuedexta became available in 2010. It was approved by the FDA for treating PBA after a clinical study of PBA patients with comorbid MS and ALS showed a 50 percent decrease in the frequency of laughing and crying outbursts versus those given a placebo. Mayo Clinic notes that a doctor can help choose the best medication and must take into account other medications the patient takes.
Conditions like PBA are serious, life-altering conditions. Americans have the right to expect their doctor to have the correct information about any drug they prescribe and have no financial incentive for favoring one drug over another. When big pharma companies pay doctors large sums to promote a profitable drug, doctors do not always receive the correct information and unethical actors can push prescriptions for financial gain.