Countering the Drug Marketing Machine

Harlan Krumholz & Howard Forman, Yale Medical School | Health & Veritas Podcast.

In a Wide-Ranging Interview, Dr. Jerry Avorn Explains How the Drug Marketing Machine Works — and How to Counter It

Source: Health & Veritas, Yale School of Management, Episode 195, November 13, 2025

In a November 2025 episode of Health & Veritas — the Yale School of Management podcast hosted by physicians Howard Forman and Harlan Krumholz — Jerry Avorn, MD, sat down for an extended conversation covering the origins of academic detailing, the erosion of FDA approval standards, the structural conflict of interest built into drug regulation, and the dangers of direct-to-consumer pharmaceutical advertising. The discussion draws directly on themes from Dr. Avorn's 2025 book, Rethinking Medications: Truth, Power, and the Drugs You Take.

What Is Academic Detailing, and Where Did It Come From?

Dr. Avorn traces the idea of academic detailing to his years as a resident physician. As he explains it, the pharmaceutical industry had developed extraordinarily effective methods for communicating drug information to physicians — sending sales representatives directly into doctors' offices, asking interactive questions, and presenting appealing materials. Academic medicine, by contrast, communicated primarily through journal articles and lectures, which left a significant gap between the best available evidence and average clinical practice.

"I figured, why can't we use the same communication strategies that drug companies use of going out to doctor's offices, talking with us interactively, asking us questions, having appealing materials to show us," Dr. Avorn says in the interview. "And act more like sales reps than academics behind a podium."

The result was academic detailing: a model in which trained clinicians — pharmacists, nurses, and physicians — visit prescribers in their own offices, engage them in interactive conversation, and deliver evidence-based drug information using the same interpersonal techniques the industry employs for commercial promotion, but strictly for non-commercial purposes.

Host Howard Forman clarified the origin of the term for listeners: "detailing" refers to the practice of pharmaceutical sales representatives visiting doctors' offices to pitch their products. Academic detailing is its evidence-based counterpart — what Forman described as "counter detailing."

Who Funds Academic Detailing?

Funding non-commercial physician education turns out to be a persistent challenge. Dr. Avorn co-founded Alosa Health, a nonprofit that provides academic detailing services, and has assembled funding from an unlikely mix of sources.

He describes one example: at the height of the opioid epidemic, Aetna contacted him and offered to fund an academic detailing program targeting opioid overprescribing. "They said, 'We just want to be good corporate citizens,'" Dr. Avorn recalls. "They didn't ask for anything in return. They didn't want to have any say about the content." He notes that the CDC has also supported opioid-related programs, both directly through Alosa and through state entities, and that the Indian Health Service has engaged Alosa for work on immunizations.

Staying on the Side of Evidence — Not the Side of "No"

A recurring theme in the interview is Dr. Avorn's insistence that academic detailing is not anti-medication. He describes checking himself against what he calls the "just say no to drugs" trap — a reference to the Nancy Reagan-era campaign he characterizes as "completely idiotic" in its approach to a complex clinical problem.

"Medications are great; we all know how much they help our patients," he says. "It's only about use the right ones and use them a lot. Just don't come out against drugs." As host Harlan Krumholz puts it, the goal is to promote appropriate prescribing "for the place where the evidence is strong." Dr. Avorn agrees: "Really what we're in love with is the evidence."

The FDA's Accelerated Approval Pathway: From AIDS Crisis to Abuse

The conversation turns at length to the FDA's accelerated approval pathway, which Dr. Avorn traces to its origins in 1992 during the AIDS epidemic. At the time, the FDA's review process had become cumbersome at a moment when patients at death's door from AIDS needed access to potentially life-saving medications urgently. AIDS activists, including Gregg Gonsalves — a Yale faculty member and former Health & Veritas guest — pushed the FDA to move faster. "We don't want a great drug that's approved in three years and we're dead," Dr. Avorn summarizes the activists' position.

The pathway made sense in that context, Dr. Avorn says, and still makes sense when used selectively. The problem, in his view, is that it has since been "abused" by the pharmaceutical industry, which has used it to push drugs onto the market that are, in his assessment, actually ineffective. He specifically cites drugs approved for muscular dystrophy that "do not work, but they've managed to give them accelerated approval and then the follow-up studies just somehow don't ever get done."

The discussion touches on ELEVIDYS, a drug for Duchenne muscular dystrophy that received FDA approval despite its advisory committee's reservations. Host Howard Forman raises the genuine tension: families of children with the disease are desperate, and any chance at benefit feels worth taking. Dr. Avorn responds with a policy proposal he finds both pragmatic and equitable: allow drugs with slender evidence onto the market, but require them to be priced modestly until they demonstrate genuine effectiveness. "There's a tremendous incentive now to market it at the full freight," he says, referring to the current system in which a drug with minimal evidence can be priced at whatever the manufacturer chooses from the moment of approval.

Direct-to-Consumer Drug Advertising: A Largely American Phenomenon

Dr. Avorn is direct about his position on direct-to-consumer pharmaceutical advertising: he would ban it. He notes that the United States is virtually alone among industrialized nations in permitting it, describing the pre-1997 legal environment — when such advertising was prohibited — as the standard he would return to.

"I would love to go back to 1997 when we had laws and regulations that said you cannot advertise prescription drugs to consumers because the ideas and evidence are so complicated, you can't cram it into a 30- or 60-second TV commercial," he says. He lists Canada, Germany, France, Japan, and Australia as examples of countries with strong healthcare systems that prohibit consumer drug advertising entirely, noting that New Zealand is the only other country that allows it, and even there it operates under tighter constraints than in the US.

Dr. Avorn acknowledges skepticism that such a ban could be achieved politically given the strength of industry lobbying, and expresses frustration with what he characterizes as rhetoric without action from the current administration on this issue. When host Krumholz proposes at least requiring equal time for academic detailing following drug advertisements, Dr. Avorn responds simply: "PSA's."

PDUFA and the Structural Problem of Industry-Funded Regulation

One of the most pointed exchanges in the interview concerns the Prescription Drug User Fee Act (PDUFA), originally passed in 1992. The law established a system in which pharmaceutical companies pay fees that now fund more than half of the salaries of the FDA scientists who review drug applications.

Dr. Avorn calls this arrangement "just not healthy" and offers a vivid analogy: "It's kind of like having one of the litigants in a court case paying half the judge's salary." He argues that the arrangement creates a structural dynamic in which the FDA knows that if industry were to withdraw its user fees, the agency "would be down half of its personnel budget and it couldn't function."

His proposed remedy is direct: a grown-up country should fund its regulatory agencies through its federal budget, without requiring those agencies to seek financial support from the industries they regulate. He acknowledges this as an "idealistic kind of post-sixties boomer fantasy," but maintains it is the correct structural solution.

Host Krumholz observes that describing these payments as "user fees" sanitizes their nature: "They're actually paying subsidies to the people who are making judgments."

Conflicts of Interest in Medicine: A Gradient, Not a Binary

The interview addresses physician-industry financial relationships in nuanced terms. Dr. Avorn rejects a blanket condemnation: if a physician is devoting 40 percent of their time to designing and managing a clinical trial, he says, "of course they shouldn't be expected to do that as volunteers." That, in his view, is legitimate.

What he finds more troubling is the practice of drug companies paying physicians to attend programs that consist largely of commercial presentations for the company's products — a transfer of cash he describes as "much less savory."

He credits the Open Payments program, established as part of the Affordable Care Act and sometimes called the Sunshine Act, as a meaningful step forward in requiring disclosure of industry payments to physicians. "Just putting that out there in the open, I think, was a step forward," he says.

For his own Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women's Hospital and Harvard, Dr. Avorn established an unusual rule: no faculty member may accept personal compensation as a consultant to pharmaceutical companies. Research grants and contracts from companies, if they relate to studying drug side effects, are permitted — but they are routed through the hospital and governed by explicit contractual terms. "I just decided... that nobody in any kind of central role is going to be able to say that they doubled their salary by being a paid consultant to Novartis or Merck or Pfizer."

Drug Policy as a Bipartisan Problem

Throughout the conversation, Dr. Avorn is careful to situate the problems he describes as bipartisan. "I think some of the problems that I write about in the book occurred in Democratic as well as Republican administrations," he says. "Some of that bad legislation was written by Democrats as well as by Republicans." He attributes the cross-party influence of the pharmaceutical industry to its status as "one of the largest lobbying entities in Washington, maybe even the biggest," which enables it to distribute political contributions across party lines. "This is not a right/left issue," he concludes. "This is a kind of a graft/non-graft issue."

About the Source

This post is based on Episode 195 of Health & Veritas, produced by the Yale School of Management and the Yale School of Public Health, released November 13, 2025. The full episode — including an additional segment on an infant botulism outbreak linked to ByHeart infant formula — is available on Apple Podcasts, Spotify, YouTube, and at the Yale Insights website.

Dr. Avorn's book, Rethinking Medications: Truth, Power, and the Drugs You Take, is published by Simon & Schuster (2025).