November 08, 2007

Is the doctor-drug industry nexus harming patients?

Companies in the U.S. that produce drugs and medical devices with a turnover of more than $100 million may soon be forced to reveal the amount of money that they give to doctors to influence their prescribing patterns. A bill was recently introduced in the U.S. Senate to this effect. Already five States and the District of Columbia have such regulations in place.

What in the first place warrants a bill to make it mandatory for the drug industry to disclose such information?

It has been well known that the medicines that doctors often prescribe are the medicines that pharmaceutical companies want them to prescribe.

Off-label use


No matter that cheaper alternatives are available, that certain medicines prescribed are unnecessary, that the medicines are put to off-label use (for indications that the regulatory authorities have not approved them), doctors tend to do what the pharmaceutical companies have asked them to do.

So what has made many doctors lose their objectivity and become the front for the industry? “Free pens and pizza lunches. Sponsored conferences and compromised medical education… and unaffordable holidays,” an Editorial in the British Medical Journal (May 2003) points out.

Doctors may be getting free lunches, but in reality there is nothing called a free lunch. For all the gifts that the drug industry provides, the quid pro quo arrangement, though unstated, expects the doctors to prescribe more of the company’s medicines.

Funding education


In some countries, the industry starts influencing the doctors much earlier. According to an Editorial in the British Medical Journal (April 2005), “over half of all postgraduate medical education in the UK… is funded by the pharmaceutical industry.”

But rarely would doctors acknowledge or even agree that their prescribing decisions are indeed influenced by the industry. They would like us to believe that they are fiercely independent and that their prescribing trends are never influenced by the industry.

Patients would only love to believe that it is indeed so. After all, they pay a price for any biased prescription.

Rewarding doctors


But the facts point out otherwise. A paper published in the British Medical Journal in 2003 noted that the industry admitted to rewarding doctors for switching from one drug to another but maintained that it was a “standard industry practice.”

A paper published last year in the Journal of the American Medical Association (JAMA) states that the industry spends about $13,000 a year per doctor on marketing activities.

In all they spend more than $20 billion a year on marketing, about 90 per cent of which goes to doctors.

National survey


A paper published in the latest issue of the New England Journal of Medicine based on a national survey conducted in the U.S. notes that 35 per cent of the respondents have received reimbursement for “…costs associated with professional meetings or continuing medical education.” And 28 per cent received payments from the industry for “…consulting, giving lectures, or enrolling patients in trials.”

One may wonder that small gifts will not have any influence on their prescribing patterns But the JAMA report of 2006 states, “…the impulse to reciprocate for even small gifts is a powerful influence on people’s behaviour.”

That has been the basis for many institutions in the U.S. for not allowing sales representatives inside their institutions or the companies from providing free lunches to doctors in their campuses. More institutions are joining the fray.

While an institution-level policing may have worked successfully, making the companies reveal information on doctor funding has been far from successful. For instance, Minnesota, which was the first State in 1993 to have such a disclosure law in place, and Vermont require the information to be publicly available.

Not accessible


But a study published in JAMA (March 2007) found that accessing information was not as easy as it was originally intended to be. It found that in Vermont about 60 per cent of the payments made by the companies were not released to the public.

And the reason? “…Pharmaceutical companies designated them as trade secrets,” the study revealed. And it was not that the information accessible revealed all. About 75 per cent of publicly disclosed payment information did not identify the recipient.

If some of the leading medical journals, and not legislations, compelled the pharmaceutical companies to register human clinical trials for consideration of results publication, probably patient groups would be able to do the same with the disclosure laws.

One more platform


Alas, most patient groups themselves depend on pharmaceutical companies for funding and they act as yet another platform for the companies to sell their products!

With only a few potential blockbuster drugs produced in the recent past and with fierce competition in the market, companies are forced to milk the most out of the existing drugs. How far the legislation will be able to cleanse the system will be closely watched by other countries.

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