Sunday, April 30, 2006

A contrarian view of the drug companies

Dr. Jerald Kreisman, associate clinical professor of psychiatry at St. Louis University, in Defending the Drugmakers writes “Over the past several years, the pharmaceutical industry has replaced managed care as the Bad Boys of Health Care. Public opinion, government oversight, and litigation pressures have obliged the industry to adopt a litany of mea culpa declarations.” Indeed “Big Pharma” has become analogous to big oil, big money and everything else that’s big and bad. Alongside that physicians, many of whom interact with drug company representatives, are portrayed as the mindless minions of an industry-led conspiracy to harm patients. Notwithstanding the patent absurdity of this characterization the drum beat is getting louder and louder.

Doctors are not devoid of critical thinking skills. Moreover, there’s no convincing evidence that physician-industry interactions result in net harm to patients’ health. Immediately comes the shrill cry “What about Vioxx?” Yes, the promotion of Vioxx has been linked to harm. What is not known is how this balances against the effects of promotion of clearly beneficial yet underutilized therapies such as DVT prophylaxis and beta blockers and ACE inhibitors for heart failure.

Finally, haven’t we heard about enough of the tired old argument that doctors succumb to drug company deception because of their dependence on free trinkets such as pens and note pads? Where’s the evidence for that argument? (I’ve done without for seven years and couldn’t care less about ‘em). I’m much more concerned that continued industry bashing will lead to an erosion of support for CME and the ultimate end of resources like Medscape and emedicine.

6 comments:

mchebert said...

I agree that trinkets, dinners, and pharma rep visits have little to do with physician's prescribing habits. Many new drugs are beneficial and are used more because they are better, not just because they are well-marketed.

But I have a big picture problem with Big Pharma. Unfortunately, as soon as a patent expires on a drug, heavily funded research also ends. Who is studying diuretics anymore? Or uses for regular insulin? Or beta blockers? A few people are, but it pales next to the intensity of research going on with blockbuster medications.

Patients lose out with big pharma because low cost treatments are not being explored or taught. Like everything else in our society, our attention is skewed to the sexy rather than the useful.

R. W. Donnell said...

Dr. Hebert,
It's true that drug companies generally don't focus on the cheapest, or at times the most useful drugs. But is this a surprise or a major disappointment? After all, their fiduciary duty is to their stockholders. And while the interest of the stockholders is not in conflict with the interest of patients (good outcomes)nobody in their right mind expects drug companies to be the sole guardians of public trust.

syed said...

I beg to disagree with both Dr. Donnell and Dr Hebert. I'm a final year resident at a largish community hospital, and have experienced the impact of these trinkets & dinners. Our noon conferences & grand rounds that are not sponsored by drug companies, are sparsely attended, while those that are sponsored are sometimes so partisan as to defeat the entire purpose. This drug company sponsorship of lunches and the like has created a feeling of entitlement amongst residents and attending staff, and this is reciprocated in the prescribing patterns.
Consider for example Restless Legs syndrome (RLS). In an informal survey with my colleagues, most of our information about this "oh-so underdiagnosed" condition has come from pharmaceutical dinners, and sponsored lectures. This syndrome has almost become a manufactured disease, and the number of prescriptions of ropinorole for this condition is rapidly growing, yet its mechanism of action differs little from other dopamine agonists including Bromocriptine and in some cases L-dopa/Carbidopa.
But because of the almost pernicious nature of pharma sponsorship, Rx are written for a drug that costs $270/mo, vs something that costs $30/mo. It is easy for us to forget our fiduciary responsibilities toward our patients not because of these trinkets directly, but the opportunities these offer for physician-pharma interaction.

This sentiment "Many new drugs are beneficial and are used more because they are better, not just because they are well-marketed" is simply not true. Most new drugs are never compared head-head with thier precusors. Consider the clever substitution of pregabalin for gabapentin by Pfizer. No head-head trials exist for the approved indications. The examples of these abound.
It remains the duty of physicians to seperate the wheat from the chaff by reviewing the peer-reviewed literature for themselves, or by using independent resources such as Medical Letter, or the excellent Candadian Therapeutic Letter or similar sources. But our new physicians are woefully uninformed about this, because of our almost near total reliance on pharma companies to fund our educational initiatives. It does seem a sad travesty that professionals whose compensation places them in the top 5% bracket, rely on handouts to educate themselves.

I've ranted enough. Thanks for the venting opportunity. Great issue though. :)

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Anonymous said...

The Damage of Legalized Lying

Amazingly, with the pharmaceutical industry, the amount spent by them on marketing is far greater than the amount spent on research and innovation, as it approaches 30 billion annually spent on their marketing efforts, as this presently takes priority over the research and development, so it seems. This includes 5 billion that is spent on drug reps, who implement the tactics created bytheir marketing departments.

Marketing in some form exists with every business regardless of the industry of the business and its purpose. Essentially, marketing in itself is a complex activity- consisting of many specialty elements of various areas and levels, typically of an aggressive nature. However, with the pharmaceutical industry, marketing needs to become more specialized and altered due to the delicate nature of health care in order to prevent harm and ensure quality health care for all.

Tactics that ignore such caution and consideration possibly could cause harm to patients in a number of ways, as this occurs presently. And recently, the marketing exposure of the drug industry has become an unfortunate issue for this industry for many reasons that remain a reality aside from what drug PR firms may try and tell us, as presently it seems as if the pharmaceutical industry, once viewed as very ethical, are now viewed as motivated by profit and greed.

Such unwise and irresponsible methods include:

1. Advertising directly to the consumer. This method of bypassing what should entirely be decided by the heath care provider, as disregarding the determining factor of the heath care provider can possibly lead to inappropriate prescribing of certain advertised meds due to the demands of an unqualified patient who believed the content of such an advertisement that suggests that they are a candidate for a particular drug involved in the advertisement. Furthermore, it potentially removes the discretion of the provider regarding the best treatment for the patient through such frequent methods of marketing to potential consumers by such advertisements directly to consumers. Assessment of a patient by a health care provider is required and necessary, most believe, in order to determine the best treatment for a patient, as well as the provider considering their medical history as well as other variables necessary to consider the best course of the patient’s treatment. Ignoring this premise could be damaging to the patient seeking treatment through this possible inaccuracies through efforts provided by the marketing departments of drug companies. DTC advertising is now occurring in doctors’ office as well
2. Clinical evidence is the ultimate determining factor for treatment selection, after drug sample availability, and this evidence should be utilized by the provider entirely absent of any marketing techniques implemented by a drug maker, which may include embellishments and lack of necessary evaluation or regulation of such patients. Analysis of such evidence is very necessary for the ultimate benefit of the patient, and should be free of interference.
3. People take issue with the use of celebrities who are paid greatly by some drug companies, possibly to attempt to expand or create a certain medical condition, so the celebrity will discuss a certain disease state determined by who paid such a celebrity. Many examples of this occurring have been noted by others, and can lead to both inappropriate prescribing and over-prescribing of these meds so often promoted to consumers. This may be appropriate if one is attempting to sell a car, but health care is more of an important topic of concern.
4. Education not only trough sponsored doctors of the drug company, but also statements from various medical groups sponsored as well by the industry for purposes of endorsement have been considered inappropriate for the welfare of public health through awareness techniques such as these methods initiated by marketing departments lacking thorough clinical evaluation that is necessarily for the best treatment of patients seeking care or concern of their health. As an ex seasoned big pharma drug rep, I can assure you that education is not the purpose of a pharmaceutical company. Offering various inducements to others tops the list, though. Perhaps research of novel and innovative medications should instead be the focus of pharmaceutical companies.
5. The over-saturation of drug company sales reps who in the past have initiated questionable tactics upon the direction of their marketing department of their drug company employer, regardless of the validity or legality of such tactics that are normally not questioned or known by the drug reps in the first place. Such forms of manipulation include for some time questionable inducements for the health care providers. This is allowed to happen regardless of whether or not it is legal. As a result, many medical establishments are progressively prohibiting the activity or presence of drug reps at their locations. With the pharmaceutical company, sales reps are required by their employers to follow the direction of their marketing departments without exception. And the questioning of these directives is not tolerated by their employers. Because of this, the drug company’s image becomes more damaged as a result.

To further illustrate this drug rep description, their employers require them to spend huge amounts of money annually to spend for doctors or to doctors that is void of any benefit for the patients, as the representative is typically void of any medical training or experience.

In the past, the pharmaceutical industry was viewed as research-driven, innovative, and patient focused- entirely for the benefit of patient heath. This is why the industry was at a time viewed as an ethical one. Clearly, this is not the case today. Instead, many view this industry as one with their primary goal is to initiate market-driven profiteering, regardless of the attempts of the industry to convince the public otherwise, as stated previously by the industry’s supporters, who have attempted to place value to the medical community as the goal of the pharmaceutical company. So the view by the public of drug companies has been damaging to what should be a concerning degree because of their tactics and deception. So the pharma industry seems to be in great need of repair and re-evaluation of their purpose. This should performed by action instead of empty statements by the industry. It is the author’s opinion that actions by this industry for the sole benefit for the patients are displaced if they exist, unless my interpretation and perception are flawed greatly. The repair can only be done by the refocus of the industry towards convincing the public of the industry’s concern of their restoration of the patient’s health in several ways. One way is to always make the medical community aware and with conviction that their products are solely for the benefit of the patients, which is rarely discussed in full detail with such people. Fortunately, medications historically have been for this reason and are often necessary for the restoration or benefit of the health of those in medical need. The need should be more clearly defined by those who determine this, and these are the health care providers, who are caregivers, and not marketers. In summary, the medicines now available to us are for the benefit of the patients, and not the developers who should create these medicines for this reason.

“Marketing is the act of making something seem better than it really is” --- Suso Banderas

Dan Abshear

Author's note: What has been written has been based upon information and belief
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