Psychiatrists Debate Ethics Of Drug Marketing

Escalating costs of prescription drugs loom large in debates about Medicare and Medicaid and have led to heated discussions about the appropriate role of pharmaceutical companies in marketing their products.

In response to this interest, the Scientific Program Committee of APA’s Institute on Psychiatric Services will offer a debate, “Resolved: It is Unethical for Psychiatrists to Invite Sales Representatives to Market Products Through Such Methods as Educational Materials, Samples, and Gifts in Clinical Settings,” at the institute, which is being held October 29 to November 2 in Boston.

Committee member Charles Huffine, M.D., told Psychiatric News that no issue raises more passion among community psychiatrists than the propriety of pharmaceutical companies trying to influence the clinical decision making of psychiatrists.

Huffine is the immediate past president of the American Association of Community Psychiatrists.

Community psychiatrists are in a bind, he said, because they are acutely aware of the effect of prescription drug costs on patients with low incomes and disturbed about the role of marketing in driving up those costs.

Good relationships with pharmaceutical representatives can be important, however, because they help provide access to prescription drugs through samples and assistance in enrolling low-income patients in programs that provide free drugs.

The Blue Cross and Blue Shield Association released a report, “Getting Doctors to Say Yes to Drugs: The Cost and Quality Impact of Drug Company Marketing to Physicians,” that compiles results from various studies and surveys exploring issues related to the marketing practices of pharmaceutical companies.

Using data reported by the Kaiser Family Foundation, report authors Michael Millenson and Mervin Shalowitz, M.D., stated that spending on detailing grew by approximately $1.8 billion between 1996 and 2000 and totaled $15.7 billion in that year (see chart).

Detailing includes various practices by which sales representatives present pharmaceutical products to physicians.

“Detailing pays off for companies even at very high levels of expenditure,” according to a study reported by the authors.

Scott Neslin, professor of marketing at Amos Tuck School of Business at Dartmouth College, analyzed the marketing of 391 drugs with revenues of at least $25 million each during the period of 1993 to 1999.

He measured the average return on investment (ROI) that resulted from increasing the budgets of four major marketing strategies: detailing; direct-to-consumer advertising, medical-journal advertising, and physician meetings and events. Detailing yielded an overall ROI of $1.72 for each extra $1 invested.

Charles Goldman, M.D., who will present the affirmative position at the institute debate, told Psychiatric News that he will be raising issues about detailing, which he described as “a highly sophisticated process that utilizes detailed data on individual prescribing patterns and other characteristics of each physician.”

Goldman asserted, “Pharmaceutical company representatives’ use of gifts, such as food and samples, and of highly biased instructional materials is strategically linked to the data in each physician’s profile.”

He said that “an even bigger problem is that the pharmaceutical industry influences, directly or indirectly, much of the published research on treatment alternatives and efficacy. The problem is not with the pharmaceutical industry as such, but with the relative lack of psychiatric leadership opposing these practices and urging independent control of research and education by unbiased psychiatric professionals.”

Michael Silver, M.D., who will present the negative position in the debate, told Psychiatric News that physicians, not pharmaceutical companies, are ultimately responsible for what they prescribe.

“The drug companies are not doing anything illegal,” he said. “They are maximizing their profits, as do other companies in a capitalistic society.”

Silver added, “There are few incentives within the current health care system for physicians to be cost-effective in their prescribing habits.”

The business aspects and costs of health care have been ignored by patients and doctors alike until fairly recently, he argued.

The Millenson and Shalowitz report noted that marketing can have a positive educational effect. They wrote that a “key question” is the “extent to which the industry’s promotional tactics lead to an increase in appropriate use versus inappropriate use of drugs by patients.”

A meta-analysis of the literature, “Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?,” concluded that “interactions with pharmaceutical representatives” are linked to “nonrational prescribing, . . .rapid prescribing of new drugs, and decreased prescribing of generic drugs.” The study appeared in the January 19, 2000, Journal of the American Medical Association.

Researchers found a similar pattern in Great Britain. In the article “Characteristics of General Practitioners Who Frequently See Drug Industry Representatives: One National Cross-Sectional Survey” in the May 31 British Medical Journal, C. Watkins and colleagues reported that frequent contact with a drug representative “was significantly associated with a greater willingness to prescribe new drugs and to agree to patients’ requests to prescribe a drug that is not clinically indicated. . . .”

The authors mentioned the use of “broad-spectrum antibiotics” as an example of a situation in which pharmaceutical promotion “may impose serious costs.”

Analysis of National Ambulatory Medical Care Survey data in the April 1 Annals of Internal Medicine found that since 1991 physicians have increasingly turned to “expensive, broad-spectrum agents, even when there is little clinical rationale for their use.”

An editorial in the same issue singled out the promotional activities of pharmaceutical companies on behalf of broad-spectrum antibiotics as “a cause for concern.”

“Getting Doctors to Say Yes to Drugs: The Cost and Quality Impact of Drug Company Marketing to Physicians” is posted on the Web at http://online_pressroom.net/bcbsa/. ▪