Saturday, July 10, 2010

Drug Samples Are Bad Medicine

The AMA's American Medical News recently highlighted results of a study from the Archives of Surgery showing that many doctors still feel kindly towards pharmaceutical/industry reps and feel that drug samples enhance care for patients and that company/physician interactions can be acceptable within limits.

Apparently, I disagree with the majority of my colleagues.  There is research showing that increased physician contacts with industry reps tends to result in physicians making decisions less likely to benefit patients.  Other physicians I have spoken to feel that they have the internal strength to ignore the advertising that reps provide, and that no-one is influenced in their choice of treatments due to a pen or a sandwich.  "Surely," they say, " I am aware of these advertising efforts and will not let myself be influenced by them.  Maybe other, less skilled doctors are possibly influenced, but not me."

From my reading, though, this position is inaccurate.  We are taught and acculturated to return favors, to be nice to those who are nice to us.  Even a small gesture--lunch, some pens, etc--can put us in a dependent position where now we feel like we should give something back to the person who gave us a gift.  We might tend to prescribe that rep's med, just because they stand out from others.  The influence might be subtle: we still wouldn't prescribe meds that the patient didn't need, but if we're going to prescribe a specific type of medicine (for cholesterol, for example), why not use that rep's products.  Doesn't hurt me, and I can justify it for the patient.  So long as the insurance covers it, then everything should be fine. 

A similar situation exists with drug samples.  Reps will bring in samples of their newest and greatest products so that we can get patients started on meds for free and see how they do.  Often, these samples have discount programs allowing patients to continue getting the meds down the road even if they are not usually favored by their insurance.  However, samples are a false economy.  True, the first few weeks (or maybe the first month) is free--but then patients are locked in to this medicine indefinitely (as physicians are loathe to change meds that are working).  At best, this means that patients will have to pay higher co-pays for a name brand med (when a generic might be available), and their insurance picks up a higher cost.  At worst, an uninsured patient ends up becoming dependent on samples or having to pay full-price for a medicine that is terribly expensive.  But as a doctor, samples look great on the surface: I get to give a gift, patients like free things, and we leave happy.  But this ignores the future or system-wide harms that can result.  This is even more inexcusable when you realize that the majority of name-brand meds have generic cousins that work just as well (or maybe better) than the name brands.  However, no-one advertises generic meds and no-one samples generic meds.  Also--if I write for a generic patients have to go buy and pay for them.  This may be a $5 co-pay for insured patients or a $4 co-pay at large pharmacy chains offering inexpensive generics.  This isn't much, but it's more than the $0 the samples would cost.

My final comment to colleagues who DO accept industry rep contacts is to remember that these reps--who come nicely dressed, asking for a moment of your time--are ADVERTISING.  They do not provide education.  They do not provide teaching or guidance.  They bring advertising material that tends to overstate the benefit of their products and journal articles that highlight their products' strengths while at the same time downplaying or dismissing any potential harms.  When Ketek (an antibiotic) was on the market, reports of liver injury began to show up after it had been in use for some time.  When I asked a rep about this, I was assured that it was 2 cases and (theatrical whisper) "One was a drinker."  I never used Ketek much (it was a me-too drug that cost more and offered no benefits to other meds on the market then), and I was glad when the FDA restricted the medication's use...due to reports of liver failure and deaths related to the medication.  The medicine was not pulled off the market by the FDA, but has essentially become a worthless medicine.  If you trust drug or other industry reps to bring you unbiased, honest information, then you're fooling yourself.

In my opinion, physicians must recognize and understand the potential harms that industry contact bring--biased information,  a risk that you will make decisions that do not benefit patients, and patients' perceptions that you are biased toward drug reps due to your contact withe them.  I think individual doctors' offices should develop policies that restrict or forbid industry rep contacts, similar to rules and restrictions in existence in many academic centers.  I think we need to help patients understand that drug samples are NOT good medicine, and that the $4 co-pay to start a generic you will be able to continue taking is worthwhile.  We also probably need to re-evaluate the policy of pharmaceutical companies producing direct-to-consumer ads (or at least be prepared as physicians to point out the inaccuracies in those ads).  We need to ensure that industry reps are abiding by their industry's voluntary restrictions and by familiarizing ourselves with these restrictions so we can call out reps who violate them.  Or we need to simply step away from industry rep contacts--they provide minimal (if any) benefits to us as doctors, to our patients, or to our health care system overall.

Finally, when we access health care as patients, start to pay attention to industry influence in our health care system.  Do you see ads in offices?  Do you get samples?  Do you really feel comfortable with your answers?

(There are some movements trying to remove industry influence from medical practice.  You can learn more about some of these by reading about the National Physician Alliance's Unbranded Doctor campaign and by learning more about "academic detailers"--medical professionals who come to doctors' offices like industry reps do, but who provide information about the value of generic drugs and who encourage doctors to follow evidence-based practice guidlines that focus on generic meds w/ proven benefits.)

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