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As it so happens, Americans are also highly medicated. A Mayo Clinic study from 2013 found that nearly 70% of Americans regularly took at least one prescription drug. Nearly half the population took at least two, and more than 20% of Americans took five or more. The researchers identified prescription drug abuse as the “fastest-growing drug problem” in the U.S. They also found prescription rates had increased significantly over that preceding decade.

Given the continuity of these trends, it would be easy to overlook a new factor in the equation: social media. Telehealth services have spent millions of dollars promoting prescription drugs on TikTok, Instagram and Facebook. They play on users’ insecurities, describing symptoms as vague as “stress” and “losing track of time.” Mood-altering medications such as SSRIs are sold as having straightforward benefits, with companies promising those suffering from depression and loneliness that 80% of customers feel better with treatment.

One major telehealth provider, Cerebral, is now under investigation by the Department of Justice over possible violations of the Controlled Substances Act. Nurse practitioners working for Cerebral said they felt pressure to see dozens of patients a day and push prescriptions, according to reports from Insider, The Wall Street Journal and Bloomberg. (A Cerebral spokesperson told The Wall Street Journal they encourage clinicians not to rush diagnoses and provide time beyond 30 minutes if needed.)

Even as providers like Cerebral draw federal attention, Meta’s and TikTok’s advertising policies still allow telehealth providers to turbocharge their marketing efforts, enticing many patients to start treatments they may regret. As one Cerebral patient told Protocol, “On principle, I want to shout from the mountaintops so no one else falls into their nonsense.”

Ad policies

Both Meta and TikTok allow telehealth providers to promote prescription drugs to users ages 18 and up in the U.S. and New Zealand. Both companies make a distinction between promoting prescription medication, which is allowed, and direct drug sales, which are not. Meta and TikTok work with third-party compliance companies such as LegitScript to approve telehealth providers. Advertisements must also comply with any other relevant platform rules — for example, both platforms prohibit ads for weight loss treatments.

When asked for comment, spokespeople from Meta and TikTok referred Protocol to their respective advertising and community guidelines. (Meta’s policies are available here and here, and TikTok’s are here, here and here.) After being contacted by Protocol, Meta also removed three advertisements from its sites for violating its policies.

Meta and TikTok also say ads cannot contain misleading or inaccurate claims. However, medical experts said advertisements on their platforms do exactly that. On several prior occasions, the companies pulled certain pharmaceutical ads only after the media brought policy violations to their attention. And despite the high stakes involved in promoting medication, both companies rely in large part on automated ad verification systems, which can be prone to error.

Telehealth provider Done, for example, promoted a TikTok ad that describes how being “spacey, forgetful, or chatty” can be a symptom of ADHD. Another Done ad warned symptoms of ADHD in women “are often viewed as character traits rather than symptoms.” In an active ad campaign on Meta, Done promises gaining access to “worry-free refills” is “as easy as” taking a one-minute assessment, followed by a 30-minute appointment available as soon as the next day. (Many of the ad campaigns referenced in this article come from Meta rather than from TikTok because, to Meta’s credit, it has a transparency tool for archiving ad campaigns.)

Ads that generalize ADHD symptoms could violate Meta’s and TikTok’s own policies on misleading consumers, as nonprofit research organization Media Matters points out.

“I think this is really playing on people’s insecurities,” Dr. Kevin Martin Antshel, a psychology professor at Syracuse University who specializes in ADHD, told Protocol. Dr. Antshel noted that ADHD in adults often co-occurs with other psychological disorders such as anxiety and depression. He expressed concern that ads from telehealth providers were leading people to believe ADHD could be treated with stimulants alone, which he said is almost never the case.

Telehealth providers also seem to play on users’ insecurities when promoting erectile dysfunction medication. On Instagram, a recently removed ad campaign from Hims depicted a man asking himself, “What if it happens again today? What if I can’t get it up?” Another of its ads, which was active as of June 26 but has since been removed, shows a couple in bed with text overlaid: “POV: There’s a gorgeous woman in your bed. But you have ED & can’t get it up.” Some of the videos instruct users to “take the quiz” — a rather casual euphemism for kicking off a process that could lead to a medical diagnosis — next to a picture of someone holding a pill.

Meta has touted Roman, one of the telehealth providers that sells ED medication, as a “success story” that could serve as a case study for marketers. Meta’s case study details how Roman was able to double its sales and click-through rate on an ad campaign that promoted testosterone supplements between mid-September and mid-November 2019. Roman was among the top 10 mobile advertising spenders on Facebook that year, as were Pfizer, Allergan and Merck.

Active ad campaigns from Hims entice customers with simple solutions for treating anxiety and depression. One advertisement — which directs users to a page offering generic versions of SSRIs Prozac and Zoloft — tells viewers that “80% of customers feel better with treatment.”

Such straightforward promises don’t always align with patient experiences. One Cerebral patient described suffering severe withdrawal symptoms after being unable to schedule a refill appointment through the company. “I would fret for days over collecting my meds. I would become sick and incapable when they’d miss the refill,” the person told Protocol.

“I find myself constantly pushing [Cerebral] on people because if they use my reference code I can get a $200-off credit,” another Cerebral patient told Protocol.

A campaign from Cerebral that was active as recently as June 26 told viewers they can “overcome opioid use 100% online.” That ad, which featured a large icon of a prescription container, linked to a landing page that said “reduce cravings with medications like Suboxone.”

“It’s not ideal,” Jeffrey Scherrer, an associate professor at Saint Louis University who researches opioid use, told Protocol. “But it’s certainly a second option for people who otherwise wouldn’t even consider seeking care — because I think it offers a little bit more privacy and reduces, for those in rural areas, the need to drive long distances to reach a provider.”

Not your grandpa’s Cialis ad

It’s hard to imagine we’d ever think of the “good old days” for drug advertising as when gray-haired men were suggestively throwing footballs through tire swings between news segments on the Iraq War — yet here we are.

In the television era, regulators faced a simpler task. To start, there were only so many ad slots to fill, which limited the pool of companies that could reasonably afford to buy air time. (Devoted NFL fans can list the blue-chip advertisers by heart.) Broadcast and cable channels could review what went in their slots, and the FCC could feasibly monitor ads on the hundred-or-so cable channels beamed into American living rooms.

Social media advertisements operate at a scale that would have been unfathomable in the television era. Meta hosted over 10 million advertisers on its platform last year. In the fourth quarter of 2021 alone, TikTok removed 3.2 million ads from its platform due to policy infringements.

Social media platforms also allow for more precise targeting. A 2021 investigation from The Markup found that Meta allowed drug manufacturers to target potential patients granularly based on proxy categories. For example, an advertisement promoting a drug used for inflammatory lung disease was aimed at users interested in cigarettes. Similarly, advertisements promoting antipsychotic medication targeted users interested in therapy. Those categories allowed for targeting even though Meta says ad rankings can’t be informed by medical conditions or psychological states.

Age verification poses another significant problem. Meta and TikTok both only allow prescription drug advertisements to be shown to users above the age of 18. But their age verification systems have loopholes that could still let ads slip through to children.

Some prescription drug campaigns seem tailored for younger audiences. A Done ad that ran on Instagram as recently as June 26, but has since been taken down, depicts a young woman telling her mom and dad, “I think I may have ADHD.” The mom in the skit responds, “You’re probably fine — you’ll always be my baby.” The dad advises, “Why don’t you go to the gym and sweat it out.” But the skit concludes with the young woman deciding to ignore her parents and instead take a one-minute assessment from Done.

The other open and troubling question is whether social media worsens users’ mental health, which could make these advertisements more appealing. In leaked internal documents from Facebook, researchers wrote that “teens blame Instagram for increases in the rate of anxiety and depression.” Mark Zuckerberg told Congress those research findings were inconclusive.

“If [social media users] are displaying symptoms of pain, despair, depression, hardship [and] loneliness, then what sort of adverts would you expect to be targeted in those situations?” Professor Victoria Nash, director of the Oxford Internet Institute, asked Protocol. “I wouldn’t be surprised that in a more unregulated context — which I think the U.S. probably is — that this is where you would see prescription drugs being targeted.”

High-frequency digital activities — like scrolling through social media — are so out of sync with the pace of ordinary life that people come to feel more distractible when they aren’t online, according to Antshel. He said social media is “in a sense conditioning people to want this kind of rapid operational speed, constant mental stimulation.” When that stimulation isn’t available in a domain such as the classroom, people are more likely to notice their distractibility, he explained.

Still, Antshel wasn’t ready to call for a ban on prescription drug advertising. He pointed to benefits from drug ads, including reaching people who lack information and access to treatments. “So knowing what to talk about with the primary care physician, I think, could potentially be a good thing. But I can also tell you that I routinely see patients coming in [and] telling me what type of medication they want [and] what type of dose they want.” The issue, he said, is that “we’re taking the direct-to-consumer advertising to an extent where it really is creating the potential for harm.”

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