Who’s really filling in your prescription?

There is a war being conducted for your prescription. The opposing sides? The pharmaceutical companies who want to profit by selling you drugs you don’t need, and your doctors, whose job is to prescribe the most effective drugs to treat your condition. Unlike most other products, however, it is your doctor who decides what you take, not you. And the stakes – and profits – are far higher. But your doctors may have already fallen victim to peer pressure, subtle bribery and outright disinformation, all in the name of profit.

The news that major US pharmaceutical company Pfizer, makers of Viagra, have recently agreed to pay out a multi-billion dollar settlement to the US government over fraudulent marketing brings the testing, promotional and marketing practices of pharmaceutical companies under the spotlight once again. The $2.3bn settlement was paid out due to Pfizer’s intentionally misbranding drugs and promoting them to doctors for conditions for which they were not tested; allegations of bribery are still under investigation. This is not the first time Pfizer have been found guilty of such practices; however, while they may have crossed a line, their competitors aren’t far behind.

Suffering from high blood pressure? There can be a hundred different possible prescriptions, some of which have been tried and tested for thirty years or more, some of which are new to the market. There may be many variants, each one promoted by a different company. Medical professionals are supposed to use their scientific training, along with published, independent clinical data to decide which of these drugs is most appropriate for your condition. But at every front, these companies and their agents are vying to sway your doctors into prescribing their products, from taking them out to expensive dinners, to suppressing the results of clinical trials in some cases.  

In-office marketing is conducted by drug sales representatives, who are the pharmaceutical company’s most expensive marketing tool. There is one rep for every 7 doctors in the UK & Ireland, and they command salaries of €100,000 per year and upwards. A drug rep’s job is to convince doctors to prescribe the drug under promotion, by whatever means necessary. Drug reps are trained to build a rapport with doctors, so that their word and the information they disseminate is trusted. They also supply doctors with branded pens, notepads and mugs so that even on a subconscious level, the doctor is constantly bombarded with the brandname of the drug in question.

Drug reps usually promote only one drug at a time, and can be considered experts on the drug in question, thus they are a primary source of information for doctors. They are required to bring research papers containing the statistics, but by becoming a trusted source of information, many doctors barely glance at the statistics, and are more susceptible to spin. The drug reps may also hint at “off-label” uses for the drug in question – that is, prescribing the drug for conditions for which it has not been tested. For example, tricyclic antidepressants are frequently used to treat migraines and chronic pain; it is, however, strictly illegal for companies to promote or suggest this type of prescription. In Pfizer’s case, drug reps allegedly promoted their drugs in exactly this manner, and also bribed doctors to encourage them to prescribe the drugs in question. Neurontin, an anti-epilepsy drug, was promoted variously for use in attention-deficit disorder, depression, and alcohol withdrawal syndrome, all of which can be treated with safer, cheaper and more established drugs.

As devious as drug reps’ in-office marketing tactics can be, they pale in comparison to the rest of the promotional strategies used by Pfizer and their ilk. Continuing professional development [CPD] is an important part of medical professionals’ competence, and is required for upkeep of their licenses to practice. By attending conferences and educational seminars, doctors are kept up-to-date with the latest clinical research and practice methods. However, instead of being funded by taxpayers or doctors themselves, most of these educational seminars are hosted and sponsored by pharmaceutical companies, who see it as an opportunity to extend their influence over prescriptions. In the past, doctors were frequently flown to exotic destinations and accommodated at luxury hotels to attend “educational events”, furthering the culture of gifting; however, new guidelines from the European Federation of Pharmaceutical Industries and Associations have curbed these practices – at least somewhat. Doctors may still be wined and dined in expensive restaurants –  they just can’t bring their spouses anymore.

However, the most worrying influence comes from pharmaceutical companies’ use of research journals to subtly promote their drugs. Leading academics and medical professionals [aka “key opinion leaders”, in pharm marketing-speak] are often bankrolled to speak at the above CPD seminars, using their reputations to support a new drug. But even peer-reviewed academic journals –  ostensibly the bastion of scientific integrity – are not free of pharmaceutical companies’ influence.

Recently, US Ivy League medical schools Columbia and NYU were rocked by scandals involving academic staff attaching their names to ghostwritten papers. The papers, which are drafted by pharmaceutical companies to show their products in a positive light, and are published in medical journals for marketing purposes, generally downplay the risks of the drug in question, as well as any adverse drug reactions. Pfizer, again, are guilty of this practice, particularly in relation to Neurontin, where they either suppressed negative results or published them in foreign-language journals. And again, they are only distinct from their peers in that they were unfortunate enough to get caught – the practice is widespread.

The practice has been condemned by medical ethics experts and US Senators, one of whom is putting pressure on the National Institutes of Health to crack down on such practices. But as the line begins to blur, it becomes apparent that it is up to individual universities to tackle the problem at the source, or risk their reputation. For smaller universities, however, the benefits of ghostwritten research – publishable and citable in journals of repute – may outweigh the drawbacks.

The practical implications cannot be underestimated. If the information supplied to doctors is deliberately misleading, it jeopardises patient health and finance. So is there a viable solution?

Many doctors are turning away from corporate sponsorship and refusing to accept any forms of hospitality from drug reps. Organisations such as No Free Lunch [nofreelunch.org] campaign for stricter legislation surrounding pharmaceutical companies’ marketing habits. And as a patient? Educate yourself about your treatment. Ask your doctor about generics and alternatives. Encourage him or her to take the No Free Lunch pledge, and let evidence, rather than profit, decide.