by Alan Cassels
The people’s briefing note on perscription drugs
• A few years ago, I was invited to be the guest on an Ottawa radio talk show, the topic being something I was well familiar with, a book I co-wrote called Selling Sickness. The book explores how the pharmaceutical industry influences regulators, physicians and patients in order to sell its treatments.
On this occasion, Steve, the show’s host, invited the station’s “house doctor” to join us. Barry, a local doctor, had his own program at that station and it soon became startlingly clear I was about to be tag-teamed. After warming me up, Barry came to the point: “How could you possibly insinuate that physicians were under the influence of pharmaceutical sales reps?” These are the salespeople working for drug companies that make personal visits to doctors, dropping off samples and otherwise ‘educating’ our physicians about new drugs. “I’m offended that you think we physicians can be so easily bamboozled by sales reps,” he spat out.
Pinned against the turnbuckles, I turned to the radio host and asked, “Steve do you own any shares in pharmaceutical companies, maybe have pharma stocks in your mutual fund portfolio?”
“Sure I do,” he said. “Well, Steve, you’re wasting your money,” I said. “You know, those companies spend upwards of $2 billion per year marketing their drugs to Canadian doctors; most of that goes to drug reps. So, Steve, if those drug rep visits ain’t having any influence on doctors, then you’ve made a poor investment. If Dr. Barry is right, pharma’s marketing model ain’t working.”
They both sputtered a bit. C’mon guys. Reality check. Does an industry this successful and this powerful invest in things that don’t work? Of course not; pharma has lots of high octane brains to invest its money where it produces the greatest return. Period. If it’s in pizza or pens, delivered by smiling drug reps, then that’s where the money’s going.
Barbara Mintzes, an epidemiologist at UBC’s Department of Anaesthesiology, Pharmacology and Therapeutics knows a thing or two about drug marketing, having studied the advertising and marketing activities of the drug industry for nearly two decades: “We know from the research that sales representatives, also known as ‘drug detailers’, have a big influence on doctors’ prescribing,” she says. “They often have much more influence than doctors realize. If doctors aren’t getting the full story [about a drug], if most of the time they hear nothing about side effects or about rare, more serious harmful effects, how can they make sure they’re prescribing safely?”
When I asked a friend, a former sales rep in Nova Scotia, he said: “Hmm, ‘good safety profile’, is about all we’d say about safety. Basically, unless they [the doctors] ask, we don’t bring up the topic.”
It’s easy to see why drug sales people are effective. Generally, they are polite, engaging and extremely good at reading people, trained to focus on the positive of their products and driven to do whatever is needed to get doctors to write their prescriptions.
Some physicians won’t see drug reps, but a 2006 survey found about two-thirds of doctors in BC see reps at least once a month and 42 percent of BC’s GPs get visited several times a week. Many doctors like the free drug samples. More than one doctor has told me that’s the only reason he sees reps. The samples are always the newest and usually the most expensive drugs on the market.
Worries about how drug reps might be biasing prescribers led researchers to think about providing doctors unbiased or academic sources of information. Thus, the concept of counter-detailing or “academic detailing” was born. The Granddaddy of this movement is Dr. Jerry Avorn, a physician and professor of medicine at Harvard Medical School. His 2004 book Powerful Medicines reflected on the thinking behind it: “If the pharmaceutical industry could change doctors’ prescribing patterns this way to increase sales, why couldn’t the same method be used to improve the appropriateness of drug use?”
That’s a very good question and he and his colleague Steve Soumerai set out to prove academic detailing could do what it purported to do: provide a lifeline to physicians swimming in a sea of pharmaceutical marketing spin. More than 25 years later, academic detailing programs are in place in many parts of North America, but they have hardly any effect on medical practice.
Why? Well, for one, it’s hard to change prescribing. As Dr. Avorn notes, it’s not easy to get “evidence-based, unbiased clinical knowledge” to supplant other types of information based on “tradition, superstition or mainly commercial agendas.”
The second reason is size: there are probably 100 drug sales reps for every one academic detailer in Canada. The academic side of things is simply outgunned. Despite good research that academic detailing can improve prescribing, there is little public investment in it. The first program started in Canada was here in BC, a single detailer based out of Lions Gate Hospital in North Vancouver. That program has grown to about 10 academic detailers covering the whole province and there are also well-established programs in Nova Scotia and Saskatchewan. However, the big provinces of Ontario and Quebec aren’t even in the game, with the exception of a program in Hamilton. Alberta had a program but it was cut. Manitoba’s program is on life support.
The third reason, and this is my own conclusion, is that no one has made a powerful enough business case for academic detailing.
A duo of ex-pharma detailers in Atlantic Canada, who call their company Prescribed Solutions have an answer. They know the selling game well and their pragmatic approach is to visit doctors armed with drug cost-effectiveness information and teach doctors how to improve generic prescribing so that both patients and drug plans can get good drug therapy and save money.
These Atlantic Canada entrepreneurs understand that one of the most important bits of information doctors need (other than drug safety information) is comparative cost information of the drugs they prescribe. Basically, if there are 10 drugs in a class that all do the same thing, why would a doctor prescribe the most expensive brand, which could be three times the price of the proven generic? A major gap in our physicians’ knowledge is the price of drugs and prescribing an affordable drug can have huge implications on whether a person gets a script filled.
A study out last month by UBC researchers shows patients will avoid a trip to the pharmacy if they don’t think they can afford them. And for many essential drugs, that can be decidedly bad for your health.
If drug reps schmoozing in doctors’ offices are trying to get new customers through free samples and evidence exists that academic detailing is effective, leading to safer, more cost-effective use of drugs, why haven’t governments or employers – who pay for your private drug benefits – embraced it?
Because they haven’t done the math. For every one percent increase in the generic use of drugs in Canada, the private payers – those with drug coverage through the employer – save over $100 million. If Canadians used generics at the same rate as Americans, it is estimated we’d shave about $2 billion per year off our drug bill. This is not small potatoes.
Is any kind of counter-detailing even on the radar of most politicians or union executives? As far as I can tell, the only politician I’ve heard asking for more investments in academic detailing is BC’s NDP leader Adrian Dix. I think he might be on to something.
If provincial governments are all about creating jobs, let’s provide jobs to the many pharma reps out of work due to the recent economic slowdown. Let’s put them on the public payroll and get them to spread the word about drug safety and cost effectiveness to our physicians.
It is time to undo the love affair between drug companies and doctors and start building some new relationships where patients can all benefit.
Alan Cassels is a drug policy researcher at the University of Victoria and author of the forthcoming book Seeking Sickness: Medical Screening and the Misguided Hunt for Disease, due out April 2012. Read more of what he’s writing about at www.alancassels.com