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Social media doesn’t tell you much about companies that want to solve your anxiety, hair loss, and E.D.
Jacqueline Day for Vox

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Startups are selling you pills through Instagram. Why don’t they say which ones?

Instagram forbids the paid marketing of pharmaceuticals. But what happens when you click through on the promise of feeling better?

Breezing through my Instagram feed, a robin’s egg-hued post catches my eye. I swipe through the slides of the sponsored post, reading customer testimonial after customer testimonial about some sort of life-changing treatment — the specifics of which have been omitted. “My quality of life is 100% improved,” one user says. “Longest time in my life I have been migraine free!” claims another.

What I can infer is that these customers are victims of chronic migraines, just like I am. I tap “learn more” and find myself on the landing page for Cove, a direct-to-consumer (DTC) health care company that has staff doctors diagnose these debilitating headaches and then prescribes and delivers prescriptions to patients.

It takes a few taps on my screen, from the sponsored Instagram post to Cove’s website, before I might learn how Cove achieved such positive results: The company sells a mix of medications, such as prescription-strength naproxen, the nonsteroidal anti-inflammatory drug sold under the brand name Aleve when purchased over the counter as well as beta-blockers, antidepressants, and anticonvulsants. Actual drug information — warnings, side effects, and benefits — can also be found on its website, after clicking “Learn More” next to each product’s name.

Cove isn’t the only DTC health care darling to advertise using the condition, not the treatment, on Instagram. Today venture capital-backed entrepreneurs are launching diagnose-and-treat telemedicine platforms at warp speed. Many factors have created a market ripe for health care at home: rising health care costs that send patients scuttling for more transparent options, expiring drug patents that lead to generics of super-popular drugs being rebranded and sold for cheap, and the expansion of on-demand services encouraging the expectation that we can do anything and everything from our beds.

Customers are captured through stylish but vague ads they see on social media, public transportation, and streaming services, and can access health care services anywhere via their phones.

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a team built to avenge the fallen follicles. ⚡️

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Roman promises to reignite the spark between long lost loves without mentioning the generic Viagra it sells or that a single dose costs between $2 and $10. Hims and Hers advertise by saying they’ve built a team to avenge fallen hair follicles but not that one of those avengers is finasteride, a drug that has some risk of causing sexual dysfunction (Hims, which also sells generic Viagra, offers help with that too). Each of these companies fills a specific niche, understanding that the country’s shrinking number of specialists leaves an opening to target patients whose needs lay outside the expertise of a general practitioner.

The names of these drugs are short enough to fit into a caption, but the reason brands don’t include them in their social media posts is simple. Companies are not allowed to use paid advertisements to market the sale of prescription drugs by name on Instagram; it violates the platform’s regulations. This works to DTC health care companies’ advantage in that they are able to skirt complicated disclosures and focus on the upbeat idea of feeling better. It’s a classic marketing technique, and it fits in with Instagram’s aspirational vibes perfectly.

But some health care and marketing professionals believe these posts should indeed come with a warning: Buyer beware. In marketing positive outcomes or you’re-not-alone quotes and statistics, DTC health care companies obfuscate the very real risks of the drugs they sell.

Marketing pharmaceuticals directly to consumers isn’t new

Advertising prescription drugs directly to consumers is an almost uniquely American phenomenon — New Zealand is the only other country in the world that permits pharmaceutical ads that target patients directly. (This is, somewhat confusingly, known as direct-to-consumer advertising.)

Beginning in the mid-1980s, pharmaceutical companies in the US debuted print and broadcast ads for drugs they distribute. You’ve likely seen TV commercials extolling the virtues of this or that prescription medication followed by a comically long list of side effects read at a faster clip or magazine spreads featuring a sexy drug advertisement opposite an inordinate number of disclosures in teeny-tiny print.

In the paper “A History of Drug Advertising”, Julie Donohue, a professor of health policy and management at the University of Pittsburgh Graduate School of Public Health, outlines the case for and against these advertisements. Proponents tout patient and consumer rights to make informed decisions, while bioethicists and historians believe pharmaceutical companies are “disingenuously using the language of individual rights to support commercial activities.”

There are three basic types of pharma ads: product claim ads, reminder ads, and help-seeking ads. In a product claim ad, the drug is named along with its uses, risks, and benefits. A reminder ad names the drug while omitting other information, assuming “the audience already knows the drug’s use” — drugs like Viagra and Prozac. According to the Food and Drug Administration (FDA), both are subject to the Federal Trade Commission (FTC) and FDA standards. However, reminder ads rely on a certain level of consumer knowledge — understanding, for example, that Viagra may cause vision or hearing loss — that may not exist.

“Help-seeking” ads, on the other hand, are exempt from FDA oversight — and also are not subject to Instagram or Facebook’s advertising policies. In these advertisements, a disease or condition is described without naming a specific treatment and, therefore, need only comply with the truth-in-advertising principles created by the FTC. Jeremy Greene, director of the Center for Medical Humanities and Social Medicine at the Johns Hopkins University School of Medicine, notes the inherent problem of not regulating help-seeking or informational advertising is that selling a medical or health product is “never just the drug or the X-ray machine or the lab test — it’s the claim that is attached to that drug,” and information about the claim needs to be attached to product advertisements.

Daniel Weinbach, president of the Weinbach Group, an advertising firm that represents health care-related companies, explained to Vox how Cancer Centers of America uses a help-seeking strategy to market its treatment services: “They don’t tell the prospective patient what kind of chemotherapy or what kind of radiation they’re going to use to treat their cancer. They just say ‘We treat cancer. We treat it well.’” Cove’s use of patient testimonials conveys a similar message: We treat migraines, and we treat them well.

Selling health care directly to patients makes advertising more complicated

When the FDA issued draft regulations for consumer advertising in 1997, it was at a time when pharmaceutical and biotechnology companies promoted their drugs only in broadcast and print ads and in doctors’ offices using brochures and posters.

Although the ads were directed to the consumer, a Pfizer ad for Viagra, for instance, didn’t take a consumer to its website to order the drug directly; they were told to talk to their doctor about Viagra and, if prescribed, to receive it from a pharmacist, who could offer further guidance. These protective layers tried to help patients seek information about their options outside of the ad. DTC health care does not always involve these same layers because so much of a patient’s personal health information is self-reported and not the result of a thorough in-person exam.

Accessing DTC health care can be as simple as typing the company’s name into Google or tapping a link on Instagram. From there, you sign up by entering your name and email and completing a health questionnaire. Your answers are reviewed by a licensed physician within 24 hours. Some of these companies want your credit card information up-front, others supplement your questionnaire with video assessments with licensed health care providers.

After their review and depending on the service, medical professionals are available by text, chat message, phone, or video call. You can often select the specific medication you want or wait for your digital doc to make a recommendation for a recurring subscription to be delivered to your doorstep. Some of these services allow your prescription to be filled by a brick-and-mortar pharmacy.

The process is smooth, perhaps too smooth. But telemedicine — the connecting of doctors and patients via telecommunication technology from video chat to text message, allowing for diagnosis and even prescription — has been a boon for remote, immobile, impoverished, or otherwise traditionally unreachable patients.

As telemedicine expands beyond necessity to convenience, the consequences of consumer marketing (and diagnosing, prescribing, and dispensing) have changed. But the FDA’s guidance for drug advertising does not seem to clarify cases in which a company other than a drug maker is advertising a drug. The agency isn’t entirely in the dark — an FDA spokesperson acknowledged that DTC health care is an area of the drug industry the agency has been fielding more questions about lately. Although this type of company is not named in FDA regulations, the agency says advertising regulations still apply, and these regulations do affect the types of marketing we see.

DTC health care companies that market themselves on Instagram are particularly keen on help-seeking advertising. Roman uses its Instagram feed to inform its followers that two-thirds of the world has herpes, a condition the company treats. Keeps, operated by Thirty Madison, which also owns Cove, draws people in with a post about hair-loss myths, explained more thoroughly on the website where it diagnoses, recommends, and prescribes treatments. Hims uses the double entendre of March madness next to an unmarked packet for its anxiety treatment.

Asked about Cove’s marketing strategy and how it conforms to FDA guidelines for risk-benefit disclosure, co-founder Steven Gutentag told Vox that the guidelines do not apply to their ad strategy. “For example, we do TV advertising, and its focus is not on the medication or a specific treatment but on the condition and awareness about the disease.”

There is a reason beyond federal regulations that DTC health care companies favor help-seeking ads over product claims and reminders, though: Facebook and Instagram prohibit overt drug advertising. DTC health care companies rely on a robust social media presence to reach swiping and streaming homebodies. Advertising policies for Instagram and Facebook prohibit paid promotion of prescription drugs and apply state and federal guidelines for paid advertising of over-the-counter drugs, but those platforms’ policies say nothing about help-seeking ads.

As such, DTC health care companies limit their paid, or sponsored, posts to vague platitudes. An ad for Hers, for example, shows a hand holding unmarked pills with the words “Your body. Your control.” written in bold lettering across the top. Companies can also subvert these policies by employing the help of influencers or using organic content on their feeds to actually discuss the drugs they sell. The FTC and FDA have yet to create uniform guidelines for payment disclosure, but influencer transactions and posts — which are subject to FTC regulations — do not violate Facebook and Instagram’s advertising policies because the platforms are not being paid to promote them.

Although Facebook and Instagram do not consider unpaid content advertising, the FTC holds a different position. According to an agency spokesperson, a company’s own Instagram page is already considered to be commercial speech or marketing. Individual posts “don’t require a disclosure that they are advertising because they are presumed to be such.”

Patients and consumers aren’t the same

The line between patients and consumers can seem fuzzy. Weinbach explains the DTC companies’ position: “It is the nature of marketing that we use all the tools at our disposal to make our clients’ products and services look most attractive to the audience they want to reach.” He does not view these help-seeking ads as a nefarious solution to restrictions on platforms like Instagram and Facebook but rather as the system at work. Echoing these sentiments, Holley Miller, founder and CEO of Grey Matter Marketing, said that “any industry follows the same process of trying to make an uneducated cohort of consumers aware of something that might interest them.”

While the goals of educating consumers and educating patients might overlap, they remain fundamentally different, and bioethicists say there needs to be more care taken. Wendy Mariner, a professor at Boston University who studies health law, ethics, and human rights, defines a consumer as a buyer of goods and services, whereas a patient is a recipient of health care services who may defer judgment to health care professionals. In other words, trained medical professionals — doctors — know how best to diagnose and treat disease, not patients.

Even without mentioning a drug, help-seeking ads, created by a brand or drug manufacturer, can still lead a patient to one name-brand remedy when another treatment might be more affordable or effective or even introduce the idea of a problem where none previously existed. And, given the newness of this style of telehealth and lack of data to support its success, Johns Hopkins’s Greene worries there is an artificial promise of personalized health care when the patient is actually on the receiving end of boiler-plate treatment: “The deep anxiety is that there’s a ruse of individualization and then the output is the same old drug.”

Anxiety over the efficacy of this health care model may be well-founded, as most DTC companies offer only one or two drugs for a condition when a traditional physical consultation may yield multiple options.

Anxiety is the most common mental illness in the US, and one that Hims and Hers purport to help you fight. To treat the disease, the companies exclusively offer propranolol, a beta-blocker approved to treat high blood pressure. In an interview with Vox, Jeffrey Lieberman, chair in the department of psychiatry at Columbia University College of Physicians and Surgeons, notes the dangers of administering this drug without regular monitoring of a patient’s blood pressure or heart rate. While propranolol can be prescribed off-label to treat anxiety, he said that the preferred treatment for anxiety would be a low dose of a benzodiazepine like Xanax, Ativan, or Valium.

Adrian Rawlinson, vice president of medical affairs for both Hims and Hers, did not explain, after multiple rounds of questioning over email, why a drug not approved to treat anxiety was chosen to treat anxiety. But companies like Hims and Hers, that exist online and rely on subscription-based medicine, cannot prescribe or mail a first-line treatment like Xanax, a controlled substance, to patients because doing so is illegal. The Ryan Haight Act prohibits the prescribing of a controlled substance without an in-person medical evaluation — the prescription cannot even be automatically refilled. Propranolol, however, is not classified as a controlled substance by the Drug Enforcement Administration and thus can be prescribed without restriction.

While advertising a look, a feeling, or an ailment is legal, health care providers also have a responsibility to patients to keep them informed and healthy. Lieberman reminds us that health care is unlike any other business “it’s the business of life” and treating health care advertising the same as any other industry conflates patients and consumers.

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