By Albert Fox Cahn
Online pill services are using the same aggressive marketing tactics that drove the opioid epidemic.
The first Adderall ad appeared in my Instagram feed during the height of pandemic isolation. I thought the slick 30-second video promising me a "super easy" way to get ADHD medication was another gimmick. But after the algorithm pushed a few more plugs my way, I started to get curious. The drugs, to my surprise, were real. Unlike countless sketchy ads for black-market supplements, Cerebral, the then-hot telehealth startup behind the ads, offered a legal path to prescription medications.
It was indeed a "super easy" path — too easy. My intake process to get prescribed a potentially addictive amphetamine turned out to be easier than getting Taylor Swift tickets or an appointment with my primary-care physician. Even as I doubted that I met the clinical criteria for ADHD, I could honestly answer the vague, brief self-assessment (e.g., "How often do you have difficulty paying attention when you are doing boring or repetitive work?") and receive the same result as tens of thousands of AI-targeted customers: "You have some symptoms consistent with ADHD. We suggest further evaluation." When I spoke to a Cerebral nurse practitioner for all of 13 minutes, the experience was much the same. Answering that, yes, my concentration was strained in the middle of a once-in-a-century pandemic got me an official diagnosis and prescription. Like its many telehealth competitors, including Done, Klarity, adhdonline.com, and Circle Medical, Cerebral could peddle, prescribe, and postmark a package of Adderall for me while I never left the couch.
A new breed of direct-to-consumer services is aggressively using targeted ads to sell habit-forming medications. Not only do these companies make it easier for those seeking recreational drugs to access them, they're also poised to inundate and threaten the sobriety of people in recovery. And unlike a typical prescriber who might interrogate answers to assess genuine need, some of these firms appear to be designed to remove every possible barrier.
In short, AI and surveillance capitalism, which empower today's targeted ads, have joined forces with the deadly OxyContin playbook. But unlike the opioid crisis of the early 2000s, advertisers today have much more data and far more precise tools to push prescriptions, and our privacy laws haven't even tried to keep up. Without intervention, another public-health catastrophe looms.
‘Throwing antipsychotics around like candy‘
An algorithm can't create addiction out of nothing, but it can be the crucial connector that lets companies reach those most at risk. Looking back on my Cerebral experience now, the similarities to the opioid crisis are clear. Having researched the rise of Purdue Pharma's OxyContin blight, the most pernicious catalyst was the same thing I saw in those Instagram ads: aggressive, data-driven marketing. As Dr. Art Van Zee wrote in the American Journal of Public Health in 2009, "One of the cornerstones of Purdue's marketing plan was the use of sophisticated marketing data to influence physicians' prescribing." The Sackler family's pharma giant, he wrote, used "prescriber profiles on individual physicians — detailing the prescribing patterns of physicians nationwide — in an effort to influence doctors' prescribing habits."
OxyContin was pharmacologically unremarkable, analogous to countless opioid medications that had been on the market for decades. But Purdue discovered an ingenious, and calamitous, edge: harnessing data to target doctors with an onslaught of marketing materials, cajoling prescribers to hand out the medication more freely, and making the disastrous promise that their formulation was less addictive. It wasn't. OxyContin was patented in 1996, and Purdue's blitzkrieg marketing campaign began soon after, largely triggering the opioid epidemic. Between 1999 and 2017, drug overdose deaths involving prescription opioids climbed from some 3,000 a year to more than 17,000 a year. By 2017, Purdue's annual revenue had grown to $35 billion.
Now bankrupt, Purdue stands as a warning for any pharmaceutical company that would try to recruit physicians with the same predatory tactics — yet they persist. Just as important, it's hard to believe that any doctor today would trust a pharmaceutical rep peddling pain meds with a similar claim. But online prescribers don't need to market to the doctor, because they are the doctor, and patients are left with no one but themselves to look out for their well-being.
Online prescribers don't need to market to the doctor, because they are the doctor, and patients are left with no one but themselves to look out for their well-being.
Physicians have already begun to warn that the Adderall crisis could repeat history. "The prescription amphetamine crisis is growing and could catch up to the opioid epidemic in scope and damage," Dr. David Sack wrote in "Psychology Today" in 2018. The Canadian psychiatrist Anthony Yeung has studied misinformation in videos about ADHD on TikTok and found that deception is rampant. "Without a doubt targeted ads (especially peak pandemic) have had an outsized impact" on Adderall prescription rates, he told me, though he noted researchers still struggle to access ad data on many platforms, so it can be hard to map out the precise effect. And while Adderall is what most fueled these telehealth firms' growth over the past three years, they also market a number of highly addictive medications. They are just as much a ticking time bomb for those addicted to sedatives like Xanax and other habit-forming medications.
With AI-augmented advertising, finding yourself targeted only takes a single moment of engagement. After I first visited the Cerebral site, I was soon faced with dozens of ads. Some days it felt like they were a majority of the ads I saw on multiple social-media platforms. For me, the pattern was suspicious, but for someone struggling with addiction, it feels diabolical. These ads may overwhelm those in recovery — imagine trying to fight dependency and protect your health while these firms constantly bombard you with temptation. (On the flip side, the growing use of Adderall recreationally makes the medication far more difficult to find for those who actually have ADHD. In 2022, telehealth prescriptions accounted for 40% of all Adderall prescriptions, driving record usage.)
This is the nature of online advertising. This is why you see the same pair of shoes following you online from website to website, or why the trip you almost booked is constantly in your feed. Advertisers systematically target those who are on the verge of buying. A dollar spent on those who've shown interest is seen as far more valuable than a dollar spent on someone who may be a terrible fit for the product. But these companies have no way of knowing who's addicted or in recovery. Last year, a nurse practitioner warned Cerebral' s approach is "risky because you really have to figure out who is drug seeking and who is really suffering from ADHD." Yann Poncin, a clinical child psychiatrist at the Yale School of Medicine, told me that "when it gets to that level of targeted marketing, there's no way for people to know what other people are experiencing." We as a society may have come to accept being stalked by targeted ads, but the consequences are much graver when the product itself is a danger. Getting hounded by that chew toy you thought of buying your shih tzu is one thing; getting harassed by a drug that mirrors methamphetamine is an entirely different matter.
And the scale is stunning. Last year, The Wall Street Journal detailed how at one point, Cerebral's ad buy had become so immense it was the third-largest advertiser on TikTok. And as the company grew, employees became alarmed. Some worried that the platform could enable addiction. One nurse practitioner told Insider that employees "will just throw antipsychotics around like it's fucking candy." Cerebral said last year that its "clinicians exercise their independent professional judgment in diagnosing and treating their patients," but that same Journal article reported that company leaders had urged employees to prescribe ADHD to 100% of patients without comorbidities. The company was far from alone in flooding the zone. In just four weeks last year, 20 telehealth companies ran more than 2,100 ads promoting unapproved uses of prescription meds or failing to list their risks. As Bloomberg reported, the approach could accelerate the crises of people already dealing with complex mental-health issues.
Ban targeted ads
Consequences for its hyperaggressive tactics have caught up with Cerebral. As the Journal reported, after ADHD medications grew to 20% of the VC-funded company's business, driving a $4.8 billion valuation, things came crashing to earth. Cerebral's CEO was fired, many employees left, subpoenas from federal prosecutors were served, and a growing number of pharmacy partners stopped filling the company's prescriptions, prompting the company to stop offering ADHD drugs.
But Cerebral's collapse is far from the end of this saga. The relaxed regulations that emerged during the COVID pandemic are a big part of the problem. Early in the pandemic, the Drug Enforcement Agency and the Department of Health and Human Services suspended the Ryan Haight Act, a 2008 law that required telehealth providers to have at least one in-person session with a client before writing prescriptions for Schedule 2 medications, which includes habit-forming medications like Adderall, OxyContin, and Xanax. The move made sense then but removed the guardrails to protect against the exact sort of abuses that led to the death of the Ryan Haight Act's namesake, a California teenager who overdosed on Vicodin that he was prescribed online.
We as a society may have come to accept being stalked by targeted ads, but consequences are much graver when the product itself is a danger.
Even after the official end of the COVID-19 public-health emergency, companies are still able to prescribe Schedule 2 substances without an in-person visit. The suspension of the Ryan Haight Act is currently set to expire on November 11, 2023, but there's no guarantee that the rollback won't be delayed.
In the interim, numerous competitors are jumping into the breach. In the course of researching this piece, I was served ads for ADHD medications from the rival telehealth startup Done, and friends sent me examples of targeted ads on Instagram, TikTok, and Twitter from firms offering everything from ADHD-care apps to Adderall and even psychedelics like ketamine.
Sadly, the solution isn't as simple as rolling back the regulations that allow companies to prescribe these drugs. Not only is telemedicine more convenient, it also offers a lifeline to millions of individuals without local access to care or who find it too expensive. Instead, we need a middle ground. Rather than restricting prescribers' ability to give medications remotely, we can focus on the promotional and sales tactics that set these firms apart from a family doctor who sees a patient over a video call. We can improve intake and assessment requirements. We can have automatic audits for firms with abnormally high levels of Schedule 2 prescriptions.
The same proposal Art Van Zee made to quell the OxyContin scourge in 2009 would stand today: "The public health would be better protected if the FDA reviewed all advertising ... for their truthfulness, accuracy, balance, and scientific validity, before dissemination."
But above all, we need rules that ban targeted ads for drugs that can get patients hooked. The United States and New Zealand are the only countries in the world that allow direct-to-consumer marketing for prescription drugs. No matter what safeguards are in place, as long as companies can combine them, habit-forming medications and AI ad targeting will make a deadly cocktail.
Albert Fox Cahn is the founder and executive director of the Surveillance Technology Oversight Project, or S.T.O.P., a New York-based civil-rights and privacy group.