How medical marketing influences doctors and patients

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[sSRI-Research] How medical marketing influences doctors and

patients

 

How medical marketing influences doctors and patients

Ben Harder

 

http://www.sciencenews.org/articles/20050730/bob10.asp

 

When John D. Abramson was practicing family medicine in Hamilton,

Mass., he prided himself on how conscientiously he selected the drugs

that he prescribed. He closely followed pharmaceutical research. He

kept track of the latest medical guidelines.

 

 

And he maintained his distance when company salespeople, with

promotional pitches at the ready, appeared at the practice that

Abramson shared with several colleagues during the 1980s and 1990s. He

typically didn't speak to pharmaceutical sales agents, although he did

let them leave behind free samples of drugs that their companies sold.

 

Abramson knew that the companies wanted him and his colleagues to

prescribe new and often expensive drugs rather than their older, less

costly alternatives. But he saw no harm in stockpiling the freebies

and handing them out to patients who were without health insurance and

unable to buy drugs on their own.

 

" I thought I was being Robin Hood, " Abramson says. Before long,

however, he grew so familiar with administering the free drugs that he

found himself writing prescriptions for the same substances for

insured patients, whose coverage would then pay for the medications.

For pharmaceutical companies, Abramson's behavior meant new customers.

" That's what they wanted, " he says. " They were playing me like a violin. "

 

Abramson left medical practice nearly 4 years ago to write Overdo$ed

America: The Broken Promise of American Medicine (2004, New York:

Harper Collins), which trains a critical eye on pharmaceutical

companies' influence on medical research and practice. He now teaches

at Harvard Medical School.

 

At least two pharmaceutical marketing strategies converge to alter

doctors' prescribing habits. On one hand, sales representatives target

physicians with visits and samples, and ads tout drugs in journals. On

the other, mass media advertisements urge people to ask their doctors

about specific brand-name medications. This direct-to-consumer (DTC)

advertising, which is not permitted in Europe and strictly limited in

Canada, has in the past decade grown into a multibillion-dollar

industry in the United States.

 

Pharmaceutical companies and some health researchers say that

promotional activities make doctors and patients better aware of

available treatments. Other researchers and consumer advocates counter

that the ads and giveaways goad doctors into giving patients drugs

that may be unnecessarily expensive or suboptimal in effect.

 

If nothing else, says internist Richard L. Kravitz of the University

of California, Davis, the consequence of drug promotions is that the

medicines that are most profitable for drug companies end up being

overprescribed.

 

Ask the doctors

 

Eighteen actors were dispersed to physicians' offices by Kravitz and

his colleagues during 2003 and 2004. Such actors are known in the

medical literature as standardized patients; they aren't sick, but

they're trained to describe certain realistic sets of symptoms.

Medical schools use standardized patients to test students' diagnostic

skills.

 

Kravitz had a different test in mind. He and his fellow investigators

instructed the actors not only to fake specific symptoms but also, in

some cases, to ask for a particular drug or a general class of drugs.

The researchers wanted to know how physicians would respond to

supposedly media-driven inquiries.

 

The researchers recruited 152 family physicians and general internists

practicing in San Francisco, Sacramento, Calif., or Rochester, N.Y.

Each participating doctor was told that he or she would be sent two

standardized patients during the next year. But the doctors weren't

told the study's purpose or how to identify the fake patients.

 

The actors then scheduled appointments with the physicians. Once in a

participating doctor's office, some of the fake patients described

symptoms of major depression, a long-lasting mood disorder that's

often treated with antidepressant medications. Other standardized

patients complained of symptoms of a less serious psychiatric ailment,

which is called adjustment disorder with depressed mood. This

condition generally disappears within months without medication.

 

When standardized patients faking major depression didn't specifically

request an antidepressant, 31 percent received a drug prescription.

However, when others claimed that a television show about depression

had encouraged them to seek drug treatment, 76 percent received a

prescription of some kind.

 

In those two groups, about 6 percent of the actors who received a

prescription got one for paroxetine (Paxil), one of several drugs in a

class frequently used to treat major depression.

 

However, when members of a third group reporting identical symptoms

asked specifically for Paxil, saying that they had seen it advertised

on television, more than half the resulting prescriptions were for

that drug.

 

In standardized patients who reported symptoms of adjustment disorder

and didn't raise the subject of antidepressant drugs, just 1 in 10 got

any medication. But nearly half of the actors who asked for medication

got it. Most who asked for Paxil walked out with a prescription for

that drug, while most who made a nonspecific request were prescribed

some other antidepressant.

 

Ads aren't necessarily having a wholly negative influence, Kravitz and

his colleagues note. " Direct-to-consumer advertising may have

competing effects on quality, potentially both averting underuse and

promoting overuse " of prescription drugs, the researchers conclude in

the April 27 Journal of the American Medical Association.

 

" It's probably promoted use of expensive, brand-name medications,

which are more likely to be heavily promoted ... than less expensive

generic alternatives, " Kravitz says.

 

Other studies support the notion that DTC ads translate into

prescriptions. One 2003 investigation found that people visiting

doctors' offices in Sacramento, were twice as likely to request a new

prescription, and twice as likely to receive one, as were similar

patients in Vancouver, British Columbia. The U.S. patients were nearly

six times as likely as were their Canadian counterparts to have

recently seen ads for most of the half-dozen prescription drugs that

the study examined, reported a team of Canadian and U.S. researchers,

including Kravitz.

 

In a more recent survey of 643 U.S. physicians, many attributed a

double-edged effect to pharmaceutical ads. Nearly three-quarters of

the doctors said that they believe that DTC ads inform people about

medicines that might help them, and two-thirds of the doctors said

that ads improve dialogue. One quarter of the ad-initiated

doctor-patient conversations lead to diagnoses of treatable problems

that might have gone undetected, the doctors report.

 

On the other hand, four-fifths of the survey respondents said that ads

encourage patients to seek unnecessary treatments and don't fully

convey the therapies' risks. Joel S. Weissman of Harvard Medical

School and his colleagues posted the results of the survey on the Web

site of Health Affairs in April 2004.

 

The pharmaceutical industry says that it recognizes its responsibility

to be candid about drug benefits and risks. " Our communication with

patients should really be thought of as direct-to-consumer education, "

said Johnson & Johnson's chief executive officer William C. Weldon at

a March meeting of the Pharmaceutical Research and Manufacturers of

America (PhRMA) in Washington, D.C. " The framework we call DTC

advertising may inadvertently minimize the importance and power of

medicines and their risks, " he said.

 

In the months since the PhRMA meeting, where Weldon was elected to

head the trade association's board of directors, companies such as

Johnson & Johnson and AstraZeneca have introduced new television ads

that include recitations of circumstances in which patients shouldn't

use the companies' products. Last week, PhRMA's board gave preliminary

approval to a set of advertising principles that encourage ads that

" reflect balance between risks and benefits. "

 

The new advertising trend has a backdrop of recent concerns about drug

safety. Since last September, when the sudden recall of the pain

medication Vioxx raised congressional concerns (SN: 2/5/05, p. 90:

http://sciencenews.org/articles/20050205/bob10.asp), the Food and Drug

Administration has sent numerous warning letters to drug manufacturers.

 

In April, for example, FDA ordered an ad for the impotence drug

Levitra off the air because the agency said that it neglected to

explain potential side effects. Another letter went to AstraZeneca in

December, warning the London-based company that newspaper ads about

Crestor contained " false and misleading " statements about risks

associated with that cholesterol-lowering drug.

 

Prescriptions padded

 

As influential as advertising drugs to consumers may be, it represents

only a small fraction of pharmaceutical companies' promotional

efforts. The industry spent $3.2 billion in 2003 on consumer-oriented

marketing, according to the health-industry research firm IMS Health.

 

a6382_1519.jpg

 

 

By contrast, IMS Health's latest data show that the pharmaceutical

industry spent about $5.3 billion in 2003 on detailing—a term for the

face-to-face promotional activities directed toward physicians—and it

distributed 16.4 billion dollars' worth of free samples that year. The

companies also spent $448 million on advertising in medical journals.

PhRMA doesn't dispute these estimates.

 

Free samples and detailing appear to have different effects than

advertising does, says health-policy researcher Julie M. Donohue of

the University of Pittsburgh. DTC advertising for a particular drug

tends to increase, at least slightly, sales of that medication and

similar drugs, she says. Detailing and samples, on the other hand,

boost sales of a drug at the expense of similar drugs.

 

In one recent investigation, Donohue and her colleagues examined

insurance claims from 1997 to 2000 of more than 30,000 people with

depression. The team compared trends in antidepressant prescriptions

with the timing of changes in manufacturers' spending on samples,

detailing, and consumer ads related to those drugs.

 

New prescriptions, they found, were 32 percent more common during

periods of greatest advertising spending than they were in periods in

which that marketing expenditure was at its lowest. In contrast,

neither detailing nor sample spending had a discernible effect on the

quantity of new antidepressant prescriptions, Donohue's team reported

in the December 2004 Medical Care.

 

The lack of obvious effects from detailing and samples doesn't

surprise Kravitz. Drug promotion aimed at doctors, he says, is " a

pretty pervasive force. It's really integrated so much into medical

practice that it's hard to say what the effects are. "

 

A survey of physicians published in 2001 found that 92 percent had

accepted free drug samples. Most doctors had received other freebies,

too, including meals, travel, and entertainment tickets.

 

Since 2002, PhRMA has stipulated that member companies' gifts to

health care providers should be " not of substantial value ($100 or

less) " and that they must be useful in providing care for patients.

Anatomical models are permissible gifts, therefore, while floral

arrangements, artwork, and sporting-event tickets are not.

 

According to IMS Health data, detailing expenditures aimed at medical

professionals fell by 15 percent between 2002 and 2003, the first

annual decline in the past decade.

 

Citing cost-control measures, Donohue says, hospitals have

increasingly restricted detailing. Some have also imposed limits on

free samples and other items. Last year, for example, Affinity Health

System of Wisconsin barred pharmaceutical companies from distributing

to its employees free meals, clocks, calendars, and other handouts,

and it restricted the distribution of free samples.

 

The notion is that physicians will feel more comfortable prescribing

cheaper alternatives to brand-name medicines when they feel they don't

owe a return favor to a drug company.

 

" It's a wonderful idea, " says Abramson.

 

However, he also notes, good treatment will always depend on a

patient-doctor agreement. Abramson recalls one patient in his own

practice who told him that she had seen an ad for Paxil and thought

that she had a chemical imbalance that the drug could correct.

Abramson, recognized that she had adjustment disorder and recommended

counseling instead. His patient resisted the idea.

 

" Because she believed Paxil was what was necessary, I did prescribe

Paxil—and counseling, " he says. " It was the Paxil prescription that

allowed her to buy into the process of counseling. That was necessary

for moving toward a real solution. "

 

(Mod. note: Being under the influence of drugs legal or nonlegal usually always

negates any counseling attempt)

 

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