About a year ago, I decided to do a rare thing:  attend a dinner at a fancy restaurant sponsored by a drug maker, Eli Lilly.  It's a regular tactic that Pharma uses to "educate" doctors about medical conditions and the latest treatments. 

 The speaker was a renowned child psychiatrist from Stanford and he was talking about drugs to manage Attention Deficit Hyperactivity Disorder (ADHD).  ADHD is the most common psychiatric disorder in children, so it seemed to me hearing the thoughts of a respected thinker on the subject would be worthwhile.  And so, over a three course meal and some nice wine, off we went. 

It wasn't until desert that he began talking about treatments, which is where this story really begins:  As many of you probably know, ADHD is usually treated by a class of medicines called stimulants.  Ritalin is the most common one of these drugs.  As a class of drugs, stimulants are very effective and data looking at them over decades of use has shown to be safe as well. 

So imagine the surprise of some of us in the audience when our speaker said that the first line drug for ADHD was not a stimulant, but rather a drug called Strattera (developed by Lilly, of course). 

I raised my hand to ask why he said that--by all other accounts, stimulants were still the first drug you try and strattera, a newer and probably less effective drug for ADHD, was second or third line.  His answer was to cite a recently published policy statement by the American Academy of Child and Adolescent Psychiatry stating that, indeed, Strattera should a considered as a first line drug for kids with ADHD. 

Ok.  now, let's look at the statement our speaker cited:

http://www.aacap.org/galleries/PracticeParameters/JAACAP_ADHD_2007.pdf

 Welcome back.  Did you see Table 2?  Because here's what it says about Strattera:

Consider if active substance abuse

or severe side effects of stimulants

(mood lability, tics); give q.a.m.

or divided doses b.i.d. (effects

on late evening behavior); do not

open capsule; monitor closely for

suicidal thinking and behavior,

clinical worsening, or unusual

changes in behavior

 Furthermore, it statement goes onto state:

Direct comparisons of the

efficacy of atomoxetine with that of MPH (Michelson,

2004) and amphetamine (Wigal et al., 2004) have

shown a greater treatment effect of the stimulants....

Cruel Lye, Dr. Stanford.  But much easier to swallow after 1.5 glasses of merlot.  And I''m sure much easier for you to tell us, since you've probably been paid handsomely by Lilly to say it. 

 Welcome to the wonderful world of drug lobbying, where even the most renowned medical thinkers sell out. The thing is, there's no way to know who to trust (whether you're a doctor or a patient).

Until now.  It turns out that Congress recently started to turn the screws on drug companies--and the doctors--who play sales rep for them.   Wisconsin Democrat Herb Kohl has co-sponsored a bill that would require drug companies to disclose payouts of $500 dollars or more. 

It turns that the bill may not be necessary, however.  Last week, Eli Lilly and another drug maker, Merck both announced that they would voluntarily begin publicly disclosing payouts to doctors.   That transparency is welcome and could go a long way to help further draw the line between doctors and drug companies.  That trend that got more momentum this past summer, when Pharma's trade association wrote a new code prohibiting drug reps give little gifts like pens to doctors. 

All of this matters because it's clear that this sort of "academic detailing" has a stronger influence on doctor's prescribing habits than actual science.  Of course, newer drugs cost more, and when Pharma promotes them heavily, we can count on health care costs rising. 

 Personally, I'd like to see things go one step further-I'd like to see Stanford, and other major universities, publicly post the payout information on their doctors' websites, since each of them has one with details of their professional lives on them.   That way, had I been at that same lecture/dinner and had my cell phone, I could have looked up Dr. Stanford's web page and figured out how much this dinner was really costing Lilly.