A prescription drug’s success is measured by the size of the population in which it is used. A common strategy for boosting sales—some call it disease mongering—is to increase the number of people who are diagnosed with the condition. Psychiatry is a prime example of a medical specialty lending its full support to the pharmaceutical industry's efforts to inflate patient rolls. One way is by encouraging undiagnosed people to seek medical treatment, urging them to “ask your doctor, if Brand X is right for you.”
Another, more lucrative tactic is to expand the drug’s indication itself. Can the drug be used effectively in more mild forms of the illness, or even in people who are merely presumed “at risk” of becoming ill? Drug manufacturers, however, are legally prohibited from promoting a medicine "off label" outside of its FDA-approved indication because medicines carry risks of harm. Doctors have the legal authority to make judgments about whether the risks of prescribing a drug for unapproved indications are justified by the benefits.
Ironically, this restricted prescribing privilege which was established to protect consumers from harmful treatments has been converted into industry’s most powerful marketing tool. Indeed, pharmaceutical companies spend at least $18.5 billion annually on influencing doctors to prescribe their products.  http://pharmamkting.blogspot.com/2006/10/free-lunch-for-physicians-newsweek.html
Today's universities also exist in a competitive commercial environment, and medical researchers who are unable to secure funding will soon find themselves looking elsewhere for work. Pharmaceutical companies, who provide a major source of funding for medical research, have succeeded in redirecting the focus of medical research to serve their business interest which is to increase sales of their products. Physicians’ interactions with drug company sales reps begin in medical school where the “free lunch,” free books, and “educational grants” establish potent bonds. Physicians whose knowledge base about medicines—their pharmacopeia “tools of the trade”—has been shaped by company sponsored promotional reports, gifts and freebies cannot render an objective opinion.
When key opinion leaders in medicine have financial interests in companies, receive “educational grants,” serve as speakers and consultants, cannot but be influenced by corporate commercial goals. A medical license obscures the commercial aspect of a treatment recommendation because the public is mostly unaware of the physician’s financial conflicts of interest. Thus, physicians with financial ties to industry pose a far greater threat to public safety than non-medical company officials. They have been shown to greatly exaggerate benefits, minimize adverse effects, and conceal life-threatening risks. 
Two cases illustrate how companies exploit physicians’ license to expand the market for their products. Today’s Wall Street Journal (below) reports how a Narcotic 'Lollipop'—Actiq—Becomes Big Seller Despite FDA Curbs. The FDA approved the drug in 1998 only for use in cancer patients. But these make up only 1% of the drug’s market.
“Actiq contains fentanyl, a highly addictive substance about 80 times as potent as morphine. Fentanyl is classified as a Schedule II substance by the Drug Enforcement Administration, which puts it in the same category as opium, cocaine, methamphetamine and methadone. Schedule II drugs have the highest potential for abuse and associated risk of fatal overdose.”
The manufacturer, Cephalon Inc., says “it doesn't market the drug for unapproved uses. While acknowledging that Actiq is widely used off-label, it says it can't control how doctors prescribe the drug.”
The WSJ reports, that “the company walks a fine line by sending its sales representatives to pitch the drug to a broad range of doctors, ranging from sports-medicine specialists to family practitioners. It gives these doctors coupons for free samples. Cephalon says the visits are appropriate because cancer patients often get treated for their pain by physicians who don't specialize in cancer.”
Actiq has been associated with 127 deaths. Two of them involved children who confused the drug for candy.
Case 2 demonstrates how physicians at prestigious universities cross medical ethical lines by exposing healthy youngsters to unjustifiable risks of debilitating, life-shortening drug effects to test a speculative, unsupportable theory. A forceful critique by Dr. Jerald Block, a psychiatrist, in the Bioethics Forum, Hastings Center Report (below), challenges the ethics of a controversial neuroleptic drug experiment published in the American Journal of Psychiatry.  [The case will be discussed in a follow up Infomail]
1. John Mack Precision Buzz Marketing, Pharma Marketing Blog, Thursday, August 17, 2006 http://www.pharmamarketingblog.com/
2. Peter Eichacker MD, Charles Natanson, MD, and Robert Danner MD. Surviving Sepsis- Practice Guidelines, Marketing Campaigns, and Eli Lilly, NEJM vol. 355 October 19, 2006 http://content.nejm.org/cgi/content/extract/355/16/1640 See also: Vioxx Redux: FDA on the Sidelines as Marketing Subsumes Evidence: Surviving Sepsis at: www.ahrp.org/cms/content/view/366/27
3.. Thomas H. McGlashan, M.D. Robert B. Zipursky, M.D. Diana Perkins, M.D. Jean Addington, Ph.D. Tandy Miller, Ph.D. Scott W. Woods, M.D. Keith A. Hawkins, Psy.D. Ralph E. Hoffman, M.D. Adrian Preda, M.D.Irvin Epstein, M.D., F.R.C.P.C. Donald Addington, M.D. Stacy Lindborg, Ph.D. Quynh Trzaskoma, M.S. Mauricio Tohen, M.D., Dr.P.H. Alan Breier, M.D. Randomized, Double-Blind Trial of Olanzapine Versus Placebo in Patients Prodromally Symptomatic for Psychosis. American Journal of Psychiatry, May 2006, vol 163:790-799.
Contact: Vera Hassner Sharav
THE WALL STREET JOURNAL
Narcotic 'Lollipop' Becomes Big Seller Despite FDA Curbs
Actiq Is Only for Cancer Pain But Cephalon Pitches It To Many Types of Doctors
'Like the Most Delicious Candy'
By JOHN CARREYROU
November 3, 2006; Page A1
While pregnant with her second child three years ago, Tiare Frontera suffered from bad migraines. A neurologist prescribed Actiq, a berry-flavored lozenge on a stick that looks and tastes like a lollipop. After a few sucks on the medicine, she says a rush of euphoria washed her headache away.
Soon, Mrs. Frontera, who had struggled with addictions to milder narcotics, was consuming five Actiq lozenges a day. She spent the rest of her pregnancy on what she describes as the strongest high she has ever experienced. When she gave birth, her baby son was cranky and wouldn't sleep. Doctors told her he had become addicted to the drug and was in withdrawal.
Mrs. Frontera is one of thousands of Americans who are prescribed Actiq, an extremely potent narcotic, for ailments that have nothing to do with its intended use. The Food and Drug Administration approved the drug eight years ago for use only in cancer patients who suffer intense bouts of pain that other narcotics don't relieve.
In the first half of this year, oncologists, or cancer doctors, accounted for only 1% of the 187,076 Actiq prescriptions filled at retail pharmacies in the U.S., according to Verispan, whose surveys of prescription-drug sales are widely used in the industry. Data gathered from a network of doctors by research firm ImpactRx between June 2005 and October 2006 suggest that more than 80% of patients who use the drug don't have cancer. Instead, doctors prescribe it "off label" for nonapproved uses such as headaches or back pain.
Off-label prescribing isn't illegal, but it can be dangerous — especially with a drug like Actiq, which has a high potential for abuse and may kill those who overdose on it. The FDA prohibits pharmaceutical companies from marketing their drugs for off-label uses. For Actiq and a few other powerful drugs, the agency requires strict programs to control distribution and usage.
MORE ON ACTIQ
• Read the full FDA risk-management program for Actiq: http://online.wsj.com/public/resources/documents/Actiq1102.pdf
Actiq's broad off-label use raises questions about whether those restrictions are sufficiently protecting patients. "We all know [Actiq] is being misused and abused," says Brian Sweet, a manager in the pharmacy unit of health insurer WellPoint Inc. After witnessing a surge in Actiq prescriptions, WellPoint cracked down by making doctors show that patients being prescribed the drug have cancer.
Actiq's maker, Cephalon <http://online.wsj.com/quotes/main.html?type=djn&symbol=CEPH> Inc., says it doesn't market the drug for unapproved uses. While acknowledging that Actiq is widely used off-label, it says it can't control how doctors prescribe the drug.
Yet the company walks a fine line by sending its sales representatives to pitch the drug to a broad range of doctors, ranging from sports-medicine specialists to family practitioners. It gives these doctors coupons for free samples. Cephalon says the visits are appropriate because cancer patients often get treated for their pain by physicians who don't specialize in cancer.
Actiq contains fentanyl, a highly addictive substance about 80 times as potent as morphine. Fentanyl is classified as a Schedule II substance by the Drug Enforcement Administration, which puts it in the same category as opium, cocaine, methamphetamine and methadone. Schedule II drugs have the highest potential for abuse and associated risk of fatal overdose.
Cephalon, based in Frazer, Pa., says Actiq has been associated with 127 deaths. Two of them involved children who confused the drug for candy. Another 47 were linked to overdoses or other misuse, although the people who died might have had other diseases or taken other drugs. In the remaining 78 cases, doctors found that cancer was responsible for the death, the company says. Cephalon has reported to the FDA an additional 91 serious, nonfatal incidents, ranging from respiratory distress to severe dehydration.
The U.S. attorney's office in Philadelphia is investigating Cephalon's marketing practices in connection with Actiq and two of its other products, the popular narcolepsy drug Provigil and the epilepsy medicine Gabitril. No charges have been filed.
Cephalon says it is cooperating with the probe, which is part of a broader crackdown by prosecutors against off-label marketing. In August, the Justice Department fined Schering-Plough Corp. $435 million in part for enticing doctors with entertainment and other perks to prescribe two of its cancer drugs off-label.
Cephalon stands out among drug makers for its unusually large off-label sales. Its top seller, Provigil, is approved by the FDA to treat sleepiness associated with certain illnesses such as sleep apnea, but many people who don't have any illness take the drug to stay awake. Analysts estimate about 80% of Provigil prescriptions are off-label. Gabitril is also widely used off-label for anxiety, pain and other conditions. Under FDA pressure, Cephalon last year curtailed its marketing of the epilepsy drug because it was causing seizures in patients without the disease, and sales dropped 23%.
Founded in 1987 by a former DuPont Co. scientist named Frank Baldino Jr., Cephalon expects revenue to exceed $1.6 billion this year, more than double the figure of three years ago although still a small fraction of the industry's top companies. Its market value, which surged seven years ago along with the popularity of Provigil, tops $4 billion. Dr. Baldino earned $2.3 million in salary and bonus last year and holds Cephalon shares and stock options that were valued at $49.6 million as of the end of last year.
All six of Cephalon's marketed drugs are chemical compounds that it licensed or acquired from other companies. Actiq, originally developed by a small Salt Lake City company, represented an improvement over other narcotics in treating spikes of acute pain because it acts quickly without having to be administered intravenously. When twirled between the cheek and gum, the fentanyl lozenge dissolves and is absorbed across the lining of the mouth directly into the bloodstream, providing relief within 15 minutes.
Actiq had sales of $15 million in 2000, when Cephalon acquired it. By last year, sales had grown to $412 million, making it Cephalon's No. 2 drug. In the first nine months of this year, sales jumped to $471 million. Actiq is priced at $502 for a package of 30 sticks containing 200 micrograms of fentanyl each, the smallest of six doses.
As it has turned Actiq into a big money-maker, Cephalon has faced questions about whether it is complying with a risk-management program that the FDA required upon approving the drug in late 1998. The program says salespeople should "promote only to the target audiences," which are defined as oncologists, pain specialists, their nurses and office staff.
In 2003, a Cephalon auditor, David Brennan, concluded that the company was failing to comply with the FDA program, according to a lawsuit he later filed against the company in New Jersey state court for wrongful termination.
An important provision of the program says Actiq's maker should report to the FDA every quarter whether "groups of physicians (such as a particular specialty)" who represent "potential off-label usage greater than 15%" are prescribing the drug. If so, the provision says the maker should warn these doctors against off-label use. Mr. Brennan's lawsuit says that means Cephalon must act if all noncancer medical specialties together account for more than 15% of prescriptions.
Cephalon interprets the provision differently. It says it only needs to act if any individual specialty exceeds 15% of the total — and then only if it can be shown that doctors in that specialty are prescribing Actiq inappropriately. Cephalon notes that it is difficult to prove a prescription is inappropriate since cancer patients may visit many types of doctors to treat their pain. It believes the 15% clause has yet to be triggered. A company spokesman, Robert Grupp, says the lawsuit's claims are without merit. The FDA declined to comment.
According to Verispan data for the first half of 2006, two specialties exceed 15% of Actiq prescriptions: anesthesiologists at 29.5% and physical medicine and rehabilitation specialists at 16%. The data show oncologists and pain specialists account for less than 3% of prescriptions. Cephalon doesn't dispute the data.
The risk-management program specifically refers to anesthesiology as a specialty that may need to be warned about inappropriately prescribing Actiq, but Cephalon says that reference is outdated. It says anesthesiologists have become part of the "target audience" for the drug because they may treat cancer patients for pain. Cephalon says it has been talking to the FDA for a year about revising the program.
After Mr. Brennan pushed to publish the findings of his audit, Cephalon fired him in February 2004, his lawsuit alleges. Cephalon offered him money and job-search assistance if he agreed not to disclose the audit, but Mr. Brennan refused, the suit says. Mr. Grupp declined to discuss Mr. Brennan's dismissal but noted that he is "a former disgruntled employee."
Mr. Brennan has been interviewed twice by investigators working for the U.S. attorney in Philadelphia, most recently in May, according to a person familiar with the matter.
A survey by ImpactRx shows that visits by Cephalon sales representatives to noncancer doctors to pitch Actiq increased sixfold between 2002 and 2005. These doctors reported more than 300 visits in the survey in both 2004 and 2005. Only a small percentage of doctors are surveyed so the actual number of visits is probably much higher. Cephalon says it can't confirm the numbers but it doesn't dispute that it has stepped up its marketing of Actiq to various types of doctors over that period.
Stephen Leighton, a general practitioner in Winston-Salem, N.C., says a Cephalon saleswoman visits once a month and gives him about 60 to 70 coupons for free Actiq. Patients can trade each coupon for six Actiq sticks. Dr. Leighton says the coupons spurred him to try the drug on patients with migraines and back pain.
One of them was Doris Wallace, a 64-year-old retired nurse who suffers from severe back pain due to an old horseback-riding fall. Ms. Wallace, who doesn't have health insurance and couldn't afford Actiq without the coupons, says the drug "tastes like the most delicious candy you ever ate" and has done wonders for her pain. At the height of her use, she was consuming 24 Actiq sticks a month.
The positive experience of patients like Ms. Wallace has led Dr. Leighton to prescribe Actiq more widely for different types of pain. Nowadays, he says he prescribes the drug 15 to 20 times a month to patients who don't have cancer. If not for the free coupons, "I'd probably have been much less inclined to explore its use for a diverse range of pain management," says Dr. Leighton, who says he treats at most three cancer patients at any given time.
Dr. Leighton says he thinks the FDA-approved usage of Actiq is too narrow. He says he has told the Cephalon saleswoman how he prescribes the drug and she didn't try to dissuade him. Mr. Grupp of Cephalon says Dr. Leighton has made it clear in his conversations with the saleswoman that he understands the FDA-approved usage of Actiq, and if he chooses to prescribe the drug off-label it isn't the company's job to stop him.
Mr. Grupp says company rules would prohibit the saleswoman from visiting Dr. Leighton only if he never prescribed the drug for cancer pain. "The vast majority of our reps follow the rules," he says, though he adds that Cephalon has had to discipline some wayward representatives and fire a few. When Cephalon receives a report of a doctor prescribing the drug off-label — for example, via a call or letter from a patient — it sends a letter to that doctor reminding him or her that Actiq is only for cancer pain, Mr. Grupp says. The company has sent more than 3,300 such letters, he says.
Earlier this year, Dr. Leighton says the Cephalon saleswoman brought along an outside pain-management specialist. Over lunch, Dr. Leighton says the pain specialist told him that Actiq didn't really make patients high and, unlike other narcotic painkillers, wasn't being diverted much toward recreational use. Cephalon declined to comment on the conversation.
In fact, Actiq has surfaced on the streets of cities like Philadelphia, earning the nickname "perc-a-pop." Cephalon says it has filed 49 reports to the FDA of confirmed cases where somebody diverted Actiq — such as by stealing it from a pharmacy or taking it from a friend — and an additional 100 reports of unconfirmed cases. Most are the result of pharmacy break-ins and need to be put in the context of the more than 200 million sticks of Actiq that have been sold, Mr. Grupp says.
Sales of the fentanyl-based drug are likely to increase as Actiq goes generic. In late September, Barr Pharmaceuticals <http://online.wsj.com/quotes/main.html?type=djn&symbol=brl> Inc. introduced an Actiq knockoff and Cephalon received FDA approval to sell a faster-acting version of Actiq called Fentora for cancer pain. Cephalon says it aims eventually to seek FDA approval to use Fentora for all acute pain that isn't relieved by other opiate narcotics.
Mrs. Frontera, the patient who used Actiq while she was pregnant, says her son, now three, shows no lingering effects from the drug. Mrs. Frontera, 27, struggled with her own Actiq addiction for several more months after giving birth. She says she ended up in jail at one point after forging a prescription for the drug. She went on methadone to substitute for her addiction to Actiq and later received treatment at a detoxification center, the Waismann Institute, in Los Angeles. Now she lives in San Luis Obispo, Calif.
"It makes me angry that it was prescribed to me," she says of Actiq. "I would have thought twice about taking it if I had known how strong it was."
Philip Delio, the neurologist who prescribed Actiq to Mrs. Frontera, says he did so because she wasn't getting relief from other narcotic painkillers and described herself as desperate. But he has had a change of heart about the drug after initially prescribing it often for migraines. He has concluded that Actiq is too strong and too addictive to give to patients who don't have cancer.
Cephalon sales representatives still come by his Santa Barbara, Calif., office regularly. But Dr. Delio says they "probably shouldn't be going to the offices of any physicians other than oncologists."
Write to John Carreyrou at firstname.lastname@example.org
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