It is rare to have a conversation that completely changes your opinion about an issue. Maybe Dr Perry is just that convincing. In this talk, Dr Perry and I chat about the role the pharmaceutical industry plays in our education and I learn to have a more critical view of industry sponsored educational events. Dr Perry is a graduate from McGill University Medical School, is a trained internist and a clinical pharmacologist. Some notable positions include Opposition Health Critic, Minister for Advanced Education, Training & Technology, MLA, Instructor and Therapeutics Initiative contributor.
- From 2001 to 2015, total pharmaceutical sales (including non-patented over the counter medicines) in Canada have doubled to $24.6 billion, with 87.5% sold to retail drug stores and 12.5% sold to hospitals (Government of Canada, 2015). Governments account for 42% of drug expenditures and private payers account for the remaining 58% (private coverage and individuals) (Government of Canada, 2015)
- Pharmaceuticals are the second largest component of health care expenditures in Canada, representing 15.7% of total expenditures (Government of Canada, 2015)
- Harvoni is the drug mentioned in my introduction. Some context: Harvoni is a combination of ledipasvir and sofosbuvir used to treat Hep C and is approved for genotype 1 in Canada (CATIE, 2015). It was the second largest pharmaceutical product sold in Canada in 2015 generating $581.5 million in sales (Government of Canada, 2015). It costs roughly $70,000-$110,000 for an 8-24 week treatment regiment or roughly $1,000 per pill (Ubelacker, 2016). (no wonder we got a free lunch!)
- According to a systematic review looking at the role of industry on medical students in the US, the authors found exposure to drug representatives for medical students occurs primarily through sponsored educational events during clinical years (Austad, Avorn, & Kesselheim, 2011). 89%–98% of students in the clinical years reported having accepted a lunch or snack provided by the pharmaceutical industry at such events (Sierles, Brodkey, Cleary, McCurdy et al. 2005). Many students approved of meals, small promotional items, and gifts with an educational purpose, but were less accepting of social events or travel (Sierles, Brodkey, Cleary, McCurdy et al. 2005). Compared to preclinical students, students in clinical years reported more educational value in industry-provided material and were more accepting of gifts from industry suggesting that more exposure has a normalizing effect (Austad, Avorn, & Kesselheim, 2011).
- At UBC, we do not receive any industry sponsored lectures on campus- but may likely attend some during clinical years.
- In a review looking at influence on doctors in training, the authors found that resident prescribing was altered with pharmaceutical representative visits and the availability of samples (Zipkin & Steinman, 2005). For example, prescriptions written for guideline-recommended agents nearly doubled among residents (from 39% to 72%) after a policy prohibiting sample use was instituted (Zipkin & Steinman, 2005). Also, when samples were given for a chronic condition and a written prescription accompanied the sample, it matched the sample 100% of the time (Zipkin & Steinman, 2005).
- Dr Perry spoke about the Celecoxib story. Summary: Pfizer cherry-picked data, under-reported adverse events, sold the product to millions of Americans, made billions in profits and got caught. Narrative of the story can be found in Thomas’s (2012) New York Times article, a summary of the data can be found on Theurapeutics Initiative Letter #43 (Therapeutics Initiative, 2002).
- Another interesting story is that of gabapentin or neurontin. Summary: Gabapentin developed by Parke-Davis was licensed in Canada in 1993 for treatment of epilepsy (Theurapeutics Initiative, 2009). Targeting a bigger market in pain management, Parke–Davis initiated an aggressive marketing campaign promoting use of Neurontin for “pain… for monotherapy… for bipolar…for everything” despite lacking clear evidence that this drug could treat these other diseases (Landefeld & Steinman, 2009). Some strategies used by Parke Davies included promotion among high prescribing physicians, cultivation of thought leaders (paid physicians which acted as speakers in “peer-to-peer selling” programs), educational grants, research designed for marketing, marketing events disguised as educational talks and speaking opportunities; some received up to $158,250 over a 4-year period (Landefeld & Steinman, 2009). The marketing worked: U.S. sales rose from $98 million in 1995 to nearly $3 billion in 2004 (Landefeld & Steinman, 2009).
- As Landefeld & Steinman (2009) conclude “What is Neurontin’s legacy?… we have learned that pharmaceutical marketing can be comprehensive, strategic, well financed, disguised as “education” and “research,” influential, and very effective.”
- A more complete history of Neurontin can be found in this Therapeutics Initiative Article #75 (Therapeutics Initiative, 2009) or in Landefeld & Steinman’s (2009) New England Journal of Medicine Article.
Pharmaceutical companies in the United States spent about US$57.5 billion, or 24.4% of their revenue, on promotion in 2004 (Gagnon & Lexchin, 2008). In contrast, 13.4% (half) of their revenue was used for Research & Development (Gagnon & Lexchin, 2008). With about 700,000 practicing physicians in the US in 2004, the authors estimate the industry spent around US $61,000 in promotion per physician (Gagnon & Lexchin, 2008).
- 42% of Canadian physicians book regular appointments to see reps and 21% seem them on a drop-in basis (Canadian Pharmaceutical Marketing, 2009). The main reason physicians meet with drug reps is the ability to obtain convenient information and to get free samples (Canadian Pharmaceutical Marketing, 2009; Campbell, 2007; Spurling et al, 2010). Only 8% of Canadian and 17% of US physicians avoid sales visits (Canadian Pharmaceutical Marketing, 2009).
- A study conducted by Mintzes et al (2013), examined the information provided to family doctors during sales visits in Vancouver, Montreal, Sacramento, California, and Toulouse, France. Fewer than 2% of the 1692 drug promotion interactions included “minimally adequate safety information” across all the countries (Mintzes et al. 2013).
- In a systematic review looking at prescribing habits of physicians who were exposed to information from pharmaceutical companies (promotional or otherwise), the authors found associations with higher prescribing frequency, higher costs, or lower prescribing quality or have not found significant associations (Spurling et al, 2010). The authors did not find evidence of net improvements in prescribing (Spurling et al, 2010).
- In fact, reduced exposure to pharmaceutical sales representative visits and promotional material is associated with an increase in generic prescribing (Spurling & Mansfield, 2007)
- Another review concluded that sales representative meetings influence prescribing habits (Manchanda & Honka, 2005)
- The main reasons that physicians say they like free samples are for treatment of low income patients, convenience, and because patients appreciate them (Alexander, Zhang & Basu, 2008). Surprisingly, however, free samples often lead to higher longer term treatment costs as patients are more likely to be put on more expensive drugs rather than generic drugs (Alexander, Zhang & Basu, 2008)
- Blumenthal (2004) found that most doctors perceive pharmaceutical promotion to be a useful and convenient source of information. Most doctors deny that they are influenced by pharmaceutical company promotion or claim that it influences others but not themselves (Blumenthal, 2004).
I am confident that if I had spoken to a physician who has a productive relationship with industry, this would have been a different episode. Some of the counter-arguments I may have heard about: the need for partnership in developing drugs for rare conditions or advocating for patients through leadership roles like consulting. I may have even been told stories of companies who offer compassionate coverage and pay the cost of treatment for select patients.
When I asked a family friend ( recent family practice grad) whether he thinks meetings with drug reps alters his prescribing practice his response was “it took me twelve years to become a doctor, it is insulting to think I would compromise all that work… my integrity or my patient’s safety for free samples or a free meal. It is going to take a lot more than that for me to sell my soul.” I get the feeling this is a common response. My concern from this episode, however, is that it takes surprisingly little to be influenced…regardless of our moral character.
- Therapeutics Initiative. http://www.ti.ubc.ca/
- Drug and Theurapeutics Bulletin of Navarre Spain. http://www.navarra.es/home_en/Temas/Portal+de+la+Salud/Profesionales/Documentacion+y+publicaciones/Publicaciones+tematicas/Medicamento/BIT/
Alexander, G. C., Zhang, J., & Basu, A. (2008). Characteristics of patients receiving pharmaceutical samples and association between sample receipt and out-of-pocket prescription costs. Medical Care, 46(4), 394-402.
Austad, K. E., Avorn, J., & Kesselheim, A. S. (2011). Medical students’ exposure to and attitudes about the pharmaceutical industry: a systematic review. PLoS Med, 8(5), e1001037.
Blumenthal, D. (2004). Doctors and drug companies. New England Journal of Medicine, 351(18), 1885-1890.
Campbell, E. G. (2007). Doctors and drug companies—scrutinizing influential relationships. New England Journal of Medicine, 357(18), 1796-1797.
Canadian Pharmaceutical Marketing. (2009). Targetting accessible physicians. Retrieved from http://www.stacommunications.com/journals/cpm/2009/04-April%2009/029-Prism.pdf
CATIE. (2015). Harvoni. Retrieved from http://www.catie.ca/en/fact-sheets/hepatitis/harvoni-ledipasvir-sofosbuvir
Gagnon, M. A., & Lexchin, J. (2008). The cost of pushing pills: a new estimate of pharmaceutical promotion expenditures in the United States. PLoS Med, 5(1), e1.
Government of Canada. (2015). Pharmaceutical industry profile. Retrieved from https://www.ic.gc.ca/eic/site/lsg-pdsv.nsf/eng/h_hn01703.html
Manchanda, P., & Honka, E. (2005). Effects and Role of Direct-to-Physician Marketing in the Pharmaceutical Industry: An Integrative Review, The. Yale J. Health Pol’y L. & Ethics, 5, 785.
Mintzes, B., Lexchin, J., Sutherland, J. M., Beaulieu, M. D., Wilkes, M. S., Durrieu, G., & Reynolds, E. (2013). Pharmaceutical sales representatives and patient safety: a comparative prospective study of information quality in Canada, France and the United States. Journal of general internal medicine, 28(10), 1368-1375.
Landefeld, C. S., & Steinman, M. A. (2009). The Neurontin legacy–marketing through misinformation and manipulation. New England Journal of Medicine, 360(2), 103.
Sierles, F. S., Brodkey, A. C., Cleary, L. M., McCurdy, F. A., Mintz, M., Frank, J., … & Woodard, J. L. (2005). Medical students’ exposure to and attitudes about drug company interactions: a national survey. JAMA, 294(9), 1034-1042
Spurling, G., & Mansfield, P. (2007). General practitioners and pharmaceutical sales representatives: quality improvement research. Quality and Safety in Health Care, 16(4), 266-270.
Spurling, G. K., Mansfield, P. R., Montgomery, B. D., Lexchin, J., Doust, J., Othman, N., & Vitry, A. I. (2010). Information from pharmaceutical companies and the quality, quantity, and cost of physicians’ prescribing: a systematic review. PLoS Med, 7(10), e1000352.
Theurapeutics Initiative. (2002).  COX2 inhibitors update: do journal publications tell the full story. Retrieved from http://www.ti.ubc.ca/2002/01/31/cox-2-inhibitors-update-do-journal-publications-tell-the-full-story/
Theurapeutics Initiative. (2009).  Gabapentin for pain: new evidence from hidden data. Retrieved from http://www.ti.ubc.ca/2009/12/31/gabapentin-for-pain-new-evidence-from-hidden-data/
Thomas, K. (2012). In documents on pain, drug celebrex signs of doubt and deception. Retrieved from http://www.nytimes.com/2012/06/25/health/in-documents-on-pain-drug-celebrex-signs-of-doubt-and-deception.html
Ubelacker, S. (2016). Health Canada approves drug doctors call cure for hepatitis C infection. Retrieved from http://www.theglobeandmail.com/news/national/health-canada-approves-drug-doctors-call-cure-for-hepatitis-c-infection/article30913012/
Zipkin, D. A., & Steinman, M. A. (2005). Interactions between pharmaceutical representatives and doctors in training. Journal of General Internal Medicine, 20(8), 777-786.