6/14/2000 – PROZAC – New directions: Science, money drive a makeover

This article which ran in the Boston Globe last Sunday does a
good job of demonstrating the awkward position the makers of
New Prozac are in- defending the new Prozac without offending
its new partner, Eli Lilly.

http://www.boston.com/dailyglobe2/163/nation/Science_money_
drive_a_makeover+.shtml

PROZAC – New directions
Science, money drive a makeover
By Mitchell Zuckoff, Globe Staff, 6/11/2000

This is a story about a drug that changed the world, the bravery of
rats, the evolution of a psychiatrist, the Jekyll and Hyde nature of
man-made chemicals, the Church of Scientology, and the
impulses that lead some people to kill.

It is also about money. Lots of money.
——
In 1848, Louis Pasteur discovered that some molecules can
exist in mirror forms – the same chemical composition can build
shapes that curve one way or another, said to be left – or
right-handed.
Natural molecules come in only one shape, but the procedures
for creating manmade molecules create both left- and
right-handed forms at the same time. Sold as the
antidepressant drug Prozac, fluoxetine include the two shapes,
called isomers, pictured below.
Because the different isomers are difficult to separate, the FDA
allows drug companies to include both in medicines, as long as
the less-functional isomer is not harmful. Isolating R-fluoxetine
could yield a more effective drug with fewer side effects.
The drug is Prozac, and its resume is lore: Introduced by Eli Lilly
and Co. in 1988 as the first notable new antidepressant in two
decades, it lifted the spirits of millions and became shorthand
for the search for answers in convenient pill form.
Yet its triumphs have been clouded by persistent accusations,
denied by Lilly, that a small but significant percentage of Prozac
users suffer a side effect that runs counter to the drug’s intent:
intense agitation that in rare cases explodes into violence,
suicide, or both.
Now, as the familiar green-and-white pill approaches the
humbling status of a generic drug in 2004, along comes a new
drug derived from Prozac – ostensibly without the dangerous
side effects – that is designed to take Prozac’s place in the
medicine cabinet and on Lilly’s billion-dollar balance sheet.
And along with that new drug comes a most unexpected
helpmate for Lilly: a Harvard psychiatrist named Martin H.
Teicher, who in the space of a decade has taken an
extraordinary journey.
Once Prozac’s most prominent critic – author of the first scientific
paper to wave the red flag of suicide and violence Teicher is now
enjoying what he calls a ”wonderfully ironic” role as co-inventor
of the Prozac replacement drug.
With a high-flying Massachusetts drug firm acting as
middleman, Teicher stands to grow rich from Lilly, despite its
continued rejection of his conclusions about suicide. If the new
Prozac clears ongoing trials and proves even moderately
successful compared to its predecessor, Teicher could
supplement his associate professor’s salary by more than $5
million a year.
At the same time, Teicher’s decade-old observations about
Prozac’s dangers have resurfaced in a very awkward way for Lilly.
The drug patent obtained by Teicher and his co-inventors says
the new Prozac is free from the suicide side effect, and last week
that claim became the basis for a federal fraud lawsuit against
Lilly. The lawsuit essentially accuses Lilly of denying any
Prozac-suicide link on the one hand, yet buying an exclusive
license for a patent that says otherwise.
For perspective, imagine that car-safety crusader Ralph Nader
identifies a major safety flaw in, say, the braking system used in
all cars. The automakers deny that the flaw exists. Nader then
invents a device that fixes the flaw and offers it to the
automakers. Despite denying the problem, they pay him millions
for it.
Now substitute Teicher and Lilly in those roles, and that’s what
makes this a uniquely American tale about the pursuit of
knowledge, the pursuit of profits, and the arranged marriages
that sometimes bring them together.

The psychiatrist’s den
Teicher’s office at the Harvard-affiliated McLean Hospital in
Belmont has all the trappings of a psychiatrist’s den. There is the
leather couch, the bursting bookcase, and the wall of diplomas –
PhD from Johns Hopkins in 1977, MD four years later from Yale
University. A clock chimes to mark the passing hours.
There are personal touches, too: a jar on a shelf jokingly labeled
”Ashes of former students”; and a quote on the wall from
Voltaire, ”No problem can withstand the assault of sustained
thinking.” A plaque commemorating one of Teicher’s two
Prozac-related patents hangs over his desk. There are two
paintings, one of a sad clown and the other of a frightened child.
They were painted by the psychiatrist’s mother.
Teicher, 49, is a suit-and-tie native of New York’s endless
suburb, Long Island. Divorced, he lives in Waltham; after the
divorce, his ex-wife took a job as a cancer researcher for none
other than Lilly, which Teicher calls ”an odd happenstance of
coincidence.”
He does not seek publicity; would-be interviewers have to run a
gantlet of McLean public relations officials. Once he agrees to
talk, however, Teicher is gracious, if seemingly detached from
the subject that could make him rich and, in certain circles,
famous.
”This is just one small part of what I do, a minor offshoot,”
Teicher says quietly, preferring to talk about his recent work on
attention-deficit and hyperactivity disorders.
In fact, a McLean-supplied biographical sketch that lists 58 of his
publications between 1976 and 2000 does not include the
scientific paper that set him on the Prozac path, and for which he
is arguably most widely known: ”Emergence of Intense Suicidal
Preoccupation During Fluoxetine (Prozac) Treatment.”
Its absence notwithstanding, there is no denying the paper’s
impact.
Just four pages, it was written by Teicher, a nurse named Carol
Glod (who has since earned a doctorate), and fellow Harvard
psychiatrist Jonathan O. Cole. It was published in February 1990
in the prestigious American Journal of Psychiatry.
In the dry language of academia, the paper describes six
depressed patients, ages 19 to 62, five of whom had considered
killing themselves in the past but none of whom had recent
suicidal thoughts.
The authors detail how all six became powerfully suicidal –
stricken by a ”state more intense, obsessive, and violent than
anything they previously had experienced” – within weeks of
beginning Prozac treatment, and remained so for anywhere from
three days to three months after discontinuing the drug. One put
a loaded gun to her head, and another had to be restrained to
prevent self-mutilation. None committed suicide.
With the imprimatur of Harvard psychiatry, the paper was
received by many as proof of the anecdotal and media reports
that flourished in the years after Prozac’s introduction.
Among the most dramatic was the story of Joseph Wesbecker, a
deeply disturbed Kentucky printing-press operator who in 1989
walked into his workplace and killed eight people, then himself.
Wesbecker had begun taking Prozac weeks earlier, and its
effects had alarmed his psychiatrist, who unsuccessfully urged
Wesbecker to discontinue the drug just days before the carnage.
Prozac doubters seized on Teicher’s paper to press the US Food
and Drug Administration to ban, or at least investigate, Prozac
and similar antidepressants.
That is where the Church of Scientology fits in. The most ardent
Prozac critics were members of a group affiliated with
Scientology, which was founded by science-fiction writer L. Ron
Hubbard, in part based on his hatred of psychiatry.
The group trumpeted Teicher’s paper and blanketed the media
with claims that Prozac was a ”killer drug.” In one press release
the group stated that ”the numbers of persons who have been
driven or are being driven suicidal or homicidal by Prozac is
astronomical.” It was one of many subtle and not-so-subtle
distortions of Teicher’s paper.
Teicher and his coauthors had written that the dangerous side
effect was observed in 3.5 percent of all their patients, and the
Scientologists extrapolated that figure to the entire population of
Prozac users. It was a leap Teicher says had no basis in
science and left him deeply frustrated.
Teicher says his contact with the Scientologists was limited to
one phone call in which he complained they were distorting his
data. Yet, he says, he suffered ”guilt by association,” despite the
fact that he always believed Prozac was a valuable addition to
the psychiatrist’s toolbox, ”a breakthrough” drug that simply
needed to be monitored closely for troubling side effects.
But, for the most part, all anyone heard was that Teicher had
linked Prozac to suicide, and the Scientologists were citing him
as their most potent ally.
The psychiatric community circled the wagons to oppose the
Scientologists’ attacks on Prozac and the entire profession,
sweeping up Teicher in what he called a ”strange, surreal”
process. Lilly fought back as well, offering studies and scientists
to challenge Teicher’s work and sending out press releases of
their own to counter the criticism.
A climax of sorts was reached in 1991, when the FDA dismissed
any link between suicide and Prozac or similar antidepressants.
A nine-member panel of experts voted unanimously that there
was ”no credible evidence” of any association, and split 6-3
against requiring a stronger warning label.
In the aftermath, critics disparaged the panel – ”a kangaroo
court,” in the words of one lawyer who has pending lawsuits
against Lilly – as riven by conflicts of interest and armed with
flawed data from the company’s clinical studies. Lilly also came
under fire.
”Lilly’s efforts to discredit clinicians, scientists, and
journalists
trying to foster greater discussions, research, and awareness of
this side effect is one of the most disgraceful chapters in
American corporate history,” said Harvard psychiatrist Joseph
Glenmullen, author of the new book ”Prozac Backlash,” which
focuses in part on tendency toward suicide.
Still, the FDA’s finding has been the cornerstone of Lilly’s
defense of Prozac in public and the courts.
Lilly officials declined several requests for interviews, but in a
written statement the company restated the 1991 FDA decision:
”There is no scientific evidence that establishes a link between
Prozac and violent or suicidal behavior.”
Today, Teicher looks back on the early 1990s with what seems
like preternatural equanimity: ”It was a good life lesson. I
basically did fine.”
Asked to define the lesson, he says: ”What I learned from all this
is I cared much less what people thought. … There are always
going to be colleagues who disagree with me about this. A
definitive study hasn’t been done. Maybe 20 years from now
there will be a clear answer, but maybe not.”

Partners looking for `cure’
What his critics did not know was that Teicher, since early 1992,
had been working on what might be called a ”cure” for the
problems he saw in Prozac.
By all accounts, that turn of events began one morning when a
bear of a man named Timothy J. Barberich was reading The
Wall Street Journal. He came across a story about the Prozac
controversy that mentioned Teicher’s work.
Barberich was not just any reader, though. He had parlayed his
undergraduate chemistry degree into founder, chairman, and
chief executive of an upstart drug company called Sepracor Inc.,
in Marlborough, half an hour west of Teicher’s office.
Barberich and one of his top scientists, James W. Young,
decided to call Teicher to talk about a chemical process
Sepracor had developed to reformulate existing drugs by
removing unwanted side effects. By the early 1990s, the
company had targeted 40 or so already-approved drugs –
including Prozac – that it hoped to improve, patent, and then
market on its own or in partnership with the old drugs’ owner.
Teicher, as it turns out, had been studying the science of that
process in his laboratory, feeding different chemical substances
to rats and sending them into a maze. In early 1992, Teicher and
Sepracor struck a deal under which the company would fund
about $150,000 of research in his lab.
To understand what happened next requires a painless
chemistry lesson, first taught in the 1800s by Louis Pasteur.
Pasteur discovered that most man-made chemical compounds –
prescription drugs, for instance – exist at a microscopic level as
twins, called isomers. Although the twins are chemically
identical, each one is not the mirror image of the other.
In some drugs, only one of the twins provides the benefits, fitting
into chemical receptors in the body to flip switches on or off to
fight illness. The other twin does not fit the same receptors, so it
is free to wander through the body. Sometimes it goes looking
for trouble. That is, causing side effects.
The most dramatic example was the 1960s drug thalidomide,
one of whose twins was the good Dr. Jekyll, effectively
decreasing morning sickness in pregnant women. The other
was the evil Mr. Hyde, a chemical monster that caused horrible
birth defects.
Until the last 20 years or so, it was difficult to separate the twins

and sometimes, both twins have problems of their own – so
government regulators allowed drugmakers to sell medicines
including both, as long as the side effects were not terrible.
That was Lilly’s argument for Prozac, which allows brain cells to
bathe more freely in a chemical called serotonin, which affects
mood and emotion. To this day, despite millions of prescriptions
for the drug, scientists are not certain precisely how Prozac
works, but it is generally believed that the added serotonin in a
brain on Prozac lessens depression.
Lilly acknowledges that the current formula also can cause side
effects including non-life-threatening ailments such as
headaches, anxiety, tremors, and sexual dysfunction. But not
suicidal tendencies.
Teicher and Sepracor set out to find a way to keep the good parts
of Prozac, or improve it, while eliminating the bad. Within six
months of starting his work, Teicher and Sepracor officials say,
he recognized which of the Prozac twins was the one most worth
keeping.
Teicher noticed that when he gave his rats the part of Prozac that
would be considered the ”good” twin – known chemically as
R-fluoxetine – the rodents bravely explored the more dangerous,
exposed parts of the maze, spending less time anxiously
scurrying to the enclosed, protected areas.
It took a lot more work, lots more rats, and five more years to get
a patent, during which both Teicher and Sepracor experienced
bumps in the road. Teicher weathered an embarrassing state
medical board investigation into allegations, eventually
dismissed, of sexual misconduct with a patient. Sepracor,
meanwhile, was frustrating stockholders with yearly losses.
Eventually, though, Teicher and the two Sepracor officials,
Barberich and Young, succeeded in patenting their discovery,
receiving one in 1997 and the second in 1998.
The patents tout their drug’s effectiveness as an antidepressant
and appetite suppressant, an anxiety reliever, and a potential
treatment for migraine headaches, chronic pain, and
obsessive-compulsive disorders. Its residual effects leave the
body sooner than the existing Prozac, the patent says, allowing
doctors to try other drugs more quickly if it proves ineffective.
Lilly has no problem with any of that. But then comes the patent
language that has caused the current uproar: ”The adverse
affects (sic) which are decreased by administering the [new
version of Prozac] include but are not limited to headaches,
nervousness, anxiety, insomnia, inner restlessness (akathisia),
suicidal thoughts and self-mutilation.”
And so, with one swing of a patent examiner’s approval stamp,
Lilly’s decade-long denials about suicidality ran headlong into
the claims of a promising new drug that Lilly was eager to buy.

Difficulty protecting Lilly
Teicher refers questions about the patent to Sepracor, and
Barberich finds himself in the awkward position of defending the
new Prozac without offending his powerful partner, Lilly.
First, Barberich downplays the issue: ”I don’t want to get my
patent disallowed, but it’s not as if you have any evidence for
what you’re claiming in the broadest sense. … There’s no court of
truth that these patents go through. I believe that they, Lilly, are
correct.”
Then, he hedges: ”Marty Teicher may be right, Eli Lilly may be
right, and the FDA may be right, and we still wouldn’t have any
idea whether [the new drug] eliminates a problem that we’re not
sure exists.”
Although Lilly officials would not discuss the patent, their
statement sought to put distance between Lilly and the
damaging patent language: ”Lilly had no input nor provided
content for the patent application. Not all the `side effects’ listed
in the patent are scientifically demonstrated facts. … Teicher’s
article was a series of anecdotal reports, and his suggestions of
a `possibility’ of a causal relationship have been refuted by
multiple … studies that have demonstrated no increased risk of
suicide associated with Prozac use.”
Barberich also said Lilly had no role in the patent. He said the
Indianapolis-based drugmaker opened talks with Sepracor only
after the patent was certain to be approved.
He also said there were no discussions with Lilly about the
suicide issue when Lilly purchased exclusive rights to the patent
in late 1998. The deal gives Sepracor $20 million up front – due
to be paid by the end of this month – plus another $70 million if
the drug gets FDA approval, as anticipated within the next two
years.
If that approval comes, the real money for Sepracor, Teicher, and
McLean Hospital could start rolling in as early as 2002. ”It’s
likely
it’s going to be a big drug. It’s just a question of how big,”
Barberich said.
Under the terms of the deal with Lilly, Sepracor gets about 10
percent of sales. McLean gets 10 percent of that, of which the
hospital gets half, Teicher personally gets one-quarter and his
laboratory gets one-quarter.
Prozac revenues for Lilly were $2.6 billion last year. If the new
Prozac becomes a $2 billion-a-year drug, Sepracor would get
$200 million a year, of which McLean gets $10 million, and
Teicher and his lab each would receive $5 million.
Back in his office, Teicher acknowledges that he finds himself
thinking about the money sometimes. He said a need for money
prompted him to stop seeing patients two years ago, so he
could focus on ”entrepreneurial” activities to fund his son’s
college education.
He also thinks about the potential conflict involved in prescribing
and lecturing about a drug in which he has a large financial
stake, but he expects to handle that by simply disclosing his
interest.
Teicher says he spends almost no time thinking about a patent
on his wall that says he was right all along, and even less time
thinking about vindication.
”I’m not sure vindication will ever come,” he says. ”I’m not sure
I
need it or want it.”

This story ran on page A1 of the Boston Globe on 6/11/2000.
© Copyright 2000 Globe Newspaper Company.

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