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Medical doctor and pharmaceutical-policy researcher Joel Lexchin joins us to discuss the impact of pharmaceutical-company sponsorship on medical research, why merely disclosing these financial conflicts of interest is not enough (and may not be accurate or complete), some of the surprising tactics drugmakers use to get more favorable study results and conclusions, and lots more. Behind the paywall, we discuss how to think critically about industry-sponsored research without getting sucked into conspiracy theories and becoming vulnerable to the wellness industry, the role of pharmaceutical companies in creating the craze for GLP-1 weight-loss drugs, and the disturbing truth about many patient-advocacy groups.
Joel Lexchin received his MD from the University of Toronto in 1977. He is a Professor Emeritus in the School of Health Policy and Management at York University in Toronto, Canada, where he taught health policy until 2016. In addition, he worked in the emergency department at the University Health Network in Toronto for over 34 years. He has published two books since 2016: Private Profits vs Public Policy: The Pharmaceutical Industry and the Canadian State (University of Toronto Press, 2016) and Doctors in Denial: Why Big Pharma and the Canadian Medical Profession Are Too Close for Comfort (Lorimer, 2017). He is a member of the Foundation Board of Health Action International and the board of Canadian Doctors for Medicare. He is a fellow of the Canadian Academy of Health Sciences and is among the top 2 percent of the world’s most highly cited researchers.
Resources and References
Contains affiliate links to Bookshop.org, where I earn a small commission for any purchases made.
Christy’s second book, The Wellness Trap: Break Free from Diet Culture, Disinformation, and Dubious Diagnoses and Find Your True Well-Being
Subscribe on Substack for extended interviews and more
Joel’s co-authored 2018 Cochrane Systematic Review on pharmaceutical sponsorship
Joel’s other academic research
Some of Joel’s recent popular-press articles
Christy’s online course, Intuitive Eating Fundamentals
Transcript
Disclaimer: The below transcription is primarily rendered by AI, so errors may have occurred. The original audio file is available above.
(Just a heads up that when we talk about GLP-1s, Joel mentions a couple weight percentages and BMI numbers in the context of critically analyzing GLP-1 research. Also, there's one correction. Towards the end of the episode, Joel says DEC for the acronym of a drug, but he actually meant DES, which stands for Diethylstilbestrol, a synthetic form of estrogen.)
Christy Harrison: Joel, welcome to Rethinking Wellness. I'm so excited to talk with you today.
Joel Lexchin: I appreciate your asking me to be on your show. I think the message about drugs for people who have large bodies is a very timely topic and something that needs a lot of discussion.
Christy Harrison: Yeah, thank you. Well, I'm really looking forward to talking with you about that today. So I want to dive into all of that around the influence of pharmaceutical companies on research and medicine, and particularly as it relates to GLP-1 drug manufacturers, and how they've influenced the discourse and the demand for these drugs, and also how to think about that kind of influence without falling into the kinds of conspiracy theories about big pharma that are so prevalent in wellness culture and that can drive people to unproven alternatives and really harmful supplements and things like that.
But before we get into all that. I'd love to just hear a little bit about how you came to do the work you do or you did, and devoted a large part of your career to, which was studying how the pharmaceutical industry affects research outcomes and doctors' prescribing patterns.
Joel Lexchin: Sure. So this is actually something I've been doing for over 50 years now. Just a little bit of background. I'm a child of the 1960s student left movement, and when I started to think about a career in healthcare, my political activities shifted to healthcare topics. And one of those, even back then, was the influence of the pharmaceutical industry. And I've been working in that area ever since then. I wrote a book about the pharmaceutical industry in Canada in 1984, followed up with a couple of more books in the mid-2000s and teens, and I've been writing articles, reports for a long time. In addition to which, I also worked as an emergency physician for 40 years and taught at one of the local universities for 15 years.
Christy Harrison: How did your role as an emergency physician play into what you saw in terms of pharmaceutical industry influence?
Joel Lexchin: Well, the pharmaceutical industry did not send its representatives to the emergency department very often, if at all. That was simply because they couldn't be sure that they would get any facetime with us. The emergency department is unpredictable, and we could be talking to somebody and then have to rush off somewhere. So we didn't see them at that level for a number of years. They were sponsoring what were called citywide emergency medicine rounds. There would be a representative at these rounds, and usually they would be displaying either a product that they were trying to get doctors to prescribe, or they might be giving out free books to the people who were attending. And then there's also the presence of pharmaceutical companies at meetings that we have. So there would be a room with display tables for the industry.
But the industry also had an indirect and quite, I believe, profound influence on the way we prescribed, because the industry would often be the payer of the expenses associated with developing clinical practice guidelines. And there's certainly research out there that shows that when the industry is involved in those guidelines production, they tend to be biased in favor of drug therapy, especially the drug therapy that's made by the companies that are providing the resources to do the clinical practice guidelines. So the industry had some direct influence on what we did, but I would say that it had more indirect influence through things like paying for either clinical trials or clinical practice guidelines.
Christy Harrison: I'd love to dig into some of that and some of the problems with the pharmaceutical industry influence on those things and on medicine in general. What impact does pharmaceutical industry sponsorship have on research?
Joel Lexchin: Best way of looking at this is to think about an American bank robber in the 1930s. When he was finally caught, so the story goes, a reporter went up to him and said, "Willie, why do you rob banks?" And Willie said, "That's where the money is." So where is the money to conduct clinical trials, especially clinical trials, when you want to get a new drug on the market? And the money is with the pharmaceutical companies, and most of that money goes to clinical trials. The industry actually does very little basic research. I think it occupies about five percent of the money that is spent. Basic research is publicly funded in the US by the National Institutes of Health.
Christy Harrison: Can you just explain the difference between basic research and a clinical trial for anyone who doesn't know?
Joel Lexchin: Sure. Basic research is what's the receptor on this cell that we should direct a drug towards? What's the physiology behind a disease? So it's an understanding at a very basic level of how diseases work and how drugs work. Clinical research is we've got this molecule, and now we want to see if it's going to be effective. So first we'll try it out on animals. We'll also do what's called in vitro testing. So how long does it take to dissolve? What are the breakdown products? Things like that. And then the clinical research are the three phases of clinical trials involving increasing numbers of patients.
Christy Harrison: Right. So pharmaceutical companies really fund the bulk of that kind of research, right?
Joel Lexchin: They do for drugs that they want to get on the market. They fund about 100% of that research because nobody else is going to pay for it, nobody else is going to make money from if it's successful. Once drugs are on the market, there is some independently funded research that's being done.
Christy Harrison: You co-authored a Cochrane systematic review in 2018 that found "sponsorship of drug and device studies by the manufacturing company leads to more favorable efficacy results and conclusions than sponsorship by other sources." Can you explain how that happens exactly? It seems like from that research, it's not that industry funded studies necessarily have worse methodology, but there are other reasons why they tend to find more favorable results.
Joel Lexchin: You can get the answer you want by changing the question. So you may be looking at a new drug for a particular disease. You're looking at changes in numbers. The question you're asking is, does drug X help to lower cholesterol, or does drug help to lower blood pressure? Things like that, which may be useful questions, but they're not the questions that people, patients and clinicians, really want to know the answers to. What we want to know the answers to are questions like, does the person live longer? Does the person have a better quality of life?
So if you ask the question about changes in numbers, you may get a good answer, but that doesn't necessarily mean that the really important topics are going to be answered or answered positively. The other thing that companies do, if you're comparing drugs, you don't choose the best alternative. You choose a so-so alternative where you don't choose the right dose of the alternative, you choose a dose that's too high or too low, you bury the results of studies that don't turn out the way you want them to, so nobody ever sees them.
Christy Harrison: And that can be in the contract, right? When the pharmaceutical company agrees to sponsor a study, from my understanding, they will sign contracts with researchers, and a clause in there is often that we have final say as to whether the study gets published. And so if it's not a result that they want, they can just not ever publish it.
Joel Lexchin: I mean, there are some very famous examples of this. So there were studies back in the mid-2000a looking at whether or not SSRI antidepressants were useful in children and adolescents. Those studies didn't produce the results that the companies wanted. And there are either memos or email messages saying, essentially, that the study didn't work out properly. We'll have to bury the results.
Christy Harrison: Yeah, that's fascinating. So there's all these ways that the outcome of studies and whether studies get published or nothing. I've also seen examples of ghost writing, and the company will actually be a part of writing and editing the final results. And so they can sort of interpret and put a spin on things that maybe weren't found in the actual trial.
Joel Lexchin: That's right. They hire what are called MECs, medical education companies, who have employees, who have PhDs, who can write well, and these are the people who will write the study in the direction that the drug company wants it to go. And at the top of a draft of these kinds of studies, where the authors are supposed to be listed, it'll say author TBA, or TBD, to be determined, and then they will go out and find an author who has got some credibility in the area. That person may be paid. If they're not paid, they may be wanting to use publications to get promotions or help them get research grants. So that happens quite frequently, although how frequently, we don't know, because these kinds of things are typically hidden and may only come out in court cases.
Christy Harrison: Wow. Fascinating. So we've been talking about financial relationships with drug companies in the research side of things. What impact do those relationships have on doctors likelihood of prescribing drugs?
Joel Lexchin: That's a timely question. I'm involved in another Cochrane review that's been going on far too long that looks at the effect of interactions between doctors and drug companies on three different aspects of prescribing. So one is appropriateness. In other words, are doctors prescribing the right drug for the right reason, for the right length of time? The second is, what's the cost of a prescription after an interaction? Does it go up, down, or stay the same? And the third is the quantity of prescribing. So are doctors prescribing a greater number of drugs, or is the prescription larger after interactions?
And we've identified 67 different trials that have looked at this question in a methodologically rigorous way. We're in the process of analyzing the results, but by and large, the overwhelming number of studies, and we're here talking about, I would say, out of the 67, between 60 and 65 show that either prescribing in one or more of these dimensions doesn't change, or prescribing gets worse. So doctors are prescribing less appropriately, more costly, or greater quantities. And there are only a few studies that show that prescribing actually improves. So the impact on patients is not well studied, but it's very likely to be that patients do not see improvement in their conditions or the degree of improvement that could be possible, or they might actually get worse.
And when you think about inducements or interactions between industry and doctors, some people will think about, okay, a trip to Hawaii in the middle of January, something that may cause doctors to change their prescribing. But in fact, studies that have been done in the US show that all it takes is a $20 meal. So that's a little more than a lunch at McDonald's to change prescribing. So if you go to a meeting where you get a $20 meal that's paid for by company X, and company X is using that event to promote its drug, when you look at prescribing behavior after doctors have attended that event, you'll see that the number of prescriptions for the drug made by company X goes up.
So it doesn't take an awful lot to influence the prescribing pattern of doctors. This doesn't mean that every doctor is going to be influenced every time, but it certainly happens enough that drug companies are willing to spend the kind of money that they do on promotion. And the latest figures from the US on the amount of money that's being spent is in the range of, I think, $28 billion a year. And that figure comes from about seven or eight years ago, so it may well be higher.
Christy Harrison: Wow. So there is a lot of transparency now about these financial relationships. And I imagine that was probably not the case when you first started doing this work. These days, you have disclosures and studies, usually at the bottom, unfortunately. So people have to kind of dig and look for it. But youll see at the bottom who the study was sponsored by, usually, and whether anyone was on the payroll of that company, who was conducting the study, or if they held stock or whatever. Conflicts of interest disclosures are common.
And then in terms of doctors relationships with pharmaceutical companies in the US, there's an open payments database where theoretically, anyone who wants to can go look up their doctor and see what kind of money they're taking from the pharmaceutical industry. In practice, I think that rarely happens but I do it as a journalist. I know some other journalists who do that just to put into context who their sources are and what relationships they might have with drug companies, although far too little when it comes to reporting about GLP-1s and other blockbuster drugs, I think.
So there is technically transparency. But why do you think that's not enough? And why isn't anything really being done about these conflicts of interest that could be swaying the research and the practice guidelines, and also physicians prescribing patterns in ways that don't actually benefit patients?
Joel Lexchin: So, first of all, you're right that there are disclosures at the end of articles about the author's conflict of interest with drug companies. But there have been a number of studies that show that those disclosures are not often complete. Doctors leave off relationships that they've had because they don't think that they're relevant. Sometimes it's at the level of the journal. The doctor may disclose everything. The journal may decide that only certain conflicts need to be disclosed. So relying on what's in the medical journals at the bottom is not necessarily good enough.
Transparency is definitely necessary, but transparency is not enough. So if I go to a talk or I read a medical journal article, and at the start of the talk, the person discloses relationships. And by the way, those disclosures have actually been timed, and they last for, on average, 2.8 seconds. So that's how long a slide will be displayed. So barely enough time to read it. If you blink, you'll miss it. But if I go to one of those lectures, or read a journal article, or look at a clinical practice guideline and see that Doctor X, Y, or Z had relationships with a variety of companies, that doesn't help me an awful lot, because I don't know whether or not what that doctor is going to say has been influenced by those relationships or not.
I mean, I can go back and try and read all the necessary literature to figure out whether or not, in my view, what that doctor is saying is actually accurate. But I don't really have the time to do that. If I'm trying to read a couple of medical journal articles a day, or if I'm going to a meeting, because I've got patients to see, I've got the rest of my life to live. So transparency only goes so far. And there have actually been studies done on the value of transparency and in some of those studies, what we find is transparency is counterfactual.
So I'm giving a lecture and I say I've received money from companies A, B, and C. And having made that disclosure, I've said, okay, I've told you about me, and now you, you being the audience, you have to be wary, you have to use those disclosures to evaluate what I'm going to say and I feel that I can tell you lies now. I've been honest up to this point, and now I'm just going to tell you whatever I want to, and it's up to you to figure out whether or not what I'm saying is correct. And when you look at it from the reverse point of view, the audience who's listening says, "Gee, Doctor Lexchin's an honest person. I can trust them." So if I'm telling you things that aren't true or that distort the evidence, you may be more likely to believe what I'm saying.
Christy Harrison: And so that's been shown in research that presenters are less honest after they've disclosed something like that?
Joel Lexchin: It hasn't been shown with doctors, it's been shown in a more experimental level, but there's no reason to think that it would also occur at the level of doctors.
Christy Harrison: Wow.
Joel Lexchin: So, as I said, transparency is necessary, but we need to go to beyond transparency, and we need to go to the level of avoiding conflicts whenever possible. And that's not being done. And it's not being done for a number of reasons. First of all, it's the money. If I'm a researcher, and in Canada, if I apply to the Canadian Institutes of Health Research for a grant, I've got about a one in seven chance of getting that grant. I mean, I've been on projects where we've had to go three or four rounds before we were successful. So you can only apply every six months. So that means a couple of years waiting to get a grant.
And the same is true in the US. The NIH, although it provides a lot more money on a population basis than Canada does, you're still in the range of 15% of grant applications get funded. So you're a researcher, you've got what you think is a good idea, you think it might help people. You get turned down by the NIH, so you go to a drug company. So that's one level. But there are other levels, too, and one of them is at the political level. The pharmaceutical industry in the United States devotes hundreds of millions of dollars to either lobbying or payments to politicians who are running for office. And that money doesn't go unnoticed.
That money that the lobbying and the politicians who are getting election funding from the companies are going to be more favorable to the companies. That's why your Medicare program doesn't have the ability to negotiate drug prices with drug companies, because that was deliberately stated in the legislation back in 2004 or 2005 that brought in Medicare Part D, where the public started paying for prescription drugs for people 65 and over. It also has influenced legislation in the US about drug pricing and influenced other things around how much is allowed or not allowed in drug promotion.
The US is one of only two countries in the world that allows direct to consumer advertising of prescription drugs. We see that in Canada when we watch American TV. The companies are spending, I believe, in the range of $6.5 billion a year on those ads that you see. And why are they allowed to do that? Why hasn't any action been taken? And again, it goes to the influence on the political process.
So for those reasons and others, the industry is economically very powerful in the United States in terms of trade balance, in terms of employment of highly talented people. The industry is extremely important and politicians don't want to rock the boat. If you're running for office, you don't want to be the one who is accused, rightly or wrongly, of causing a company to let go half of its research staff or close its research facility or something like that.
Christy Harrison: Yeah. So there's so many incentives keeping the pharmaceutical industry's influence and sort of sway over the healthcare system in place. And I want to make sure that we don't give rise to or sort of inadvertently fan the flames of this conspiratorial worldview that I see so much in wellness culture that blames big pharma for everything and then turns around and says, "Use my supplements. They're natural, they're not influenced by pharma" or "Don't use vaccines because big pharma has everyone in his pocket and vaccines can't be trusted and so avoid them. Don't see a doctor, see a naturopath instead," or whatever. So how can we think critically about industry sponsored research without inadvertently getting sucked into these kinds of conspiracy theories and being vulnerable to wellness industry and all of its harms?
Joel Lexchin: Thats a very difficult question to answer.
