Saturday, April 23, 2011

How Drug Marketing Influences Use

There is do doubt that the way pharmaceutical companies market drugs to both doctors and consumers sways prescribing and drives up health costs.  Prescription drug costs have outpaced other health care spending and are predicted to exceed the growth rates for hospital care and physician services going forward from 2010-2019.

Two researchers (Howard Brody, MD, PHD, University of Texas Medical Galveston and Donald Wright, PhD,  University of Medicine and Dentistry of New Jersey) have outlined 6 things that have a large effect on physicians and lead us into prescribing drugs that may not be needed.   It's not just the pharmaceutical marketing that has led us to this is also how journals publish literature that physicians rely on for changing medical practice.  Here are the 6 strategies that influence us:
  •  Reducing thresholds for diagnosing disease.  For example, a diabetes diagnosis used to be fasting blood sugar above 130.  Now it is glucose above 100.  There is no evidence that tight control leads to improved outcomes in preventing stroke, total mortality, blindness or renal failure.  Early detection  is a good thing if it helps with diet and exercise but recent data shows that the intensive therapy (HbA 1c-<6%) group did worse.
  • Relying on surrogate endpoints rather than outcomes as goals.  We know that Statins lower cholesterol.  From 1994-2006 the use of Statin drugs by adults 45 and older increased 10 fold.  In a meta-analysis of 11 clinical trials involving 65,229 participants of high-risk patients without prior cardiovascular disease, the Statin use did not lower all- cause mortality.  Surrogate endpoints make it easier for marketers to make claims that the drug will benefit the patient.
  • Exaggerating safety claims.  When drugs are initially tested, the test population is usually homogeneous and small.  As a larger number of patients take the drugs, the potential for adverse effects increases.  We need to always be aware of this.
  • Exaggerating efficacy claims.  Marketers often emphasis that a new drug is better than an established (lower cost) drug when actually the drug performs no better than the old one.  New drugs might have an advantage for a smaller subset of patients but marketers emphasize the benefit for everyone.
  • Creating "new"  diseases.  Social anxiety disorder (aka: shyness),  Erectile Dysfunction (aka: aging men), Pre-diabetes etc. creates millions of new customers who might benefit, but will also be exposed to high cost and potential side effects.
  • Encouraging unapproved uses.  It is illegal for a pharmaceutical company to market a drug for a non-indicated condition, but that doesn't stop physicians who are on the honorarium payroll from shilling for dollars.  This has been a common practice that has just lately had a light shown on it.
I am not bashing big Pharma here.  They have a product to sell and patients and physicians are the customer.  It is up to physicians to understand the subtle marketing manipulation and published research.  We need to remember that epidemiological data linking a risk factor to a bad outcome does not prove that changing the risk factor by taking a drug will reduce the risk for an individual  patient.

Modern pharmaceuticals are lifesavers and have increased longevity and good health for millions.  But we should always stop and think before we start a patient on a "lifetime" drug if they have no complaints and make sure we are really preventing an outcome, not just a lab test.

(Jama, Vol 305, No.11)


dawn holliday said...

good for you dr brayer! calling it as it is.

Anonymous said...

This is an important point I have also seen going on with marketing that is in the non pharmaceutical arena, but why is it not being stopped by the government?
If it is unethical and illegal why are they getting away with it?

"Encouraging unapproved uses. It is illegal for a pharmaceutical company to market a drug for a non-indicated condition, but that doesn't stop physicians who are on the honorarium payroll from shilling for dollars. This has been a common practice that has just lately had a light shown"

Toni Brayer, MD said...

Anon: It is not such a cut and dry issue. Many medical innovations have come from discovering uses for drugs for conditions that are not yet officially approved. Many of these doctors are involved in the clinical trials and truly believe it is working to help patients. Now that Pro-Publica and other watchdog groups have shined a light on it, there will be much more self-regulation.

My point is that physicians are obligated to understand research, marketing,competing interests and use evidence based medicine so they can help patients make the right choices.

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Barbara K. said...

This is an important post and raises big concerns.

How can patients know if their doctors are prescribing a new medication largely because a persistent pharma rep touted it -- and the new med may not offer much value over the old one and may even produce unwanted side effects?

What questions might you suggest a patient ask her doctor that won't offend the doctor?

Toni Brayer, MD said...

Barbara K: I believe most doctors are prescribing the medications they think will best help the patient. That said, some doctors are not as cost conscious and it does help to ask some questions like:

1. How long will I be taking this medication?
2. What are the side effects?
3. Is there a generic equivalent that might be cheaper
4. How long has this drug been on the market? What is your experience with it?

paul said...

Advertising can definitely influence people to take medicines and other drugs. We should always take what's necessary for our health.

-Supplements Canada

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