Monday, November 14, 2011

Eli Lilly's "Pain TV": Are they serious?

Sometimes in the CME field you come across something that seems so embarrassing for everybody involved that you just have to shake your head and wonder what they were thinking. So here is the link to Medscape's ACCME Accredited Category 1 CME activity called "Pain TV", supported by an "unrestricted educational grant" from Eli Lilly, manufacturer of Cymbalta, which recently won the FDA indication for chronic musculoskeletal pain--in addition to its indications for depression, generalized anxiety disorder, diabetic neuropathic pain, and fibromylagia. According to Pharma Marketing Blog, each new indication means another $500 million in the bank for the company.

To ensure that it will gain its windfall, Lilly has teamed up with Medscape, several academics on speakers bureaus for multiple companies, and lord knows what other ancillary production and medical writing companies, to produce a lavish 12 part series called "Pain TV" in which they will "educate" doctors about how to diagnose lots of patients with chronic pain, and how important it is to treat it. Will they blatantly push Cymbalta as the very best treatment? Of course not, since that would reveal the promotional intent of this CME program. Instead, they will teach us about the horrors of pain, the dangers of opiates, and about a new non-addictive treatment with a recent FDA approval for the condition that Lilly is paying millions to educate doctors about.

Maybe Cymbalta is, indeed, a miracle drug for chronic pain. Maybe all pain patients would benefit enormously from it. I'm not a pain specialist, and therefore I am in no position to judge the relative advantages or disadvantages of Cymbalta for pain. I'm certain there are thousands of complicated studies in the medical literature that have some bearing on whether Cymbalta is the go-to medication for this condition--and I am also certain that reasonable doctors would disagree about the relative merits of these studies. Accredited CME is supposed to be a way for doctors to learn about best medical practices from unbiased and credible colleagues. Unfortunately, I'm assuming that doctors who are paid by Lilly (indirectly via Medscape in this case) will have an overwhelming financial incentive to emphasize the strengths of Cymbalta and the weaknesses of its competitors--which is the very definition of commercial bias. It doesn't mean that Pain TV isn't of some educational value--many promotional activities can be quite educational. Just don't pretend that it meets ACCME's criteria for accredited CME.

I am certain that this is not the kind of CME that the AMA's new ethics guideline condones: "For the most part, accepting support from a company or permitting participation by an individual when there is an irreducible financial interest would not be ethically acceptable."

But then again, maybe I'm misreading the intent of these guidelines. Perhaps the AMA would be all for a CME activity in which Lilly funds a 12 part TV show highlighting a disease state for which it happens to have a treatment all dressed up and raring to go.


Neuroskeptic said...

Oh dear.

"the dangers of opiates"

'Opiates are very dangerous for two key reasons: 1) they work 2) they're off-patent.'

Bernard Carroll said...

Plus ça change, plus c’est la même chose.

SteveBMD said...

"I'm not a pain specialist, and therefore I am in no position to judge the relative advantages or disadvantages of Cymbalta for pain."

But that's exactly the point. Lilly doesn't want pain specialists prescribing its drug, they want primary care docs, RNPs, psychiatrists, OB/GYNs, etc to prescribe it. Much bigger market there (and docs with less time to critically evaluate the data).

Working in several psychiatric (i.e., non-pain-management) settings over the last few years, I can confidently say that Lilly has done a fantastic job of teaching us to think of Cymbalta almost as a conditioned response whenever a patient with depression mentions "pain."

And to them, that's all that matters.

(Incidentally, the FDA panel's comments on Cymbalta's pain approval make for some interesting reading. I include some excerpts in this post.)

Joseph P Arpaia, MD said...

Having patients tell me that it was easier to come off oxycodone than it was to come off Cymbalta I am not sure that the FDA has done us a favor.

Also since most patients with chronic pain are also taking NSAIDS and there is a much higher risk of GI bleed when NSAIDS are combined with serotonin reuptake inhibitors I wonder what the eventual outcome is going to be.

SG said...

"Having patients tell me that it was easier to come off oxycodone than it was to come off Cymbalta I am not sure that the FDA has done us a favor."

BINGO. I recently spent an eye-opening hour on a message board for recovering and current drug users and they had a poll where people were asked which the hardest drug they had to come off of was -- legal or illegal. Almost all of them said benzos. Keep in mind some of these guys were hardcore drug users who did stuff like speedballing (simultaneously shooting heroin and coke). Many of them said that they'd rather go through heroin withdrawal any day compared to benzo withdrawal.

Yes, benzos are not the same class as SNRIs, but it's still a psych med and it ties into what you're saying, Dr.

And for what it's worth, Effexor (another SNRI) shares the dubious distinction with Paxil for being THE WORST SSRI/SNRI to withdraw from, where withdrawal for some unfortunate patients can drag on for years. I'm sure Cymbalta is way up there too, since it's another SNRI and has a shorter half-life than Paxil!

Isn't it amazing what drugs this society chooses to demonize? Who'd a thunk it all comes down to $$? We should have known.

Anon said...

Cymbalta was directly connected to the death of a family member. I am not able to go into details but suffice it to say that the chief complaint was a backache.

Sean Paul said...

Multiple antidepressants have been shown to be useful for the treatment including Tricyclics. The NIH would be well directed to do a head to head trial with other SNRI's, TCA's and Cymbalta and see what wins out.

Anonymous said...

dr carlat-
i found your site through a search engine while researching the effects of stopping cymbalta. although i've followed my doctors instructions, i have to agree with a poster below...the withdrawal from this drug are far more painful than any opiate that i've (mis)used.
please forgive my lack of punctuation and what may seem to be a lack of education. i am educated and am a professional. i'm also consistently not able to sleep for two days straight, have hallucinations and am intense pain. the good news is that the side effects that inspired me to come off have disappeared. the better news is that what i'm now experiencing is easier than coming off of effexor.
i know that what i'm going through will pass. my inspiration for posting this is to thank you for taking the time and effort for this blog. your writing and insight has been a tremendous help.