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How A Black-And-White View Of Pharma Companies Blinds Us To Real Problems

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Larry Husten, cardiology journalist extraordinaire, takes issue with my criticisms yesterday about the black-and-white view many people take of pharmaceutical industry conflicts of interest. He writes that the pen is mightier than the scold (me):

For many people, small things like pens or meals are a litmus test: if you’re against them then you’re an acidic pharmascold, wasting your time on the most trivial of matters; if you’re ok with them then you’re a base defender of industry.

Well, yes, and that's exactly the problem, because it really is never that simple. Part of my point is that we've been relatively impotent when it comes to dealing with pharma's marketing behavior: we got rid of the pens, but not so much the television advertisements for Pfizer's Viagra or Amgen's Enbrel or the big payments to doctors at the top of the food chain.

My other worry here is that an oversimplified view of how financial conflicts affect medicine leads people to miss the point. One problem is that a view of a demonic industry that is simply paying off doctors and cannot be trusted, and thereby leads people to avoid good products like vaccines (see yesterday's post about Merck and GlaxoSmithkline's rotavirus vaccines cutting the death rate from diarrhea in Mexico by half) and cheap, generic statins that have been proved to prevent second heart attacks.

It's better to have more disclosure of pharmaceutical payments than not, partly because industry itself has been so short-sighted that there seems no other solution. But I think we need to recognize that making payments to doctors a matter of public record is, as I said before, an Orwellian solution. I think it might be a better world if everybody's salaries were out in the open, but we don't live in that world. This is removing a layer of privacy for the doctors in question. It also seems intended to shame physicians into not having associations with pharma. The assumption is that making the disclosures public will result in fewer payments, or at least less influence for the speakers. And indeed, a some big academic centers now limit how much speaking people do for industry.

Shame isn't the only possible result, though. I recently had a great talk with Jaideep Baijaj, the very thoughtful Managing Director of ZS Associates, which consults with the drug industry on sales practices. And he said that he thinks that in some cases, when companies see that a competitor is paying a particular doctor a great deal, they may feel a need to ante up too. Think about it: if that's why your sales representatives aren't getting access to Dr. X, might he be worth the money?

There's a real danger here of creating a smaller class of physicians who are paid more by industry, without the natural checks and balances that big name clinical trialists and university doctors always had. Last year, John Fauber of the Milwaukee Journal Sentinel did a wonderful piece showing that when GlaxoSmithKline wanted to find a doctor to talk about its fish oil pill Lovaza -- a lucrative gig worth $15,000 a month -- it went to a primary care doctor, not a heavyweight academic.

The big name doctor at least had the consequence that if he went too far and seemed totally in the pocket of industry, he'd lose the very credibility that made it worthwhile to pony up for his talks in the first place. (I have to say, I've never seen a drug company realize that a doctor was useless because he'd gone native. But if they did, they'd be better marketers for it.)

And then there's the problem that viewing medicines through the lens of conflict of interest is often easier than understanding their actual risks and benefits, and obliterates nuance. When a panel of FDA advisers voted  in 2005 that the heart-attack-causing arthritis pill Vioxx should be returned to the market, one interpretation was that industry ties had led some of them to favor the position of Merck, Vioxx's maker. Another, which I think is more important, is that the rheumatologists on the panel wanted to keep an option for treating arthritis.

There is absolutely no denying that a culture that allowed close financial ties between doctors and drug companies resulted in some horrible instances of over-marketing. Pfizer's marketing of Bextra, a Vioxx-like drug that seemed to increase heart risk in a clinical study, is one example that springs to mind. Another was the marketing of Natrecor, a Johnson & Johnson heart failure drug to patients who were not like those in clinical trials. When a large clinical trial was finally done, the drug turned out to have no big risks, but no real benefits either.

Then we have the rampant overuse of drugs like Vioxx, antidepressants, and antipsychotics -- although we can't blame as much of this on drug companies as people like to think. Xanax, long off-patent, is still the most popular psychiatric drug. Sometimes I think people like to beat up on drug companies for fulfilling medical wants and needs that make them uncomfortable.

I don't like seeing huge payments have any effect on what medicines people get. But I think as we look for fixes, we should think about what it is we're trying to fix. We have done a good job of cracking down on off-label use of many medicines, and on limiting the overselling of new drugs. But as we move from the old suystem to a new one, I worry that we're doing so with our eyes closed and our blinders on.