Healthy Skepticism Library item: 4474

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: news

Ong A, Mansfield PR.
Controversies: Should free drug samples be banned?
Australian Doctor Weekly 2004 Feb 6

Full text:

NO, says Dr Angela Ong, a GP in Matraville, NSW.

THE concept of pharmaceutical companies providing gifts to GPs has long been controversial. So too has pharmaceutical company sponsorship of drug trials. Some people see the issue of pharmaceutical companies providing drug samples to GPs in the same light. However, I believe drug sampling offers important advantages for both doctors and patients.

One of the most obvious benefits is that samples can help GPs educate patients about using particular drugs. For example, if a doctor starts a patient on a corticosteroid puffer, a sample inhaler can be used to demonstrate correct use. Not only does this increase the effectiveness of the medication, it probably also increases compliance. It also saves the patient time and the community money if the patient doesn’t need repeat visits to the GP to learn the correct technique.

Samples also make it easier to explain the use of time-labelled medication. The oral contraceptive pill, for example, can be clearly demonstrated to a patient, including instructions on what to do when doses are missed, etc. The use of samples in these situations leads to more extensive patient education about the drug being prescribed.

Perhaps one of the major advantages of drug samples is the benefit they offer poorer patients. The rising cost of health care, reduction in bulk- billing and the increasing prices of prescription drugs make it difficult for low-income families to buy some medications. Is it unreasonable to supply a patient with a course of antibiotics when it is clear they would be unlikely to fill a prescription because they can’t afford to? I don’t think so. Most doctors are very grateful for free medication to use in these situations.

Benefit can also be seen when patients change medications. Let’s take the scenario of a patient not tolerating an angiotensin-converting enzyme inhibitor because of a cough. If the decision was made to try another agent, tolerance could be assessed with samples until the best option was found, saving the patient and community money on wasted drugs. There are many similar examples of when it is preferable to use samples to determine side effects, rather than wasting standard packs of medication.

It also has been documented that potential dispensing errors can be decreased if a patient has been familiarised with a drug before obtaining it at the pharmacy. Patients who have been started on a drug with samples are more likely to realise if incorrect medication has been dispensed before an adverse event can occur.

Many drug samples are accompanied by educational material which GPs can use to assist patients understand conditions and medication. This is satisfying both for the GP and their patient and provides a tool to enhance doctor-patient communication.

Free drug samples also offer benefits in acute care. This is most notable when a medication needs to be started sooner rather than later, when the consult occurs outside of normal pharmacy hours, or when the patient is seen on a home visit and can’t get to a pharmacy.

In summary, drug samples undoubtedly offer benefits. It seems reasonable for GPs to use available resources to aid their patients. As long as drug samples are dispensed in the patient’s best interests, it’s difficult to find fault with this practice.

YES, says Dr Peter Mansfield, a GP in Moana, SA, and the director of Healthy Skepticism.

DRUG samples have some obvious advantages. The disadvantages are less obvious but outweigh the advantages. I will highlight some important disadvantages and then explain why it would be better to ban samples and replace them with a free-drug voucher system.

One important disadvantage is that using drug samples distorts drug use. Drug companies ‘give’ samples because they know samples influence drug use often enough to give them a good return on investment.

Use of samples distorts drug use towards whatever is available in sample cupboards. The contents of sample cupboards are biased towards the drugs that are more profitable for drug companies. They make more money from expensive new drugs that have patent-monopoly protection.

Drug companies spend about

$1 billion to $1.5 billion a year in Australia to persuade us their new drugs are better than the older ones.

However, studies of new drugs have found only 3% are really a significant advance. Use of samples often leads to patients being started on drugs that are not as good medically or are more expensive than what we would otherwise recommend. Once a suboptimal drug has been started use may continue for many years. Prescribing can also be distorted when we become more familiar with sampled drugs and thus prescribe them more often.

Samples can also distort drug use by making us feel grateful to drug companies. We get a good feeling when patients express appreciation for free samples. Some of us use samples for family, friends and ourselves. It is normal for us to feel grateful, but it leads to reciprocal obligations.

Social science research has shown reciprocal obligations can distort decisions without our being aware of it. After receiving samples it would be rude for us to refuse to give drug representatives a good hearing. That is why they use samples to get their foot in the door. Once we have accepted samples it does not seem so bad to accept other gifts. Reciprocal obligation increases the effectiveness of other components of drug promotion.

Drug promotion doesn’t fool all of the doctors all of the time but it is often more effective than we realise. Doctors who believe they are not influenced by drug promotion are probably the most vulnerable. Many studies have shown that the more we rely on drug companies for information, the worse our prescribing becomes.

Another disadvantage is that using samples leads to drugs being started without help from pharmacists. This is a problem because three heads – doctor, patient and pharmacist – are better than two. Pharmacists often know more about drug storage and interactions than doctors. Double-checking by pharmacists can save patients from harm and save doctors from litigation. The most dangerous time in drug therapy is when a drug is started. Use of drug samples often means drugs are started without patients and doctors gaining the protections that pharmacists should provide.

A third disadvantage is that many samples become out of date. If expired drugs are given to patients they may be harmed or angry. Checking for, and disposing of, expired samples is yet another hassle for overworked GPs. Expired samples are not good for the environment.

A solution that retains the advantages without the disadvantages is to replace samples with a system of vouchers for free drugs. This would enable poorer patients and patients starting drugs to receive drugs for free at the expense of the PBS.

Patients would benefit from getting the best drugs rather than whatever happened to be in the sample cupboard. Doctors would benefit from saving time because vouchers are quicker than ferreting for samples. Doctors would also benefit from having more freedom to choose which drug to recommend. Both patients and doctors would benefit from the protection of double-checking by pharmacists.

It may be possible that replacing samples with a voucher system could benefit drug companies by reducing their costs and increasing their income from better drugs. What I am certain about though, is that it would benefit patients, taxpayers, pharmacists and doctors.

References available on request from peter@healthyskepticism.org