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Book Review   |    
Danny Carlat
Psychiatric Services 2009; doi: 10.1176/appi.ps.60.3.409
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by Melody Petersen; New York, Farrar, Straus and Giroux, 2008, 448 pages, $26 hardcover, $16 softcover

Dr. Carlat is assistant clinical professor of psychiatry at Tufts University School of Medicine, Boston.

The book Our Daily Meds, by New York Times reporter Melody Petersen, is the latest addition to a growing body of literature on the deceptive marketing techniques of the pharmaceutical industry. Unfortunately there is more than enough material to fill this book and many others, including Jerome P. Kassirer's On the Take, Marcia Angell's The Truth About the Drug Companies, and Alison Bass's Side Effects. Bad behavior in the drug industry has become low-hanging fruit indeed.

Part 1, titled Rx Republic, argues that drug companies have turned America into a medication nation by either creating new diseases or exaggerating the dangers of established disorders. Part 2, or The Rise of the Medicine Merchants, is about the history of pharmaceutical marketing techniques, culminating in a magnificent chapter called "Neurontin for Everything." Finally, part 3 details the dangers of side effects of modern medications.

My advice to you is this: buy the book, but skip parts 1 and 3, both of which pander to an excessively antimedicine mentality. Buy the book to read part 2, and you will learn how and why the pharmaceutical industry has dug itself into an ethical hole and how it has dragged too many physicians along with it. Psychiatrists will find the chapter on the off-label marketing of Neurontin fascinating in the horrifying way that watching a disaster is fascinating. Here, Petersen profiles David Franklin, a doctoral-level biochemist who worked as a medical liaison for Parke-Davis before blowing the whistle on the company's illegal practices.

Neurontin was originally approved for epilepsy, but the data on seizure control was so weak that the Food and Drug Administration (FDA) approved it for adjunctive use only. Because this limited indication was unlikely to lead to many sales, executives created a plan to market it for disorders such as neuropathic pain, migraine headaches, bipolar disorder, and attention-deficit hyperactivity disorder. The evidence for efficacy was poor, consisting of anecdotes or small open-label studies. Aside from its use in neuropathic pain, for which it eventually won an indication, whenever Neurontin was tested in a double-blind trial, it generally did no better than placebo.

But Franklin was instructed by his managers to sell the drugs for these indications anyway. At one meeting, for example, John Ford, a senior executive, exhorted Franklin and other representatives to pitch Neurontin to doctors for a long list of disorders, none of them adequately researched. "That's where we need to be, holding their hand and whispering in their ear," the book quotes Ford as saying; "Neurontin for pain, Neurontin for monotherapy, Neurontin for bipolar, Neurontin for everything." Ford went further, encouraging his sales representatives to get doctors to ramp the dosage up higher than the FDA's recommended maximum of 1,800 mg per day: "I don't want to hear that safety crap either," he said. "Have you tried Neurontin? Every one of you should take one just to see there is nothing. It's a great drug."

The book details other damning facts about the off-label Neurontin campaign: pharmaceutical representatives were explicitly instructed to not leave a paper trail: "Anything you write down can be audited. So don't write anything down," they were told by executives concerned about future lawsuits. The company mined prescription data to reward high prescribers with free trips, dinners, or cash. The company also hired marketing firms to ghost-write articles pushing Neurontin; physicians were paid $1,000 for no work other than granting their permission to be listed as authors. One memo from the marketing firm to Parke-Davis read, "Draft completed. We just need an author." In one case, a marketing company mistakenly hired doctors who refused to use the company's slides. To ensure that their talk to physicians at a meeting stayed "on message," the firm seeded the audience with employees who were assigned questions to ask that would highlight putative benefits of the drug. The company paid doctors to allow representatives to read patients' records and to shadow doctors during visits. In some cases, representatives convinced doctors to prescribe Neurontin for off-label uses during these so-called preceptorships.

Franklin, disgusted by the practices, quit Parke-Davis after four months and sued it for illegal marketing practices. Eventually, the company agreed to pay $430 million to resolve the allegations.

The power of this material is in the steady accumulation of detail, leaving the reader awe-struck by the enormity of the deceptions perpetrated by Parke-Davis.

When writing about disease mongering in part 1, however, Petersen veers into sketchy territory. In order to prove her point that we are an overprescribed nation, she presents a series of statistical comparisons intended to impress—but they rarely do. For example, she reports that Americans spent more on prescription drugs in 2004 than they did on gasoline or fast food. Petersen sees this as a glaring indictment of our obsession with pills; I see it as evidence that we have our priorities straight. We are evidently more concerned with our health than with eating Big Macs and driving cars.

Beyond this, Petersen sometimes exhibits a kind of medical Puritanism. We take too many pills, she argues, because we have gullibly bought the drug company line that we should treat what she would consider minor problems, such as "baldness, low sex drive, and menopause, all once considered a normal part of aging." Turning to psychiatry, she laments that "we now have clinical names and treatment guidelines for unhappiness, loneliness, and shyness, as if it were no longer okay to feel the emotions that make a life."

I suppose the severity of such problems is in the eye of the beholder. At 47 years old, I admit to suffering from a gradually expanding doughnut on the top of my head. Minoxidil and Propecia are beginning to sound pretty tempting. If I choose to ask my doctor for a prescription, does this make me a victim of a drug company's slick marketing, as Petersen implies, or am I simply making a personal choice—taking advantage of an effective nostrum?

Petersen begins the book by ridiculing the marketing of Detrol, a medication for urinary incontinence. She shows how Pharmacia, the drug's maker, "created a disease" called overactive bladder. The marketing department came up with terms such as "toilet mapping" and "defensive voiding" to describe the behaviors of patients with this newly named ailment. For Petersen, this is manipulative marketing. To be sure, overactive bladder is hardly a life-threatening disease, but for those who experience it, having to map out the location of toilets to prevent incontinence must be annoying. If Detrol makes their lives even a little bit better, why shouldn't they take it?

Petersen's answer to such questions is expanded in part 3, where she argues that medications can cause dangerous side effects. Although this is certainly true, it is also true that physicians are supposed to inform patients of these dangers. Arguing that this system is not working, she cites the alarming statistic that "on a daily basis, prescription pills are estimated to kill more than 270 Americans." But the source is a 1998 study in the Journal of the American Medical Association of patients hospitalized primarily in tertiary care university hospitals. Most of these adverse events occurred among very ill patients who were given drugs of high toxicity, such as warfarin, in order to prolong life. Using this figure in the context of a discussion of drugs used for minor conditions seems alarmist and misleading.

To sum up, part 2 of Our Daily Meds provides 137 pages of the most eye-opening descriptions of despicable drug-marketing practices I have ever read. Its faults notwithstanding, the book is worth buying for this extraordinary material alone.

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