Healthy Skepticism Library item: 20536

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: Magazine

Blutstein H
Dealing Drugs Legally
The Big Issue 1996 Nov 1714-16

Abstract:

Pharmaceutical companies can be very persuasive when they want to be. So when they offer free dinners, trips interstate and ‘educational’ seminars there are questions to be answered.

Full text:

The scene is a fashionable South Yarra restaurant where general practitioners and a smattering of specialists have gathered to sup and listen to the latest developments in their profession. The evening is made possible by the generosity of a major pharmaceutical company.

An eminent professor talks about the latest drug treatments for hypertension. His talk presents data that supports the effectiveness of the drugs sold by the host, although dietary controls are one of the most effective forms of controlling blood pressure. The good professor obviously had little time for this argument; he asks the GP sitting next to him whether he can have her uneaten dessert as seconds.

The young GP who went without dessert, Dr L, works in a small outer-suburban practice. She occasionally attends such free talks to keep up with the latest research. The other option is to attend courses organised by the Royal College of Australian General Practitioners, for which she would have to pay.

Dr L would be offended at any suggestion that she would prescribe her host’s products just because she has enjoyed the company’s hospitality. There are other equally effective products on the market… but there are so many names to remember.

The drug company hopes that its dinner and talk will help Dr L recollect the names of its product instead of competing brands when she is faced with her next patient with high blood pressure.

Pharmaceutical companies are the dominant voice in the healthcare industry. In Australia their promotional budget has been estimated to be between $173 million and $235 million. Some would say that it is at an unsafe level for good health care because doctors are unable to hear other opinions – opinions that may caution against over-prescribing or against accepting at face value the superlatives showered on the latest drug.

The impact of this promotional spending often irritates Dr L, who finds its presence pervasive. The medical magazine that interest her contain more drug advertisements than articles. Her letter box (and soon after, her bin) is regularly filed to overflowing with glossy circulars on the latest medicines, and an army of sales representatives is always knocking on her door. When she occasionally allows one in, the representative often leaves behind a small gift such as a pen or a textbook or a sample of the drug for Dr L to try out on her patients. And, of course, there are invitations to information nights with dinner included and free films. Once she was flown to Launceston for a two-day seminar, all expenses paid by a drug company.

Dr L is adamant that attending such functions does not influence her. Nor is she swayed by advertisements or drug company sponsored talks. Her reaction is typical to that found in a UK study. It showed that 91 percent of doctors believed that advertising was of minimal importance in influencing their prescribing. However 77 percent accepted and acted on a misleading claim with came from a drug company’s advertisement.

All these promotional techniques ensure that doctors listen to what the drug companies are peddling, are influenced by claims made and, in time, will prescribe their pharmaceuticals.

Against the thunderous noise of the industry a lone voice seeks to be heard. By exposing misleading advertising, the Medical Lobby for Appropriate Marketing encourages pharmaceutical companies to provide reliable information. “Misleading drug promotion can result in inappropriate drug prescribing, which may ultimately harm patients”, says Agnes Vitry, spokeswoman for MaLAM. According to Australian studies, an estimated 7 to 31 percent of pharmaceutical advertisements contained unjustified statements.

The pharmaceutical industry is aware that such statistics can damage it. To protect itself, and avoid government surveillance and intervention, pharmaceutical advertising and promotional practices are controlled by an industry Code of Conduct, running to 89 pages of rules and ethical statements. The government has accepted the industry’s self-regulation system, and maintains a watching brief.

The Code was prepared and is policed by the Australian Pharmaceutical Manufacturers Association (APMA), which has fifty-three members and covers about 95 percent of the industry. Only two significant manufacturers are not members of APMA, but during the last 3 years thirty-one drug companies breached the APMA Code. This translates to breaches by 64 percent of the member companies.

The Code allows for fines to be issued but only two companies have been fined in the last 3 years, even though eighteen companies are repeat offenders. “It is not possible for the industry to address the whole problem through self-regulation. Other stakeholders, like the government and health professionals should intervene”, declares Vitry from MaLAM.

The chief executive officer of APMA, Mr Pat Clear, defends the industry: “Self regulation of the promotion of prescription products has proven to be successful in maintaining high standards”. But Agnes Vitry disagrees. She points out that APMA picks up some cases, representing what she terms ‘the tip of the iceberg’. She believes that the self regulation system is flawed, but recognises that MaLAM needs more support. Government funding allows MaLAM to pursue about eight cases of misleading advertising each year. This funding is currently under threat.

One area that Vitry believes is open to abuse is the information provided to GPs by pharmaceutical sales representatives, as it is supplied away from public scrutiny. Pat Clear disagrees. “To suggest that such scrutiny should be undertaken is neither helpful or practical. It’s impossible to scrutinise everyone all the time unless you record every interview, because representatives work in a one-to-one situation with medical professionals”.

MaLAM cites overseas surveys that show that this activity can be, and should be, scrutinised. A US study shows that 11 percent of statements made by representatives contradicted their own company’s publications. What is particularly worrying about this survey is that doctors generally failed to recognise the inaccurate statements. In France, one third of therapeutic information provided by representatives failed to match information provided by representatives failed to match information provided by official data sheets. Furthermore, negative aspects of drugs, such as side-effects, were not mentioned in more than 70 percent of visits.

While unable or unwilling to police sales representatives, the APMA has improved education programs and raised their awareness of their ethical responsibilities. Yet there are other means used by pharmaceutical companies to influence doctors.

The industry showers doctors with gifts. This practice raises the ethical question of whether gifts place doctors under an obligation. Dr L and her partner recently accepted an invitation from a major pharmaceutical manufacturer to attend a first-release film at a cinema. According to the APMA’s Code: ‘Entertainment or other hospitality offered to members of the health care profession should be appropriate and in proportion to the occasion’.

In this case, the ‘educational’ event offered to Dr L was a 15 minute promotional film, which contained minimal medical information but attempted to amuse. In response to the example, Mr Clear asked dismissively: “How much does it cost to go to a film? Seven dollars?” Answering his own question, he says: “Not much of a gift, is it?”

This example shows the difficulty in interpreting the Code. Does gift-giving compromise doctors or is Pat Clear correct to shrug off the matter as trivial?

Dr Mary-Margaret Chen from University Hospitals of Cleveland has published several papers with her co-workers in the medical literature on this issue. Gift-giving establishes an implicit relationship between doctor and drug company, according to Chen. She writes: ‘Inherent in this relationship is an obligation to respond to the gift; this obligation may influence the physician’s decisions with regard to patient care of possibly even erode the physician’s character’. Another study by Dr Chen found that physician’s prescribing habits can be independent of scientific drug-performance data.

Admittedly, the research in this area is circumstantial. If true, however, gift-giving by drug companies may be undermining doctors’ ethical standards.

Dr L muses on how the intense promotion of drugs affect health care. Have doctors become dependent on pharmaceutical company functions for meeting their future education needs? She would like to spend more time in the library looking up original papers to make up her own mind, but there is rarely enough time. She also reflects on whether her prescribing habits have been subtly influenced by drug promotions. Do gifts compromise her in any way? The question that most exercises her mind is whether her profession will one day see themselves as prescribers of medicines rather than dispensers of health care. If so, it is not a profession she wants to remain part of.