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McKinsey Advised Johnson and Johnson on Increasing Opioid Sales (nytimes.com)
261 points by acalmon 30 days ago | hide | past | web | favorite | 156 comments



The marketing of medicine in inherently unethical because it seeks to override doctors and consumers information-based evaluations, and instead make a choice based on emotional propaganda.

The harm caused by any given medical advertisement is directly proportional to its effectiveness. Every pharmaceutical sales rep is an immoral cancer on our society.


I think society would benefit immensely from banning the advertising of drugs. This includes both medicinal and recreational drugs.

Make all drugs legal, but mandate they have boring text/information-only labels, put the more dangerous ones behind the counter in smaller quantities, and let the only thing influencing their purchase be doctor recommendations/prescriptions or personal research. It should apply evenly from ibuprofen to allergy pills to marijuana to cocaine to alcohol.


> I think society would benefit immensely from banning the advertising of drugs.

This is already the case in many places outside the USA (Canada, Europe, Brazil, Hong Kong).

https://en.wikipedia.org/wiki/Direct-to-consumer_advertising


I believe the list is shorter if you make it about which countries allow direct-to-consumer advertising:

USA, New Zealand.

That's it.


Indeed. The Advertising Standards Authority (ASA) in New Zealand has a code of practice for Therapeutic and Health Advertising (below). My father was running the ASA when this came in, and NZ and the USA were the only 2 countries with D2C ads for pharmaceuticals.

The advertising amount and impact in NZ is a lot lower than in the US as our healthcare system is largely public (government funded) with a single buyer (Pharmac) of pharmaceuticals that exercises considerable pricing power, and is unafraid to change brands. Most of us go to the doctor and take what is prescribed.

https://www.asa.co.nz/codes/codes/therapeutic-and-health-adv...


The marketing is dispicable in NZ.

For example, I loath that they advertise paracetamol (acetaminophen) as "better for the stomach" directly targeting Aspirin and other NSAIDS. No mention of how many peoples livers get permanently fucked by paracetamol.

Unfortunately the advertising propaganda is successful, and people avoid safe drugs that have side effects that can be managed. Evil.


GP is talking about all drugs, not just prescription drugs.


Word of mouth or "personal research" is a really ineffective way to discover what drugs are suitable for you. It might be better than TV advertising, but that's a pretty low bar to set. You can understand the desire for a compromise solution like "TV advertising, but you can't lie about it too much and you have to mention side effects". And that is more or less the US status quo.


Nobody needs to discover what drugs are suitable for them. This is medicine, not a restaurant menu.

If you're diagnosed with a medical condition or have a specific ailment, then you can investigate potential treatments.

The status quo "compromise" solution gets this exactly backwards. "This drug will make your life better. So ask your doctor so they'll comb through your medical records and history looking for something kind of like what we claim to treat[1], so they can prescribe our drug for you." Lies and failure to mention side effects are not the only problem with advertising. The problem with advertising is that it seeks to persuade people, using every trick in the book short of actionable lies and omissions, to buy drugs that even doctors can't properly evaluate because drug research is pathologically flawed. And those advertising tricks are effective at getting people to buy drugs which they don't need and which will do harm, because most drugs do some kind of measurable harm whether it's potential liver or kidney damage or increased risk of dementia or cardiovascular problems or cancer or whatever.

Pharma companies that seek to extract rent from your "conditions" are the last entities you want telling you what you might have, and they're the least trustworthy entities to be allowed to get you thinking that their drug might be your best option for treating your "condition" because you heard about theirs first and they made sure their advertisement stuck a bunch of positive associations to it in your mind.

"Ask your doctor about our drug instead of asking for advice on whether other things, including exercise, eating better, and getting better sleep might help, because those take time and effort and you have no time and no willpower except when you're dancing in a field of flowers like we showed you doing when our drugs solve all your problems so you should pay us rent for life for your 'medical condition'."

[1] Have you noticed most drug advertisements don't even claim to treat anything specific, or are intentionally vague? The charitable explanation is that the condition is often something taboo or embarrassing, but I think a bigger part of the reason is that pharma doesn't want you losing interest in the drug before you ask your doctor about it.


> If you're diagnosed with a medical condition or have a specific ailment, then you can investigate potential treatments

I know at least a few people who didn't realize they had an ailment until seeing the symptoms listed on an ad. There is a balance between promoting new drugs (and the affiliated afflictions) to the general public and pushing medicines to doctors.


In Australia you're allowed to advertise about the existence and symptoms of medical conditions just not to recommend any specific treatment other than "talk to your doctor". The pharmacist is also obliged to offer generic versions of drugs at purchase.


I think that’s a good compromise.

BTW, it’s actually pretty common in many US states for pharmacists to be required by law to fill prescriptions with their generic equivalents.


That's because medical companies made it up to sell more drugs. Restless leg syndrome wasn't a thing until pharma starting pushing drugs for it.

Legit palsey is a completely different story.


Well this country's medical system is too bad to even begin to try to do preventative medicine. (You can think of it as a 400 million person medical poverty trap. We all live in medical poverty.)

We're that fixed you would learn about conditions you didn't know you had from the doctor. Or therapist.


I think that almost immediately ends up in a morass of private information web sites, none of which are as trustworthy as current FDA-regulated labeling.

Do you prefer Instagram "influencers" to have more control over what drugs people take than the current regulated advertising? I don't.


I don't think they would. Do they currently have instagram drug influencer in Europe, where direct-to-consumer drug advertising is illegal?

https://en.wikipedia.org/wiki/Direct-to-consumer_advertising


I would think that pharma companies currently instead just advertise in American media and trust that the word will get over to consumers in Europe...


No, they send doctors on symposiums to the Caribbean.


> where direct-to-consumer drug advertising is illegal?

The US and New Zealand are the only countries where direct-to-consumer advertising is legal.


Isn't the opioid crisis caused by sales reps directly marketing to doctors and promising benefits that didn't really exist (lower risk of addiction, lower dosis required for certain amounts of time)? Not sure how removing marketing to consumers changes the situation.


In my view it is that combined with the welfare reform act. Once welfare was limited to 5 years people moved to SSDI to receive payments, opiate drugs became more popular and now we have a system when the government will pay you and give you heroin if you jump through the right hoops. As we have effectively subsidized addiction it shouldn't be surprising that it has increased dramatically.


I think beer should be considered food, but otherwise I can get on board with this.


Gruits were medicinal herbal meads - funny to think that in not-so-distant history, a doctor may have prescribed one of several "medicinal beers".

It's interesting how molecules can be considered 'food', 'medicine' or 'poison' in different contexts.


>Every pharmaceutical sales rep is an immoral cancer on our society.

This seems like one of the most cleanly horizontally divided opinions in all of the US - where nearly everybody agrees loudly and strongly with it except the wealthy and powerful. I wish a presidential candidate would have the balls to echo this severe but obviously popular thought and fix the fucking system with extreme prejudice.


There are at least two currently-running candidates who do seem have the balls to directly confront the pharma industry! Why do you think there aren't?


There are 20-some people running...I wouldn't call them a presidential candidate yet...more like presidential hopefuls.

And because big pharma seems to always win.


They are technically all candidates. The winner of the primary is a nominee.

Pharma gets what they pay for. Vote for someone who isn't beholden to them.


Yeah, but after continuing to vote for people that don't have backing and therefore never have a chance to start really is starting to feel like I am wasting my vote.

Hell, because of the Electoral College, my vote ultimately doesn't count if it isn't what the whole state picks.


they win because not enough people care!


Because the people that will likely win the nomination will almost certainly have big money, to include Big Pharma, behind them. Ads, research, propaganda, and aggressive ground games work, but they need money. Like multi-national corp or nation-state level money[1].

Hilary had some uncomfortable ties to Wall Street -- she was a Senator from NY, mind you -- and the DNC chair Debbie Wasserman-Schultz picked up a lot of Budweiser money by scrapping any DNC talk of Marijuana Legalization (DWS has long battle MJ Legalization in Florida, so she's been taking their money for a while, or was a sympathetic bribe for Alcohol). But I could have lived with that in exchange for working health care and sane foreign policy.

[1] see also: the russian firehose of propaganda -- https://www.rand.org/pubs/perspectives/PE198.html


I think you’ve got a very skewed view of the US population if you think it’s clearly divided populous on this issue.


[flagged]


Why play the victim before anybody has attacked you? I agree, that's my favorite thing he's done. He can be a bad orange man on the par too.


I think this is needlessly inflammatory. I agree with Trump on this and I’m sure many here do as well. No one has yet said, “orange man bad” so we shouldn’t conjure up that bug bear until it happens, it detracts from good faith conversation.


This may come as a shock to you, but marketing pharmaceuticals is really no different than marketing other products. It really comes down to educating consumers about your product.

Doctors as decision makers are not some monolithic block of individuals who are super educated about every product on the market and every piece of data. Just developing awareness of new drugs is a huge job. I'd say less than 5% of doctors are cutting edge enough that they require no additional education on new drugs.

The best story I can tell was from a friend who worked at a drug company that sold a hepatitis C drug. Once Gilead's drug came out, this company basically decided to discontinue their drug. Incredibly, there were doctors out there still ordering the old drug. The company had to send reps out to these doctors to tell them to stop ordering it. Continuing to use it made zero sense at all.


The problem here is that pharmaceutical companies' marketing departments have a deep conflict of interest. They're incentivized to encourage doctors to use the drug that makes their company the most profit, not the drug that is best for the patient.

And there is plenty of research demonstrating that this is exactly what they do, and that doctors are indeed swayed by it, because, as you say, they don't have the time to do keep up with it all on their own.

And yes, there is a fundamental difference to consider here: My doctor has a fiduciary responsibility to do what's best for my health, to the best of their ability, and drug marketing compromises that. By contrast, nobody has any fiduciary responsibilities related to which brand of toilet paper I use.


Maybe an alternative to drug marketing would be to have an independent national or international group (e.g. NIH or CDC) inform doctors about new drugs based on their prior prescriptions, and to present the preregistered clinical trials at medical conferences just like any other research result to reach the rest.


At the same time, when a breakthrough happens like with Gilead’s hep c drug, a single governing body is far less likely to educate and inform doctors that a major disease can basically be cured even if all the evidence points this to be the case. Think about how long it took the food pyramid to be changed despite all the evidence that you should be eating six loafs of bread each day.


A drug that good tends to sell itself.

There will be those that don’t change their practice ever once they graduate (seen a few).

Things get more complex when you have dozens of treatments for a condition with no clear winner.


I appreciate how you said “tends to sell itself”.

Before I got in the industry I thought “what the hell does marketing do?”. Then once I saw what they do, I realized, no, most drugs don’t sell themselves, there is too much inertia for doing the same old thing.


The key word was good drugs tend to sell themselves.

If you develop yet another blood pressure drug or cholesterol drug and want GPs to prescribe it, you're going to have an uphill battle.

A blockbuster drug for HepC (where treatments before weren't particularly effective and had ugly side effects) will have a much easier time becoming well known amongst the specialists that treat the disease.


Do you think there could be a substantial time lag in that case though? Sure, some movies become hits with no marketing, but DiCaprio, Brad Pitt, Ana Margo Robbie have been everywhere to market a movie with stellar reviews and a top director. Maybe that is a poor analogy. I’m not in the pharma industry, but to me, I’d hold my doctor accountable for prescribing me something I saw in a tv commercial, or not doing the legwork to understand why it could be a beneficial drug.


Plenty of resources exist. But they’re boring/not flashy.

The government isn’t going to get away with hiring entire teams based on looks and then have a marketing line item for free fancy lunches for people that are definitely not starving.

Choosing Wisely is a broad approach that is somewhat like you described.


My counter to your comment, and my own personal experience, is that doctors are fully aware of the manufacturers conflict of interest. They know that the drug companies will present everything in the best possible light.

Other things that exist to counter this bias are competitors, who will provide a different perspective and most importantly, the FDA that regulates all pharmaceutical promotion for accuracy and will quite swiftly drop the hammer on a company that bends the rules.[1]

[1]https://www.fda.gov/drugs/warning-letters-and-notice-violati...


Yeah, but this starts to break down when the pharmaceutical representatives can give laundered incentives(fancy "educational" dinners, "educational" yacht parties, etc.) to prescribe their product. In the US, pharma reps can see the prescription amounts of doctors to verify that they are actually prescribing their product(last I heard from a pharma CRM company in 2016). This seems deeply and fundamentally unethical.

Then you bundle all that up with the various studies that show that doctors(as with all professions) do a poor job with continuing education so that they are further inclined to take the recommendation from the pharma reps(which can be seen in the roots of the opioid crisis), I don't think we're in a very good place from a regulatory standpoint.


The practice of greasing the skids with lavish events ended a while back. Drug companies can't even give free pens to their doctors now.[1]

[1]http://phrma-docs.phrma.org/sites/default/files/pdf/phrma_ma...


Not to take a position in this debate as a whole, but I just want to interject that there is research suggesting that you actually are more likely to be affected if you are aware of the other person's conflict of interest. (Can't find a link right now...)

If memory serves me right, the theory is that it makes you overestimate your ability to stay objective and unaffected, so you're effectively lowering your guard, or something along those lines.


You should read "the honest truth about dishonesty" by dan ariely where scientific studies of conflicts of interest found folks fall for this stuff unconsciously and repeatably.


>They're incentivized to encourage doctors to use the drug that makes their company the most profit, not the drug that is best for the patient.

The job of the marketing department isn't "best drug for patient". That's the doctor's duty. The marketing department is there to bring awareness of the product to both doctor and patient. There is no conflict of interest at all.


Not all marketing is "educating consumers about your product". Some of it is manufacturing a desire for your product.

Look at car ads. Do they say "The new 2019 models are available"? A few do. Do they say "This car gets better gas mileage" or "This car is safer"? A few do. Most say "If you drive this car, you'll get the hot girl". That's not "educating consumers". That's trying to make consumers want your product on the basis of something completely unrelated to your product.

And yes, I fear that marketing pharmaceuticals may in fact not be different from marketing any other product.


A very interesting read for me was an FDA survey on direct to consumer TV ads for drugs.[1]

A few of the negative findings:

-Eight percent of physicians said they felt very pressured to prescribe the specific brand-name drug when asked.

-In addition, about 75 percent of physicians surveyed believed that DTC ads cause patients to think that the drug works better than it does, and many physicians felt some pressure to prescribe something when patients mentioned DTC ads.

And positive findings:

-Many physicians thought that DTC ads made their patients more involved in their health care.

-Most physicians agreed that because their patient saw a DTC ad, he or she asked thoughtful questions during the visit.

-The study demonstrated that when a patient asked about a specific drug, 88 percent of the time they had the condition that the drug treated.

[1]https://www.fda.gov/drugs/drug-information-consumers/impact-...


I simply wondered if I could play devil's advocate by looking up some research about men spending money for cars in order to attract women. I mean, most psychologists are men right? Surely, someone had the bright idea to look into this (I wonder if anyone has done it regarding the other way around, I'm too lazy to look it up since I can't play devil's advocate with that). As it turns out, there is research on it!

The introduction is the most juicy bit as the particular article I found is about intra-sex competition but states a few interesting studies in their introduction about being desirable to women.

In short what I skimmed so far related to this idea is:

"And indeed, a man who was seated in a luxury car was perceived as more attractive by women compared to the same man seated in a nonluxury car (Dunn & Searle, 2010). Hence, men appear to use showy spending to attract women in intersexual competition contexts. Sundie et al. (2011) further revealed that men’s flaunting of luxury goods signals their desirability as a shortterm (rather than long-term) mate."

Personally, I don't car about any of this. However, academically (from an evolutionary psych. view, lol): yes, men are seen as a more desirable mate!

If this conclusion is also actually true (and not subject to whatever ails the field of psychology) then I'd chalk it up to most of humanity being vain and if you want to get vain people you need to be the vainest of them all and get the sports car, the fancy house, other desirable 'high value' women in pictures and all that jazz. Though, why not just immediately go for the private helipad and private jet with built-in Jacuzzi? Nothing attracts as much as offering young people in general a trip around the world in pure luxury! Or so I presume. So don't buy the sports car. Buy the helipad with helicopter on top.

Source

Title: What If the Rival Drives a Porsche? Luxury Car Spending as a Costly Signal in Male Intrasexual Competition

DOI: 10.1177/1474704916678217

URL: https://journals.sagepub.com/doi/pdf/10.1177/147470491667821...


>"And indeed, a man who was seated in a luxury car was perceived as more attractive by women compared to the same man seated in a nonluxury car (Dunn & Searle, 2010).

Surprised the PC Police haven't demolished you for pointing out that, on average, women are attracted to men who convey wealth (even though it's blatantly obvious).


A couple of things:

I said:

> Personally, I don't car (sic! also no pun intended) about any of this. However, academically (from an evolutionary psych. view, lol): yes, men are seen as a more desirable mate!

So first, I see evolutionary psychology as a joke and I don't care about the research because I think it's all lies anyway. I'm a bitter man when it comes to the promises of psychology being truthful about how humans think (the field has too many issues).

Secondly, I simply quoted research. And remember from point 1, distanced myself from that opinion.

Thirdly, in my experience I never needed to flaunt my wealth in order to attract women. I think the same is true for most if not all of my friends (both sexes). Disclaimer: I'm Dutch (maybe culture is a thing).


> Look at car ads. Do they say "The new 2019 models are available"? A few do. Do they say "This car gets better gas mileage" or "This car is safer"? A few do. Most say "If you drive this car, you'll get the hot girl". That's not "educating consumers". That's trying to make consumers want your product on the basis of something completely unrelated to your product.

You and I must be watching different commercials, because I see far more of the former.


>You and I must be watching different commercials, because I see far more of the former.

I think it's changed a lot since the 60s and 70s. Cars are seen as more utilitarian now, and younger people don't even care about getting their license, let alone being concerned with "what you drive".


Except it's not marketing products to doctors, who are the gatekeepers to access. It's marketing to consumers, who aren't informed, and are then used to badger doctors to make them prescribe medicines they heard about on TV.


Actually, big pharma does both. Marketing to doctors is sometimes even more sinister, because of (often implied) incentives for pushing more of a medication on the physician's patients.

Some resources:

[1] https://www.sciencedaily.com/releases/2018/05/180514132441.h...

[2] https://www.pewtrusts.org/en/research-and-analysis/fact-shee...

Plus, this classic Scrubs clip describing a particularly chauvinistic (but truth-in-television) take on the practice: https://www.youtube.com/watch?v=VMXa0U4WZyU


That's only in two countries in the world (NZ and USA).


And in reality, it's really only the US. Even though pharmaceutical ads are legal in NZ, they are pretty rare and most GPs won't just write a script because a patient asks for a particular drug unless there's a clear need for it. The role of Pharmac (NZ's central drug purchasing agency) also tempers the effectiveness of drug advertising so you just don't see it like you do in the mainstream US media.


Medicine is absolutely different from other markets. The entire premise of the multi-catastrophic neverending train crash in the US is that it is treated as though it isn't different. Educating doctors is critical, but that doesn't necessitate treating pharmaceuticals like any other product.

As an aside, it's insulting to preface a rebuttal with, "this may come as a shock to you".


Marketing comes down to educating consumers about your product? Have you ever seen marketing? Any education that occurs is either accidental or legally mandated.

I do agree with you that pharmaceutical marketing isn’t fundamentally different from marketing other products. Although my conclusion from that is not that pharmaceutical marketing is therefore good.


Consumers who care enough about the medicine they’re taking to request certain prescriptions want to understand them. Mass media like TV ads drives searches and visits to more detailed official material (websites, pamphlets, etc.) Without providing useful information, the manufacturer would have trouble convincing more engaged patients to switch, and similarly to other product markets, engaged customer word of mouth is vital to growth. Word of mouth is bolstered by the more familiar mass media. It’s not perfect, but it’s far from axiomatic that the communications from the entire marketing campaign are valueless. It only appears that way to TV viewers with no medicinal motivation to research the drug.


Not to mention that much of the 1st world prohibits drug advertising. The US is somewhat of an odd case in this regard.

I often ask foreign expats in America about the strangest aspect of American culture in their opinion. Believe it or not, pharmaceutical advertising is one of the most common answers I get.


> This may come as a shock to you, but marketing pharmaceuticals is really no different than marketing other products. It really comes down to educating consumers about your product.

That's how it is, in practice.

But some of us take that Hippocratic Oath thing seriously.


This may come as a shock to you, but educating the consumer is not the primary purpose of advertising.


A huge part of it is education when it comes to drug advertising.


> It really comes down to educating consumers about your product.

A lot of marketing does not seem very educational and more manipulative.


> It really comes down to educating consumers about your product.

Most advertising is more about triggering emotions and using other cognitive dark patterns than educating anyone.


You make a good point. I wonder how is drug marketing handled in places like EU. How do their doctors learn of new drugs and decide which meds to prescribe?


Talking to my European colleagues, it’s not that different from the US (although the specific rules can differ).

Personal and non-personal promotion is how it’s done in Europe.


If this system only educates doctors about the benefits of profitable patented effective drugs, they are overprescribing an arbitrary subset of effective drugs because they lack information about non-profitable treatment options.


Advertising can in general involve misleading. It’s not even close to education.


>> This may come as a shock to you, but marketing pharmaceuticals is really no different than marketing other products.

Really? You don't see the difference between marketing, say, a car or a smartphone, and marketing a drug that treats a life-threatening condition?

Perhaps you should think about this subject a bit more deeply.

>> I'd say less than 5% of doctors are cutting edge enough that they require no additional education on new drugs.

What do you base this on? Do you have some citations to support it?


I'm not a fan of drug advertising (I want it regulated, not banned) but I don't see how it's categorically different than other advertising.

Chronic pain (and a whole host of other issues) aren't life threatening. Until the mid 20th century people just lived with chronic pain and tons of other things. Look at the kinds of TV ads you see, they're for drugs that minimize the symptoms of some some negative, but not life threatening thing. These are not essential products. They're luxuries of modern life that we consider to be nearly essential. Depending on one's specific situation having a smartphone or car may actually be more "essential" to daily life than having one's condition treated.

As an aside, drugs that actually save lives don't seem to get marketed much.


On the other hand heroin and other drugs were available.


To play Devil's Advocate - without pharmaceutical companies developing and marketing drugs, how do we set up an incentive structure that encourages R&D and innovation?


If there is any devil that doesn't need your help, it's the pharma industry.

It's important to realize that to a first approximation, advertising prescription drugs is pure waste. The main case is pharma companies battling for fixed market share. That is, there are N people who have the problem, and companies X, Y, and Z are spending money trying to maximize their share of the market. The ad spend changes which pharma company does the best, but that money comes from the sick people, who would be better off without it.

The other case for advertising is demand generation, and for drugs I think it's mostly waste as well. I definitely know a couple people who are not sick enough to really need drugs (or perhaps not sick at all), but advertising-induced hypochondria means they badger their doctor until they get a prescription. That's an expensive boondoggle.

I'm sure there are some people who hear an ad and realize they have an actual problem. But if that's a significant issue, I'd rather we just paid for public service announcements for disease awareness, rather than hoping the very profitable drugs are the same ones people have the biggest medical need for.

And theory aside, advertising prescription drugs to the public was illegal for decades and we still did fine on the medical innovation front.


You realize there are a handful of therapeutic areas where they are really competitive?

It’s inaccurate to suggest that’s the only market for drugs.


As I said, I see two basic cases. In one, they're competitive. In the other, they aren't. I think general audience advertising is even less justifiable in the latter case.


Why attach all of developing and marketing, when it's only the advertising that's in question?

Doctors/hospitals can learn about new drugs through dry, informative leaflets - TV ads or salesmen talking directly to doctors distorts the demand.


I find the argument that humans will stop studying pharmacology if they can't monopolize their results quite unconvincing. Current pharma co R&D and innovation only effectively investigates the benefits of drugs with recent patents (with enough years remaining to monetize).

There is moral validity to profit-seeking investment in drug trials which find effective treatments, but the current system enables this only with great amounts of inefficiency.


>I find the argument that humans will stop studying pharmacology if they can't monopolize their results quite unconvincing.

agree

>Current pharma co R&D and innovation only effectively investigates the benefits of drugs with recent patents (with enough years remaining to monetize).

Can you elucidate the connection to your first statement - I don't see how that follows.


Defenders of drug monopolies often argue that removing the monopoly will reduce our intensive drug research spending. This may be true. However, I'd argue that the focus of this intensive drug research spending is perverted by economic incentives and overinflated because of the artificially constrained scope.

For-profit Pharma companies have a fiduciary obligation to only invest in research which they can profit from. This leads them to only invest in research in the tiny proportion of "interesting drug candidates" that can be monopolized.

Ex. - Imagine scientists find that saffron can be an effective antidepressant with few side effects. They research the active molecule and find that adding a bromine atom would make the molecule patentable, but it is slightly less effective and has more side effects. The drug company has an incentive to spend great amounts developing the less-effective patentable drug, and no incentive to research the other. Drug company has incentive to try to convince the public that their inferior molecule is actually preferable.

Now, we have a lot of data about the safety of saffron - people have included in their diets for hundreds or thousands of years. If this can be used to treat depression, it will likely have a much better safety profile than a novel molecule which has never been ingested by humans before. The therapeutic index of saffron (delta between effective dose and aversive side effect dose) is huge! Likelihood of getting it through safety trials has very high bayesian prior.

(Saffron as antidepressant is an area of recent research - all papers I've seen published by academics https://scholar.google.com/scholar?hl=en&q=saffron+antidepre..., I made up the bromine part for the example. Saffron may also be useful as anti-tumor and in ADHD treatment)

Pharma Co's may be investing intensely in researching a tiny fraction of drugs, but this fraction is less likely to contain the safest candidates and thus I don't think those dollars are being spent very effectively.


Unless money starts growing on trees, it makes sense to invest in the profitable drugs, that way you can fund future research.

Investing in a tiny market and low prices means that investment is gone and won’t support future R&D.


From what I understand the vast majority of innovative pharmaceuticals are funded by academia.


The vast majority got their start in academic settings. Most of the R&D money (in particular the expensive phase 3 clinical trials) is spent by pharmaceutical companies.


Yes, so the actual innovation occured in academic settings, as was the query.


No, that isn't the case. The fundamental research occurs in academia, but early development which includes working out how to deliver it, how to mitigate side-effects and then the clinical trials. Getting a drug into use is very distant from finding compounds in a lab.


> so the actual innovation occured in academic settings, as was the query.

Well no not at all. Innovation is both the process itself + the supporting requirements necessary to make it work on a massive scale. We cannot minimize the cost of investment in making sure treatments are effective and non-harmfulu in the general population. That is a critical part of medical innovation.


Absolutely not.

That’s like saying Apple didn’t invent the iPhone because Shockley discovered transistors.


Why do you think advertising promotes innovation? I would see it as the other way around, why innovate when you can just invest more into advertising an inferior product?


Because consumers aren't stupid and that doesn't work, probably? Because your competitor will gladly advertise their more innovative and better product, and yours will look inferior?


If you drug looks inferior to competitor's ad, you will get better return by hiring a better ad agency, not a researching a better drug (that's a crap shot at best times).


Can you discern the quality of two different drugs based on their respective ads? I certainly can't, if you have a way, I'd be interested to hear it.


Another Devil's Advocate argument- make patients aware of drugs that could solve XYZ health problem that they weren't previously aware of. They just want you to "ask your doctor about..."


I can see advertising that a condition exists and or a treatment for it exists. But, I have no idea why naming a specific drug benefits the public.


It ought to be government-funded.

What the current system gives us isn't "R&D and innovation". It's mostly ~equivalents of top-selling products. Plus new stuff that's actually less effective than old products that went generic so long ago that there's ~no promotion.


Submit them to a central, vendor-independent database so doctors (or consumers for non-prescription) can find available ones based on their ailments.


I think the takeaway is that is already available and doctors don’t consistently use it.


It would be nice if we tried to shift our focus away from drugs. We generally over emphasize the importance of drugs and surgeries to so-called healthcare and downplay or outright pooh-pooh more basic things, like hygiene, exercise and good nutrition.


provide big bounties for drug development. from the government.

we're gonna pay for the drugs either way, so we may as well create our own incentive structures to ensure that it's done right.


>how do we set up an incentive structure that encourages R&D and innovation?

Well, there's disease, death, suffering and injury. If you need more of a structured incentive than that, then I am not sure really what to suggest.


Ad supporters will sometimes say that ads are meant to get the word out about a product so people know its an option.

How can we prove that this is false or that the benefits are smaller than the drawbacks?


Seems simple: what are they willing to pay for a completely boring just-the-facts advertisement, the sort of thing you’d see in the classifieds? If the answer isn’t “pretty much the same” then they know the glitz and bullshit is critical.


For prescription drugs this wouldn't make sense. Only a doctor is qualified and legaly allowed to prescribe a drug. They have a tough job of making difficult diagnoses, weighing pros and cons for each treatment and dealing with a human in their specific life situation.

A patient that walks into a doctor's office asking for a certain medicine they heard about on TV distorts the process. After all the patient needs to believe in the treatment and might shop around for the doctor that gives them what they want.

Learning about a product in a medical context can't really happen in an ad. A doctor would have to go to a conference or read journals to figure out the latest science on treatments, and can then go and then choose an appropriate drug. They would probably look for the one that has 20mg of X in it, regardless of brand name or hype.


It was certainly closer to true historically that ads were a necessary and mostly harmless way to inform and educate consumers. Now we have advertisements being tuned with machine learning and marketers that fully understand memetics. Advertising is now dangerous and it will only get worse.


I would like to see a compromise where new drugs are allowed to be advertised to the public for say 1 year following their release then never again.

People need agency in their own medical choices, and knowing there is a drug for your medical condition is very empowering. Especially as we talk more and more about moving to a single-payer system, it's important to make sure patients have the power to question their doctors and explore their own health instead of essentially being dictated to by the state.


I live in a single-payer system in which advertising is banned, and I know every drug that could potentially be taken for my condition and all the upsides and downsides of them, including some side-effects that my doctors refuse to believe are a thing.

There's no way the only possible method of resulting in having informed patients is to put them directly in the middle of a struggle between big companies and doctors. I'd argue that putting doctors in a position of power is terrible (whether single-payer or not), but giving pharma companies' marketing departments the freedom to manipulate people with advertising is also terrible. Two wrongs do not make a right - adversarial systems are poor designs.


How about we periodically publish a big book that lists all approved drugs, their uses and side effects, and send it to every residence in the country like we (used to?) do with phone books.


In the UK most doctors have a copy of this book on their desks. Drugs and side-effects are also listed on the NHS website. (And on Wikipedia, sometimes.)

Of course the problem is the reliability of the evidence. I recently had to decide whether I wanted to go on a course of some fairly severe drugs with nasty side effects.

The original papers didn't make a lot of sense. The statistical conclusions seemed to be - if not nonsense, then certainly not very consistent.

My doctor said "Well, these are new drugs, so we're still learning about them." I didn't find that reassuring.

The real problem is that big statistical studies don't say much about why side effects happen. There seems to have been far too little research into understanding why/how side effects happen at all, and whether or not it's possible to screen for them.

That would probably require a level of personalised medical screening and dose control that big pharma isn't interested in providing.


How?

Find a natural experiment where two very similar populations, chosen at random, were placed into two different cohorts. I'm sure there's one somewhere in the recent and well documented past.


This study tested kids but it supports the argument you made, and it's pretty reasonable to assume it applies to adults as well. https://www.cbc.ca/news/kids-think-food-in-mcdonald-s-wrappe...


>The marketing of medicine in inherently unethical because it seeks to override doctors and consumers information-based evaluations, and instead make a choice based on emotional propaganda.

This is far to simplistic. It's fairly common for doctors to be unaware or poorly informed on new or uncommon treatments. They have a finite amount of time and brainpower and are not all knowing.


>They have a finite amount of time and brainpower and are not all knowing.

Yeah, there seems to be this contradiction here that doctors are naive or corrupt and are going to be swayed into prescribing us drugs we don't need, but also that we should be leaving it 100% up to doctors to be informed and prescribe us what we need.


Maybe the pharmaceutical companies can help by flying these overworked doctors to Hawaii for an informational conference.

or possibly just delivering takeout to them at the hospital so they can relax and research new treatments while eating.

(seriously, drug companies give doctors free takeout)


Most other first-world countries have banned drug advertisements, and they appear to be doing just fine. Actually, they appear to be doing significantly better than we are: no opioid crisis.


Why restrict this to medicine? It would seem that anything that takes people away from just informed reason is bad.


Marketing can provide information to aid in an information-based evaluation of the best course to take. IMO, that means it’s not inherently unethical, only that done wrong it can be unethical.


I agree that there is, theoretically, the possibility for moral advertising/marketing/promotion in medicine, but the status quo has dropped so low I'm not sure any companies today only use moral methods. I think the key is that moral marketing only serves to inform, and must deliberately avoid any bias or intentional persuasion.

- Supply your molecule for free to all researchers without any strings attached.

- Maintain an inclusive directory of research people have performed with your molecule. Publish a journal of all research and redistribute it for free.

- Commission impartial fact sheets that are surveys of treatments for a given condition - what objective measures of outcomes can be made between treatments, both positive and negative?


Yep. You do not earn by not prescribing something.


Always wondered how they get away with it.

Every time I hear “Ask your doctor about ____” I cringe. How is this ok?


I don't like the current system of pharma sales reps either, but black and white thinking like this is not healthy or productive.

Your final sentence isn't conveying any objective information -- in fact, it seems pretty close to emotional propaganda itself. Does that make you an immoral cancer on our society? (No.)


Not to mention, outright bribery.


Pretty strong opinion to posit about 1000s of people without any supporting evidence.


Morality is not objective, determining it is not an evidentiary process.


For better or for worse, consulting companies exist to:

1) Enrich their partners

2) Lend credibility to their clients

Consulting firms are hired based on an "appeal to authority" fallacy. Companies don't want to make hard/unpopular decisions, so they outsource them to consultants. Data point: management consulting is one of the industries that is hit hardest by a recession. [0] If consultants truly provided value, this is exactly when they would be most needed.

The people actually doing the work on these deals are 22-25 year olds. They are highly incentivized to make their firm look good (thus enriching the firm's partners). Anything else is gravy. Anecdotally, I have many friends who worked in the industry, and when asked if they would hire consultants for their own hypothetical businesses, the answer was always "No".

I highly recommend this article on McKinsey's work restructuring Puerto Rico's debt - it pulls back the curtain on the industry: http://nymag.com/intelligencer/2019/04/mckinsey-in-puerto-ri...

[0] https://www.ft.com/content/1a229d54-4548-11de-b6c8-00144feab...


Overly cynical.

All companies exist to provide profits to their owners.

Your argument about the datapoint can also be argued for lending: credit disappears when it’s most needed. It must be completely and utterly useless, then.

Or perhaps when a crisis strikes, if you want to minimize spending, you first eliminate consultant bills, instead of, idk, firing internal employees?

Part of the value of a consultant is that they are more mobile than an employee, so they get to see the same problem in different companies, and get expertise on that issue more quickly that if you stay on the first company in which you solved that issue. I’ve dealt with the same very-specific software on about 20 different banks, for example (disclaimer: I’m a consultant :) ); I have people under 25 on the team that are real experts on very specific things, and run cicles around people with 2x - 5x their experience if you count it in days and not problems solved.

And then of course consultants are sometimes hired for the wrong reasons and asked to do obvious recommendations. Politics were there before the consultants arrived.


>All companies exist to provide profits to their owners.

Management consultants nearly always have a conflict of interest though (i.e. the preoccupation of consultants is almost always "sell, sell, sell" rather than "help the client make money") due to the nature of their work and their short-term contact-based engagements mean they rarely have to stick around and deal with the messes that they create.

Large management consulting firms IME tend to hire (or develop maybe) people who are smart and ambitious but highly conformist and reluctant to challenge authority. Combined with nature of the work I described above (and ofc existing to make owners /partners rich), this is sort of a perfect storm for lots of "semi-unintentional" unethical behavior and sometimes fully intentional unethical behavior.

Fwiw, from what I observed this dynamic actually makes the consulting work environment terribly exploitative and miserable for non-partner consultants but consultants tend not be the personality types who would leave consulting (and the prestige/"potential to become a partner") over it --unsurprisingly, else the industry wouldn't exist as it does now.


> Management consultants nearly always have a conflict of interest though (i.e. the preoccupation of consultants is almost always "sell, sell, sell" rather than "help the client make money") due to the nature of their work and their short-term contact-based engagements mean they rarely have to stick around and deal with the messes that they create.

Not my experience at all. If you show value to the client and you build a trust relationship then you enter into a relational mode that is fruitful for both sides, and you skip/streamline all the tedious commercial topics (RFPs, competitors, beauty contests, the purchasing department demanding a 3% discount...). On the other hand, if you want to milk the cow dry then you end up on a very transactional relationship and you need to start cold selling from scratch after every project, which takes a lot of effort, time and energy.

In any case, again, the conflict of helping the client vs. overselling is hardly a consultant-specific topic; I’d say the smaller the shop, and the closer the ownership to the sales team, the more pressure there will be, in general. Case in point: the actual doctors that overprescribe opioids!


>If you show value to the client and you build a trust relationship then you enter into a relational mode that is fruitful for both sides, and you skip/streamline all the tedious commercial topics (RFPs, competitors, beauty contests, the purchasing department demanding a 3% discount...). On the other hand, if you want to milk the cow dry then you end up on a very transactional relationship and you need to start cold selling from scratch after every project, which takes a lot of effort, time and energy.

This is greatly at empirical odds with the near ubiquitous distrust for consultants among almost everyone who has worked with them.

And there is certainly no shortage of willingness to repeatedly cold sell in order to advance one's own career in consulting.


> near ubiquitous distrust for consultants among almost everyone who has worked with them

Perhaps this empirical observation doesn’t have enough unbiased samples. Consulting in general, more in particular management consulting, and even more in particular strategy consulting (where MMB, McKinsey, Boston, Bain are leaders; and the kind that sparkled this discussion), are 3 different, huge, mature, global industries. So there are empirical odds enough to say that people trust them enough to pay them, which is at odds with that universal distrust you state.

Perhaps that “ubiquitous distrust” is just more prevalent in HN or in the IT industry.


>i.e. the preoccupation of consultants is almost always "sell, sell, sell" rather than "help the client make money"

The hilarious part for me, as an independent consultant, is my partner and I often agonize over how to help the client make money in spite of themselves.

I'm not disagreeing with you---if we were employees for a big-c Consulting Firm we'd likely be under the gun to act as you describe whether we wanted to or not, and what we offer is definitely different from the most common experience people have of working with a consulting firm, but it's just funny for me to read.


Right! I should clarify that I'm only describing the big management consulting firms that most everyone has heard of. I should have wrote "management" before each time I wrote" consultant" but I didn't want to be repetitive and hoped it would be clear from the context.

Independent consultants are an entirely different group and behave very differently.


>All companies exist to provide profits to their owners.

No. This is very mistaken. There are many more stakeholders that companies have than their owners. For example, their customers. For example. Private Hospitals do not exist to make money. They can make money. But they exist to provide healthcare to sick people. As a side effect they pay their employees and make money for their owners; but if they fail to provide healthcare then they cease to exist. On the other hand, if they fail to make money they are often taken over and continue with new owners.

Companies exist to serve a function in our society, they depend on our society and they are part of it. They are not cash machines.


I get what you mean, really, but it is not what I’m talking about.

Depending on the country, the “companies” that you mention have a different legal status than an enterprise / business kind of company. I think my point was clear: not only management consultants are the ones who seek to make money out of their business.

And of course to belabor your point, if private hospitals and bakeries and carmakers are all in to make a better world, up to that standard of idealism, consultants are there too.


I feel that you're describing companies as they should be, while the quoted comment line is describing them as they have become treated.


Overly cynical.

All companies exist to provide profits to their owners.

Overly simplistic.

Not all companies exist to provide profits to their owners. There are thousands of companies in the U.S. and elsewhere which exist for other reasons.


Sure, “all” is a powerful word. It was simplistic enough to support my point, which still stands though. Perhaps it is more useful to discuss the central point on debate, instead of being picky on points that are not central to the debate?


I wonder if it's just McKinsey is the bad apple in the mgmt consulting industry or if NYT just has more inside sources there than at other firms.

https://www.nytimes.com/2018/12/15/world/asia/mckinsey-china...

https://www.nytimes.com/2019/02/19/business/mckinsey-hedge-f...

https://www.nytimes.com/2018/12/30/world/mckinsey-bribes-boe...


--- table via google ---

Firm Employees (Year) Revenue (Year)

McKinsey & Company 21,000 (2017) $10.0 B (2017)

Boston Consulting Group 18,500 (2018) $7.50 B (2018)

Bain & Company 8,000 (2017) $3.8 B (2017 est.)

--- end table ---

BCG is the only one that should have as much headlines provided they are similar in nature to McKinsey. If they are, then your hypothesis might be correct that the NYT has a lot of McKinsey sources. But how could you rule out that newspapers simply like to bash the #1 instead of the #2 or #3 if the industry leading companies are behaving in a similar fashion?


"It's almost like these people were addicted to this stuff. Oh wait, they are!"

Was an actual quote from distributors...


As someone currently dealing with chronic pain, suits like this are highly aggravating. It's just another front of the failed drug war.

People who need pain relief get screwed as doctors, hospitals, and pharmaceutical companies treat every single patient like they're a drug addict waiting to happen. The real drug addicts will continue to get their pills, while the upstanding members of society writhe in pain.


I see comments like this on every single opioid news thread.

I'm sure that you are being honest about feeling that you need to take opioids every day, but I'm sure that you understand the addictive nature of the pills and why we should avoid making more people addicted.

I have had a total of two opioid pills in my life and I could feel exactly how it could take over.


The attitude towards prohibition that your parent comment described is exactly what set the stage for the recent opioid epidemic.

We were just coming out of another era where opioids were restricted to the inhumane point where people with serious problems were left in debilitating pain - to the point where Purdue's lies were accepted because doctors felt genuine sympathy towards the suffering they saw.

There is a happy middle ground. There are people who benefit from opioid medications.

It was bad moral choices by this generation's pharmaceutical companies that caused this outbreak. That is where the fault lies.


Management Consultants: A bunch of 20 sth year olds with fancy degrees and zero experience in growing a business helping huge companies grow by whatever means possible. I always found this hugely ironic.


It's an interesting business. I've known some management consultants who were serious pros and it's a seriously impressive skill. I've also seen the army of kids who descend on an office and produce nonsense reports to provide the execs with CYA for whatever predetermined decision.


And yet these consultants created a plan so successful NYT is writing about it.


20-year-olds are also quite good at selling addictive drugs.


I wouldn't say management consultancy is unsuccessful by any means. The ethicality of what some of these firms have done? Hmm...


I'm like, isn't this old news? But no, that was Purdue:

https://www.motherjones.com/politics/2019/01/report-mckinsey...


"How Management Consultants Steal Your Watch and Then Tell You the Time"


I cant imagine how much Johnson&Johnson regrets their decision to take this to court. This is gonna hurt their reputation for decades. Its basically the second opium wars, except they went to war against their own country


Cha-ching. (Sound of analog cash register closing.)

http://www.news.com.au/finance/business/states-want-their-cu...

"There is an enormous need in developing countries who don't have access to pain relief, it's a human right to have access to pain relief."

Are we supposed to believe demand was being fueled by "developing countries"?


there are a lot of comments on this thread about the moral hazard of pharmaceutical advertising. i think the arguments against such advertising largely hold water, but i’m curious; what are the arguments for it?

can anyone substantiate an argument for why consumer advertising for prescription medications is good for patient outcomes?


Reminds me of the tosh.o episode where he interview parents of kid actors


Sure, sell more of a product that kind of sells itself without proper advising. Some of these allegations seem predatory. How does this affect the reputation of McKinsey and its future business? Would there actually be any impact? They are good at their job. Is McKinsey attracting the same talent it historically has or are other kinds of companies getting what would be their talent?

""" McKinsey recommended “targeting and influencing” doctors who specifically treat back pain in the elderly and those in long-term care. The consultants also advised the company to move physicians who were “stuck” in prescribing less potent opioids into prescribing stronger formulations. """




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