Pill Mills Are Back, And They’re Not for Pain Anymore

With the advent of GLP-1s for weight loss, enterprising doctors and specialty pharmacies are giving shots to any and everyone.

After greeting the clinic staff on my rotation, the nurse practitioner (NP)  turns and says to me, “we’re mad at Mounjaro.”

I’m surprised— this office gives Mounjaro, a blood-sugar-lowering weight loss injection, to anyone who can afford it, whether they have insurance, obesity, diabetes or otherwise. I ask if they have seen some new adverse effects and am told, “no, they’re just being really annoying about prior auth stuff. It’s an amazing drug.”

I’m aware. I am a second-year medical student on my family medicine clerkship, which is a mandatory apprenticeship for budding doctors. After intensive courses teaching anatomy, physiology, and pathology, I now spend my days with patients and doctors, learning through doing and by example until I graduate in two years. I’ve been in clinical medicine for six months now, and have seen these and other outpatient primary care doctors “ooh and ahh” over Mounjaro, a GLP-1 medication, and the others, the more famous injections called Ozempic and Wegovy. I get free lunch from the drug reps of these companies several times a week, taking my own little slice of the big pharma wonder drug’s profits. They leave samples, branded pillows, pamphlets touting the spectacular results of these new injections, that can lower a patient's body weight by 15-20% while decreasing appetite, improving blood sugar, and preventing cardiac disease.

Last year, as a preclinical student, I was taught about this class of drugs to treat diabetes, how it was a nice option for the type two patient who was “totally crazy about losing weight” (the lecturer’s words, not mine). During my internal med clerkship, doctors were starting to buzz about these injections for our diabetics, how patients tolerated them so well, and ended up so slim!

During my eight weeks on surgery, a scrubbed bariatric surgeon quipped, “my entire office staff is on Wegovy.” This was the same doctor who told me, “God made stomachs too big,” as she sliced apart an obese patient’s organs. 

Now on family medicine, it seems like half of my patients at this clinic have gotten their hands on these special “skinny shots.” I have seen patients get samples of Ozempic who have a BMI of 25.1 (BMI of 18.5-24.9 is over, 25-29.9 is overweight, 30+ is obese). I have seen patients with normal BMIs who simply want to “look better” take this diabetes drug to lose a few pounds without all the trouble of improving their diet and increasing their activity level.

When I was admitted to medical school, my soon to be alma mater sent me a copy of Dopesick, the stunning expose-memoir by Beth Macy, which details how the opioid epidemic began with prescribed opioids (particularly oxycontin). It went into detail about the doctor’s offices running “pill mills,” writing prescriptions for impossibly many of these painkillers to anyone who mentioned persistent pain. Her book tells of doctors going on ritzy cruises hosted by Purdue Pharma, who made Oxycontin, lies told about undertreating pain to encourage more prescription, and the research studies padded by faked data to convince physicians to ignore any reports of addiction. This, of course, has led to millions of people becoming opioid and heroin addicts, and hundreds of thousands of fatal overdoses.

Now I see patients asking for Ozempic, “the shot” for short, by name. They tell me how amazing their sister/mother/bestie looks now that they are on the GLP-1 that my bosses in this clinic prescribed, and how they were told they had to come here for primary care. They come in clusters with similar stories of feeling so puffy and heavy, and how no diet has worked and they’ve tried “everything.”

Yesterday morning, I heard  an Ozempic rep conspiring with the NP about how metformin was a “ridiculous” drug, about the cruelty of doctors who prescribe it at 2000mg a day, with all those GI side effects! Metformin is the first line drug for diabetes or insulin resistance, is inexpensive and covered by all insurance, and tends to have robust effects on lowering markers for diabetes and improving outcomes. Its most common side effect is diarrhea for the first few weeks of therapy, which self resolves.

Wegovy and Ozempic’s most common side effects are inducing insulin resistance, nausea, vomiting, diarrhea, and constipation, which are sometimes so severe that the drug must be discontinued. He speculated that metformin was only prescribed because it’s basically free. This drug rep, who is not a clinician, drops Ozempic branded pillows on our desk, which perhaps explains why his drug is about $1000 per month.

My patients on Ozempic are not all rich. They hear about the drug because celebrities have been taking it, and some news companies have been reporting that the drug is in “shortage” for patients who have diabetes. The patients have heard of Elon, Mindy, then Kim and Khloe, who have confirmed they are taking the drug or vehemently denied it, but who all look slim and sexy despite public struggles with adiposity. The patients want to be slim and sexy, understandably, and suddenly feel that is in reach. But how to afford this drug, which will run them $12,000 over the regular course of treatment if insurance won’t pay?

It starts with samples from generous drug reps, handing needle pens of their magic out for free to doctors office, while also dropping off lunch. Then the specialty pharmacies sweep in. They take all the work out of paying for the drug, calling insurance companies, finding loopholes, inventing ways to get drugs paid for. I have no idea how they make money out of thin air, but with a combination of strong relationships to drug companies, drug coupons from said companies, and speaking convincingly to insurance companies, most patients get the drug covered or at a severe discount.

These drugs have been mostly studied in diabetes, so there are few robust guidelines for who other than diabetics needs this medicine. If there are no guidelines, who is to say who does or does not qualify for or benefit from this drug? The demographic of people on these medicines, from my limited sample size, seems to be women of all backgrounds, all BMI’s (yes, even normal ones), who have expressed at least vague interest in losing weight. A classmate watched an NP hand Ozempic samples to a patient with a BMI of 25.1 who had remarked she may be interested in shedding a few pounds. I know many healthcare providers who are using samples (expired or fresh) themselves to lose weight. I have seen samples and prescriptions of these drugs handed to patients was obvious body dysmorphia or eating disorders.

It’s worth noting here that doctors don’t make money from prescribing specific drugs (except oncologists who can bill for chemo regimens). They don’t make money directly, but they can and do bill for follow up visits, vitamin B12 shots, even sick visits from side effects. Perhaps more lucratively, putting patients on drugs that make them skinny is incredible advertisement for your practice. Everyone loves the doc who made them hot, and will tell their friends and family to come see you for similar results. At least the drug isn’t addicting, I think. At least it doesn’t lead to heroin use. At least, at least, at least…

As with all medications, GLP-1’s are a tool to treat disease. They just so happen to be very good tools, with relatively few side effects, demonstrated efficacy, and proven reductions in morbidity and mortality in diabetes and heart disease. Good tools should be used, and I have seen GLP-1’s used to improve the lives of patients with diabetes and obesity. The American Diabetes Association has recommended these as first line drugs for diabetes given their robust ability to lower blood sugar and decrease cardiac complications, and using these medicines to treat obesity instead of surgery or the amphetamine phentermine is well supported. Even more off label, I once saw this medicine used to help a patient of normal weight with extensive facial reconstruction from trauma, ostensibly to help treat their body dysmorphia and give them a sense of control of their appearance. Wegovy as psych medicine? I’m not opposed.

   What I cannot support is using this drug for cosmetics in patients with poor diets and little physical activity. I am also against giving any weight loss medication to a patient with body dysmorphia or an eating disorder, as we are reinforcing on “weight loss” as “goodness” in patients already suffering from diet culture and mental illness surrounding food and eating. These medicines should not be given in a vacuum based on patient requests, just as opioids should not be given to anyone who cries “ouch.” We need to use these drugs as a prescise tool to help patients make lifestyle changes that improve their health, not as a medical “fad diet” that encourages patients to weight cycle and need multiple courses on these drugs.

At the end of the day, I am a medical student without the years of experience or buildup of burnout changing my decisions and opinions. I am naïve to so much medicine, so much of the world, and may cast these stones unfairly.

I am grateful that I am most likely going to be an emergency medicine doctor. It means I won’t have drug companies trying to woo me, won’t have patients insisting I write them for weight loss drugs, which takes the temptation of skinny shot samples out of my reach. I won’t have to fight to keep my moral code that says patients with signs of disordered eating should not be given weight loss drugs. It makes things easier for me. I am taking an easier way out.

I will allow myself some excuses. Maybe I hate these drugs because I am secretly jealous of patients who are effortlessly skinny, while I work hard to eat well and exercise often. Maybe I hate them because I grew up in the age of Oxycontin, and am naturally afraid of any medicine that gets asked for by name. Maybe it is because I read Dopesick and see the same medical practices that got us into the opioid epidemic playing out right in front of me, but can’t do anything to stop it.