--> As much as we hate to admit it, the pharmaceutical sales representatives who come to our offices daily control much of what we learn in regard to new treatments. And I have yet to see a pharmaceutical sales rep show me a study on CoQlO and its effects on cardiomyopathy. There simply is no money in it.
Emma's Story
Emma is a delightful patient of mine in her early eighties. About four years ago, her cardiologist diagnosed her with cardiomyopathy. An ejection fraction of 20 percent severely limited Emma's life. |
 Big Pharma's monopoly over pharmaceutical sales and allow U.S. consumers, cities, states and businesses to purchase their pharmaceuticals from safety-certified pharmacies located in Canada, Japan, the U.K. and other nations.
Americans currently pay the highest prices in the world for prescription drugs. Canadians, Europeans, and even citizens of Mexico pay only about one-half to as little as one-tenth the price paid by Americans for the very same chemicals. Drug companies actually import many of the raw materials used in pharmaceuticals from other countries, meaning that some U.S. |
| High priced, focused pharmaceutical sales reps are in place to accomplish the task. Though many of these "salesmen" have no formal medical or pharmacological training, they provide to doctors the answers and the training regarding their companies' products. If a doctor is enterprising enough to "research" the pros and cons of any drug pushed at him by a pharmaceutical rep, he can find supporting information in most medical journals. |
| Pharmaceutical sales representatives are profit-driven, as are the corporations that drive them. The more doctors who can be convinced to switch from proven drugs to the current "latest and greatest," the more the greed factor is satisfied. As a Type 1 diabetic, I was forced into a position of compromising my health to satisfy Lilly's corporate greed.
When rDNA human insulin was developed, my (former) doctor told me it was the best protocol and recommended that I switch. In my pursuit of a Ph.D., I had sat in many of the same classrooms as my doctor, but because he was an M.D. |
 In it, coauthor Shahram Ahari—a former pharmaceutical sales rep for Eli Lilly—wrote: "It's my job to figure out what a physician's price is. For some it's dinner at the finest restaurants, for others it's enough convincing data to let them prescribe confidently, and for others it's my attention and friendship ... but at the most basic level, everything is for sale and everything is an exchange."
High prescribers are identified from the Physician Masterfile database maintained by the American Medical Association, which pharmaceutical companies license for their own use. |
 Physicians learn about the latest treatments for Alzheimer's and Parkinson's from the pharmaceutical sales representatives, but they have not been trained to recognize when an affliction is actually caused by medicines.
No one knows how many patients suffering from such drug-induced disorders die every year without knowing it was their medicines that caused their mental or physical decline. Any one of these cases is a tragedy because the symptoms will often subside—memories will return and tremors will ease—if the patient stops taking the offending drug. |
| At the annual educational conference for the Iowa Academy of Family Physicians in the summer of 2005, pharmaceutical sales representatives seemed almost as numerous as doctors. At a time when many Iowans struggled to pay medical bills and families wondered how they would afford the fast-rising tuitions at public universities, the state's doctors were enjoying low-cost, corporate-subsidized education in four-star accommodations. |
| She slept peacefully even though the pharmaceutical sales representative had set her down next to the ham sandwiches and cans of pop chilling on ice. The angelic woman, a model featured in a large poster advertising the sleeping pill Ambien, served as a suggestive centerpiece as twenty Iowa women filed by the table to pick up their free lunches. The women chatted about the sudden bout of hot, humid June weather before settling into their seats to listen to the drug saleswoman tell them how they too could fall into blissful slumber. |
| They found they could significantly boost their bank accounts and upgrade their lifestyles by winning favor with a pharmaceutical sales representative and joining a company's payroll as a speaker, consultant, researcher, or adviser or by serving in all these functions at the same time.
The doctors most in demand could boost their incomes by hundreds of thousands of dollars a year. Dr. |
| It was more likely that these towns were in the territory of a particularly aggressive pharmaceutical sales rep, or perhaps they simply had physicians who gave in too easily to patients' requests for a Z-pak, the popular nickname for a box of Pfizer's drug.
"We see Zithromax being prescribed like water," Dr. Randel Cardott, the medical director at a group of clinics in Davenport, said in 2003, when Wellmark issued its report on the fast-rising use of antibiotics. Iowa's doctors were frequently prescribing Pfizer's drug, Dr. |
| Few members of the public attended these meetings, but the pharmaceutical sales representatives showed up in force. A dozen or more drug salespeople sat in on many of the meetings, watching the proceedings like the coons that had a nightly predilection for patrolling my father's chicken coop.
The sales reps and the companies that employed them had hundreds of millions of dollars in revenues to protect. Prescription drug costs were consuming more and more tax dollars in Iowa and every state in the country, a trend the pharmaceutical companies were working hard to extend. |
 Pharmaceutical sales reps will typically jump from one drug company to another with the hopes of landing the opportunity to push blockbuster drugs that offer long-term, guaranteed income potential.
One of the many ways drug reps achieve their sales targets is with samples passed from the drug company to the sales reps to the physicians and on to their patients to see what works. Physicians quite often use these samples to treat symptoms that the drug was never intended for. |
 On the message board Cafe Pharma, created for pharmaceutical sales reps, comments on Pfizer's board ranged from, "The guys got a set of brass balls. I'll give him that. . ." to "He's awesome—finally one person who will tell Hank to stick it," and "He's a self promoter. All his statements are for the greater glory of himself." Yet another wrote, "This guy is a disgrace, he doesn't get paid to do the stuff he's doing. If reps aren't allowed to speak to the media on issues, why should this dork."
The fact that I had a competitive salary also didn't pass unnoticed. |
 REPPED: As the drug companies are running out of real diseases to boost their pharmaceutical sales, they're increasingly inventing new, fictitious diseases in order to scare people into thinking they have some sort of disorder or dysfunction. Attention-Deficit Hyperactivity Disorder (ADHD) is perhaps the best known fictitious disease invented to sell psychotropic drugs, but there are many other made-up diseases such as General Anxiety Disorder (GAD). |
| The question in my mind was simple: Since everyone knew this basic fact of pharmaceutical sales and marketing, why the memo?
I knew that Darren was the epitome of integrity, so I didn't believe for a second that he would do anything wrong, but he had taken responsibility for my area only recently. Who knew what had been the practice before he came on? Or what people might stillhzve been doing? I would get many opportunities during the coming years to reflect on these initial concerns.
More Discoveries
My worries increased as my first months with Pharmacia passed. |
 Doctors routinely get visits from pharmaceutical sales reps. These sales reps do not tell doctors how to cure and prevent disease. These sales reps have very sophisticated presentations that are designed to tell doctors how they can increase their profits. These pharmaceutical sales reps tell doctors how they can make more money by prescribing more drugs. These presentations have almost zero information on the safety or effectiveness of these drugs. The concern is not the patient; the emphasis is how doctors can make more money.
• Doctors receive cash bonuses to prescribe drugs. |
 Thirty years later, annual pharmaceutical sales have soared to roughly $180 billion and the average prescription costs $56.4 Some of the most popular brand-name medicines, like Lipitor (atorvastatin), Nexium (esomepra-zole), Plavix (clopidogrel), and Prevacid (lansoprazole), can easily cost more than $120 a month.
If you think that's a lot, hold on to your hat. People with cancer or rare medical conditions are at the mercy of an industry that has lost all sense of decency. At the time of this writing, Herceptin (trastuzumab), a drug for breast cancer patients, costs $3,200 per month. |
 One of the most popular on-line courses from the Learning Annex is entitled "Three Days to a pharmaceutical sales Job Interview!" In the workbook for the course, a former pharma sales representative named Lisa Lane, presents the work diary of Corey Nahman, also a sales rep. Although obviously sanitized for mass consumption, it gives a peep into what doctors encounter daily:
7:45 a.m. Attend grand rounds at the hospital early in the morning to meet my customers for coffee and a bagel and some friendly lobbying. I might work the room, making pseudo-appointments for later in the day.
10 a.m. |
 Already, sales of water worldwide total one-third again as much as pharmaceutical sales.26
We've also cut back government's role in regulating industries in the public interest. To cite just one example, in the '90s a new federal system for inspecting meat was developed with help from the meat industry itself. In it, federal inspection has been reduced to a sample of less than .01 percent of carcasses— even though the Centers for Disease Control estimate that almost a third of all turkey and six percent of all ground beef carries deadly salmonella. |
| These pharmaceutical sales reps tell doctors how they can make more money by prescribing more drugs. These presentations have almost zero information on the safety or effectiveness of these drugs. The concern is not the patient; the emphasis is how doctors can make more money.
• Doctors receive cash bonuses to prescribe drugs.
• The Wall Street Journal reports that professors take payments to express certain views.
• Doctors on government advisory panels make recommendations for drugs while being paid huge amounts of money by the manufacturers of those same drugs. |
| Since the U.S. would have a much higher price differential, let's be more realistic than the HHS and assume about 20 percent usage in the U.S.
The math, then, is quite simple. We would save 40 percent of the drug cost on 20 percent of the market, which would result in an 8 percent savings (not 1 or 2 percent). Our drug spending is more than $200 billion, so this would result in savings of more than $16 billion.
No wonder the drug companies were nervous. The HHS report was so misleading that I wrote a third op-ed about this situation, published in New Jersey's Star-Ledger. |
 The global effort to contain health care costs had finally caught up with pharmaceutical sales. After a decade of double-digit growth in global drug sales and little outside pressure to contain prices, the industry now faced only 5 percent sales growth and increasing price competition. And regardless of how hard the industry was working to highlight its contribution to scientific research, few new drugs were coming down the pipeline that might reinvigorate sales.
"I was having dinner with a major drug manufacturer . . . |
| Even though doctors are the ones who recommend these drugs, they generally receive little education on drugs in medical school and what is learned after that is often picked up from a pharmaceutical sales rep. Many doctors admit that their drug information is gained from the newspaper. We would hope that a specialist, such as a psychiatrist, who is focusing on a limited number of specific types of drugs, would have a better working knowledge of them, but unfortunately even that isn't necessarily so. A pharmacist or one who specializes in drug abuse tend to be the most knowledgeable. |
 Over the past four years, the pharmaceutical sales force for the top forty companies has shot up from 35,000 to over 56,000. The industry spent $5.3 billion in the United States alone in 1998 sending "detail men" into doctors' offices and hospitals, and another $1 billion on marketing events for doctors. That translates into nearly one drug salesperson and almost $100,000 for every eleven practicing physicians in the United States, according to the New York Times. National spending for prescription drugs has more than doubled in the past decade to $78. |
 This type of funding is not available to an individual practitioner and even if available, there is no guarantee that successful results would be published in a reputable journal because of the clear conflict of interest medical journals face in publishing articles that could hurt pharmaceutical sales and decrease advertising revenue.
Pharmaceutical companies normally sell drugs that have been patented. For this reason they have little interest in natural solutions that cannot be patented. This certainly does not mean that these natural substances have no value. Just look at one example. |
| According to published reports, it was common for players to trade pharmaceutical sales reps tickets to games, or access to locker rooms or after-game parties, in exchange for samples of narcotic painkillers.
One morning in the spring of 1996, I opened The New York Times and saw a peculiar full-page ad having something to do with retired financier Jack Dreyfus spending $80 million to expose a "flaw in our system of bringing prescription medicines to the public. |
| And the postwar era saw an increased reliance on battalions of pharmaceutical sales representatives, the "detail men," who went door-to-door to doctors' offices. It was a very American way of doing business, and it was one of many examples of the Americanization of the world's pharmaceutical industry in the late 1940s and early 1950s. The industry power shift from Germany to the United States was so clear that Schering—the Berlin-based producer of laxatives and hormones, which also had large facilities in New Jersey—decided, after being nationalized by the U.S. |
| In just the past year or so, several people I knew had given up careers in, for example, construction and banking to join training programs and become pharmaceutical sales reps. These people represented what I assumed was the broad range of people in the job. On the one end was a guy my brother had gone to college with, who was one of the most honest and forthright people I knew. At the time, he was working for Burroughs Wellcome, which had a reputation as a high-end company with particularly scrupulous reps. |
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