Evan Levine, M.D.

Healthcare - A behind the scenes look

Dr. Evan Levine

Dr. Evan Levine
March 17
Author of What Your Doctor Won't (or Can't) Tell You - Penguin Publishing. Fellow of American College of Cardiology and practicing cardiologist in Bronx and Westchester New York. Today Show Interview: http://www.youtube.com/watch?v=63cWvtGPonU Follow me on Twitter: https://twitter.com/vanlev


MARCH 30, 2010 9:47PM

A Drug Rep's Story Part II

Rate: 21 Flag




Sam the drug rep:



"Though it is getting harder

to find ways to give gifts to

docs -even docs who know

how to play the game--

there are still

 lots of ways to get docs to

prescribe medications they

really shouldn't be

prescribing..And it doesn't

exactly require a rocket

scientist to figure out what

is going on. It shouldn't be

very hard for a sharp or

interested journalist, or,

the feds to figure out what's

going on."



Pharmaceutical companies know exactly how many prescriptions your doctor prescribes- so they can reward him for his services or make sure he is telling the truth about his “faithfulness to the company and its product. Prescription information is collected by health information organizations (also known as HIO's):IMS Health is the largest HIO; others include  Verispan, Dendrite, and Wolters Kluwer.  And for a nice fee many pharmaceuticals can find out just how many prescriptions a doctor writes for their drug or for the competition's.


There are a bunch of drugs on the market that I just don’t know why anyone would prescribe consistently, unless they had some kind of reason,  like money, dinner, or sex.
Some that come to mind include Lovaza,  Sular, Bystolic, and Avandia.  

Lovaza (GSK) is a drug that is approved only for patients with isolated elevations in triglycerides  of above 500 and , in my opinion, has no particular clinical advantage when compared to the inexpensive  fish-oil capsules one can buy at places like Costco

The company is required to place the following in their prescriber information:
LOVAZA, along with diet, helps to lower very high triglycerides (≥500 mg/dL) in adult patients.

Talk to your doctor about any medical conditions you have and any medications you are taking, especially those that may increase your risk of bleeding. In some patients, LDL-cholesterol levels may increase. Your healthcare provider should do blood tests before and during treatment with LOVAZA to check your cholesterol and
triglyceride levels. If you have liver disease, you may require additional monitoring

Now, there aren’t a heck of patients out there with isolated triglycerides over 500mg/dl, the only FDA approved indication for this drug, and even the manufacturer states that LOVAZA can increase your bad cholesterol and that there is ZERO data to show that the drug reduces your risk of heart attacks.   So all of you reading this: Go tell your friends that some doctor may have prescribed this very expensive drug for them, even though it may not do them much good.

Sular (Sciele Pharaceuticals) is a calcium channel blocker, used to treat hypertension. It is not generic, and while quite expensive, it is arguably  no better ( many would say that it has more side effects) than another and similar type of calcium channel blocker known as  Norvasc (amlodipine.)  The price for Sular 17mg at Costco comes to around $1,800 dollars a year while the price of an equivalent dose of Norvasc (amlodipine) will cost you a little under $40 bucks!
So why the heck are there doctors out there prescribing Sular?  Are they naïve, indifferent, or are they getting some type of compensation (friendship, lunches, dinners, paid meetings) from someone selling Sular?  I’ll say it again and again, go find the top 100 prescribers of Sular and you will most likely find doctors that have some type of relationship with the manufacturer or the reps of Sular – Sciele Pharmaceuticals.

Bystolic (
Forest Pharmaceuticals) is a beta-blocker medication approved only for high blood pressure. The FDA recently denied its approval for heart failure, and  it is actually a generic drug in Europe. Most experts believe that these Beta Blocker medications are not the best treatment of hypertension,  and most guildelines now suggest that you not chose this type of drug as the first line treatment of high blood pressure.  Many generic blood pressure medications can be purchased, in bulk , for under ten –cents a pill (some as little as five-cents) while Bystolic will run around $2 dollars a pill in the US. So, how come sales keep going up and up?

Avandia (GSK)  is a medication used to treat diabetes. It also causes weight gain and raises LDL (bad) cholesterol!  Why the heck would anyone give a diabetic a medication that raises LDL cholesterol?  This drug may eventually be taken off the market since many believe it is responsible for many deaths. So tell me what you think?  Do you think that if we found the hundred, or perhaps even the top 1,000 prescribers of this medication, that many of them would have some sort of financial or other relationship with the makers or reps of this drug?

This seems obvious to me yet, evidently, it is not obvious to the FDA or to any decent investigative reporter. So, I suggest to the FDA or any good investigative reporter:  Go out and purchase the same information that these drug companies do and find out what doctors are prescribing these drugs in disproportionate numbers and my guess is you will find a doctor involved with the company and playing a quid-pro-quo game with the reps for his own gain -- at his patients expense.


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like money, dinner, or sex.

This is an eye opener for sure. I've never heard of any of these drugs. I am writing them down so that if I do, I know to question them strenuously. The idea that some doctors are preying upon patients (who are at a weak point in their lives, sick and in seeking help) for profit is sickening. I hope this is -- as a percentage -- rather rare?
All the more reason we need to be fiercely proactive about our health and the meds we consider taking. You and I have something in common: The appreciation for Costco's low cost prescriptions for the identical medications that chain drug and supermarkets are profiting more than two to threefold. And often more! It's shocking!

Pharma reps are often pimps in a designer suit and big expense accounts, fronted by the drug companies.

You offer valuable incite and information here. Now if we could just shake more folks out of their drug stuper and addiction to RX's they could likely live without (surely not in all cases) and educate more people that their health is their personal responsibility and not to be left in the hands of big pharma and some doctors without souls.

Lends new incite on we should always insist on "a second opinion." If we're lucky, one of the two will actually care enough to prescribe the truth.
Well gee whiz, if we had national health care with the government being the main buyer of phramceuticals, would these drugs even be in existence?
Hey, Evan--good to see you! I miss you when you're not posting! But I know you're probably a little busy (!) so I just wait patiently.......

OK, enough waiting. Thank you for this. These facts need to be presented every day--to everyone. I'm that patient who needs quite a bit of medical intervention to keep me stable--but I also question everything my internist says/prescribes. Fortunately he knows me pretty well so he knows to expect lots and lots of questions--and then I tell him I'll do some research and let him know if I want the script. He gets annoyed, but, guess what--it's MY body and MY life he's dealing with. And I won't simply be quiet and docile.

My doc has 2 PA's that I often see instead of the doctor (I'm essentially housebound and they make house calls). Do you know if the drug reps try to influence PA's at all? I haven't noticed a rise in prescribing new, expensive drugs with these guys. Of course, most (if not all) of their patients are on Medicare/Medicaid so they may not even be on the reps' radar. But I have a good friend whose daughter is just graduating from PA school and will probably be going into practice with a private doc, treating private patients. Will she need to be aware of this drug-rep-ripoff? Rated. D
frightening but important information here...
Some of these drug reps remind me of patent medicine salesmen you see in old movies. Most of those 19th century "cures for what ails" you were toxic and expensive just like a lot of the meds that are marketed today. Patients need to be educated and they need to ask questions, especially if their tried and true meds are working and all of a sudden their doctor wants to switch them to a newer, more expensive drug with far more side effects. That should raise a red flag. Thanks again, Dr. Levine for another enlightening post on the back room dealings and black box warnings of our health care system.
Just a quick note on a doc I went to recently who said he could prescribe something if I wanted it. When I told him I don't want to take pills, he didn't argue. Some docs actually listen. Yay!
Why will no one report on this? I think it should become public knowledge who gives out this pills of poison. How do these doctors sleep at night?
Big Pharma is every bit as evil as Big Tobacco and Big Oil -- an d no better -- and in some ways worse -- than somebody selling crack on the street corner. It is an absolute scandal and an outrage that Big Pharma is allowed to advertise prescription drugs on television.

But since the SC in it's infinite travesty has decided corporations are people, too, with "certain inalienable rights", it's going to be difficult to remedy that outrage. Rather than the occasional fine which returns a small portion of the ill-gotten gain, maybe the solution to the problem is to put the people who control these "corporate persons" in prison when these "corporate persons" commit fraud.

The bandits at Big Pharma act like they should receive a king's ransom for "inventing" this stuff, when many of their products are merely bastardized versions of home remedies made wore with contaminants and fillers. And what little is revolutionary is usually based on research by the CDC or the NIH.

I caught a commercial yesterday for a drug -- didn't catch the name -- and one of the precautions was "do not use if you have a reaction to fish". My immediate reaction was I bet you could get the same or better results -- without the side effects -- by taking cod liver oil -- just like granny used to insist.
Thank you for this. I've seen it first hand in my doctor's office.
Thank you all for your kind comments. I suggest everyone read today's article in the NY Times about Pfizer's relationship with docs that prescribe their drugs.

I will bet you all, every single one of you, that if we looked at the docs that were the top 100 prescribers for the four drugs I listed, or for just about any other drug, we would find that those doctors had a relationship with the maker of the drug. Shameful!

NY Times story on Pfizer that was printed a day after this post
Dr. Levine, this is so intriguing. Please keep sharing your insights -- it is so needed!

Warm vibes always!
Dear Dr. Evan,

This series is so essential. It reminds me of Patrick Smith's "Ask the Pilot" on Salon. It is of extreme importance that you point out who where what and why. I encourage you to continue and eventualy find a publisher for this. Why? Because what you are uncovering is something that only doctors or maybe nurses would know. It's under most patients' radar.

I was given Avandia and I never took one pill, don't ask why. then as I've told you my type 2 diabetes morphed into or was from onset type 1. I went back to the Avandia guy who was one of those PR's they now have in most cities. You pay higher and get seen faster, what is that about. anyway, I had a few free sessions left and thought I'd tell him not only that Avandia felt wrong to me but that I was now insulin dependent. He and this I will never forget, said: "I am sure you would benefit from Avandia and you can't be type 1." Well maybe I was type 3 or type 1.2 but what is amazing is that only NOW after reading you does he spring to mind. One of those crooked ones, no doubt about it. Thanks, keep on keeping on, we can only learn great things from your articles. r love,
Poor Wendy. I am sorry to hear some Shmohawk (reference from LD show) put you on Avandia. Aside from causing patients to gain weight, raising their bad cholesterol, and swelling their ankles it is........ very very expensive!! I do not believe I have ever prescribed the drug.
O woe.

I shouldn't be typing a post at almost three hours past midnight, two days after Aprille Fooles Day and one before ?"Easter"?

I'm the ex-wife of an oncologist I was sidetracked from my hopes and studies to become an M.D. by marrying, 46 years ago and from whom I was divorced 32 years ago. During our fourteen years of marriage, my medicine research/practice interests were largely deflected to my (welcomed!) responsibilities to and hopes for his six then "kids".

He is now "on his third marriage" [and I'm typing a post to OS ?! ;-)]

All of which is just (in part) by way of trying to beef up, a bit, my connexions with OS at an awkward hour of the night. But more to the point:

Is there no one here who has an honest, mutually sharing, trusting and trustworthy relationship with his/her (for today's jargon) "primary care provider"? My OS sign-in name is "podunkmarte" and -- this changing season time of year -- my musings, dreams & etc. have been a lot preoccupied with themes about small (podunk?) communities and large [urban? Internet?! ;-)] ones. My personal story of medical care -- and workplaces during my studies -- ranges over pretty much the gamut of the Big Name Urban hospitals to where I live now. At pushing age (to my still incredulous almost-disbelief) 80, I've been in a lot of review of my so-far stated Medical Conditions (type II diabetes, what one of my favorite previous M.D.s called "labile" hypertension; for the rest what us non-pros would call "growing old and hoping not to be labelled with that word one m.d. honestly admitted meant "we don't know what we're talking about": 'dementia').

I've lived alone for most of the past 20 years so by now one of the manifestations of all of that by now is more and more often coming online in the middle of the night, in search of ?"virtual reality"? community and conversation. So my apologies all around for being so verbose.

But: Question/comment:

Am I -- now so long removed from the big-name hospitals & etc. and often worried about that -- the only person "around here" who has a decent one-on-one share-information relationship with my socalled "primary provider" [Who got her m.d. from my long-ago hometown University medical school -- I was surprised, initially, to learn]?

Oh, O.K., so I ought not send this because I know I've been typing at length because manic typomania is my sofar DSM not identified ?"mental illness"?.... But, hey, us old folks with computers do what we can to try to take care of our own mental health ... whatever the cost (passing, I sure hope) to OS readers!

But to get back to my basic question:

Is there no one here who has the good old fashioned trust and "one-on-one" relationship with his/her "primary care provider" that I do?
Are we all now ?"beholden to"? the media and even especially friendly online sites like OS to the extent that we don't feel we can trust the individual practitioners we consult?

Thanks for ?"listenin'", all ;-)

great blog post. informative, although you didn't exactly explain how big pharma was providing cooperative doctors with sex. the money and dinners change hands easily enough to be understood, but the sex? that would be interesting to hear about. I've seen some pharmaceutical reps now....I just never thought,... well you know.

rated anyway. good post.

thanks for your kind words. Big pharma does not go out and tell reps to do what they do, they are too smart, but they tell them the more scripts doctors write in their territory the more money they will be paid. For the rest just use your imagination. I wrote a bit about this in "Part One."

Regards to all, except these losers that are placing spam ads on my blog.

Dr. Levine
Avandia, Lovaza, Bystolic, and Sular are only four of the "Top Ten" drugs I don't prescribe. I truly get nauseated when I see patients, who cannot afford these drugs, come in for consultation.
This infuriates me. Snake oil. What infuriates me is that I know...and people don't believe me when I suggest what you have written here....well done. xox
From a social work perspective this frustrates me to no end! Often my clients cannot afford much and to know that doctors (who they really trust) are possibly misinforming them when it might break them over their income limit goes against my ethics and tolerance limit.

I work too much with cases of clients losing their financial stability because of expensive medical treatments. I know that healthcare as a whole needs to reform to make it more affordable, but the best we can start with is to expose this unfair and biased practice.

Thank you for writing this important article. Healthcare and other disciplines really need to begin to speak up for those that are currently being victimized with this system. We need to start caring more about the patient again.
Intriguing, Evan, that you don't list these drugs' non-trade names (I am sure intentionally). This is just the tip of the iceberg. One problem is that some patients (because of direct to consumer advertising) specifically request expensive, brand name drugs, and don't believe they are being treated adequately if given a safer, cheaper, proven generic. So there are several issue here.
The two drug reps that I know personally are very well paid. One makes in excess of $200K and was a former copier machine salesman. The other makes in excess of $100K and was a former salesman for a replacement window company. Neither one had any education in biology, science, chemistry, or medicine. Both are charming, articulate, and believable. I was in sales for over 30 years and was once recruited by a medical company. I told my interviewer that I was a top producer for any company I worked for, but I knew nothing about medicine and wondered why they were interested in me. He told me they did not require a medical background (and seemed to prefer that I not have one), and were just looking for professional sales reps. They could teach us all we needed to know.....
The two drug reps that I know personally are very well paid. One makes in excess of $200K and was a former copier machine salesman. The other makes in excess of $100K and was a former salesman for a replacement window company. Neither one had any education in biology, science, chemistry, or medicine. Both are charming, articulate, and believable. I was in sales for over 30 years and was once recruited by a medical company. I told my interviewer that I was a top producer for any company I worked for, but I knew nothing about medicine and wondered why they were interested in me. He told me they did not require a medical background (and seemed to prefer that I not have one), and were just looking for professional sales reps. They could teach us all we needed to know.....
The Feral Conservative's comment is a must read!
Thanks for all the especific info. What is most surprising to me at this point is that there are so many people who do not know this goes on. You'd think it would be basic common sense by now.

In my experience, your pharmacist is one of the best sources - or should be - of info on any drugs your doctor prescribes. It's good to have a good relationship with your pharmacist.

Good post Rick. A pharmacist is a great source of information, if you can find one and the crappy HMO that you belong to does not insist you get your prescriptions from some mail-order company.
There are many facets to this story. One that we really need to remember is that any scam or other questionable action has to have two willing parties. The physician who prescribes these medications owes their patient a full and honest explanation of their reasons for doing so.

I am a physician and always prescribe from the WalMart $4.00 list. There are over 400 medications on this list and, except for circumstances where the patient demands other medications, most general outpatient medical care can be easily accomplished using this formulary. By the way, I don't see the used car salesmen of the pharmaceutical industry when they come in to pitch a product. I prefer to read the studies and make my own decisions on the benefits of a medication.
I practice the same way you do Dr. Compton and I commend you and all the other great physicians in this country that do so. I tell patients to go to Wal-Mart, or Target, or Costco to purchase generic drugs. For a year supply drugstore.com is often less costly for generics.
Dr. Levine,
The information you are sharing is so important. Money has become such a corrupting element in health care, and often in ways, that as you point, are invisible unless people really look for them. My (possibly naive) hope is that health care reform will begin to change the relationship between money and medicine, but we'll have to see. Certainly the bill that passed didn't address the influence of the pharmaceutical industry on medical practice and trends in prescribing.
Thanks for putting us all in the loop,
Theresa Brown, RN
this is why we need the government off our backs, and let the profit sphere stay on our backs!! yea right
This week a new patient came to me who was prescribed, by her general Doc, Sular. She complained how expensive it was and I just changed it to a better and less expensive medication, amlodipine. I suspect her doc is either a fool or more likely a bit of a fool and enjoys free lunches and dinners from the Sular rep.