Online pharmacy weblog

AS guardians of the nation’s prescription pads, doctors are the
gatekeepers that stand between American patients and the
pharmaceutical companies that have drugs to sell them.

Physicians’ choices — whether to medicate, with which medication,
generic vs. brand-name drug, and for how long — profoundly affect
sales of a drug company’s products. So pharmaceutical manufacturers
focus the bulk of their marketing budgets to influence those choices.
The drug companies’ promotional efforts reach into physicians’
offices, pervade their medical specialty organizations and often shape
the messages that doctors receive in educational settings.

“There is a big bucket of money sitting in every office” a drug
representative visits, said an AstraZeneca marketing director in a
widely circulated newsletter interview. “Every time you go in, you
reach your hand in the bucket and grab a handful,” said Mike
Zubillaga, who was fired after his blunt comments made their way onto
the Internet last April.

Each day in the United States, an army of roughly 100,000
pharmaceutical company sales reps storms the waiting rooms and offices
of the nation’s 311,000 office-based physicians. Called “detailers” –
and earning, on average, $81,700 per year — they are the smiling,
well-dressed men and women often seen in a physicians’ waiting room
toting a cavernous briefcase and making small-talk with the
receptionists. Their ranks have more than doubled in the last 10 years.

Sales reps say they want nothing more than to drop off drug samples
that doctors can dispense at no cost to their patients, and to brief
physicians on the FDA-approved benefits and risks of the prescription
drugs their companies make. That’s an accurate job description. But it
doesn’t nearly capture the sophistication of their efforts or the
complex web of relationships that marketing departments cultivate with
physicians. In recent years, drug-company insiders have come forward
to detail the enticements, persuasive techniques and market-tracking
systems that their organizations use to nudge doctors’ prescribing
decisions to boost sales. The picture they provide is of an industry
in hot pursuit of physicians’ hearts and minds.

Relationships with drug reps
THE inducements that doctors accept are more than just pads, pens and
gadgets such as the Viagra calculator that stands up on its base when
the “on” button is pushed. A national survey of doctors published in
the April 2007 New England Journal of Medicine found that 94% of
physicians in the six specialties studied reported some type of
relationship with pharmaceutical companies’ representatives. Most
(83%) received food in their workplace, or accepted drug samples (78%)
proffered by visiting representatives. Thirty-five percent reported
that drug companies had reimbursed them for the cost of attending
professional meetings or company-sponsored sessions that satisfied a
physician’s “continuing medical education” requirement. And 28%
received payments for consulting with a drug company, giving lectures
or enrolling patients in trials.

The American Medical Assn. and the pharmaceutical industry group PhRMA
adopted non-mandatory codes of conduct in 2002 that discourage the
offering or acceptance of items that bring only “personal benefit” to
a physician. Shahram Ahari, a former drug rep with Eli Lilly, says
that in many cases, those guidelines have given the practice of
gift-giving “a nice veneer of respectability.”

But the practice’s impact is often unaltered — and may even be
greater than when drug reps were permitted to offer extravagant gifts
such as theater tickets and golf bags. That is because psychologists
have shown consistently that a small token or gesture of friendship
often inspires a sharper sense of obligation in the recipient than
does a showy gift, for which reciprocation is impossible.

Moreover, Ahari says, “the amount of money invested in gifts hasn’t
changed. In the past, I could spend $100 on a golf club and give it to
you. Now, I can spend $100 on a textbook you need so you can spend
your own $100 on that golf club.”

Sales reps bear many gifts, but none is more important than the
prescription drug samples they bring to doctors. In 2003, the
pharmaceutical industry distributed $16.4 million worth of them to
doctors, according to PhRMA, the industry’s most important trade group.

“For me, that’s access,” Ahari says. “The doctors are first grateful
that you’re giving them samples, because it makes them seem like a
hero to patients . . . and when they feel that sense of gratitude,
they feel obliged to spend some time with the drug rep delivering
them.” But in the end, it is the patient who often will pay more,
because even a short course of sample use builds customer loyalty to a
brand-name drug, even when a generic or a cheaper, older drug might be
just as effective.

Among the not-so-well-kept secrets of the medical world is the
physical attractiveness of the men and women who make up the
pharmaceutical sales-rep force. “It seems pretty cynical,” says UCLA
internist Dr. Martin Shapiro. “I mean, the people that do the
detailing aren’t your average-looking individuals.”

Ahari laughs at the description. Pharmaceuticals’ marketing
departments look to hire “young, attractive people, quite charismatic”
– and scientific training is completely optional, says Ahari, now a
researcher at the UC San Francisco’s School of Pharmacy, who describes
his former profession on a website ( www.Pharmedout.org) devoted to
exposing drug company marketing practices.

“They’re looking for gender icons — cheerleaders and ex-military
types — fun to be with, someone with whom you’d like to have a beer
or watch a game,” Ahari says. To establish friendship and assure
access to a physician, a detailer “will scour a doctor’s office for
objects — a tennis racquet, Russian novels, ’70s rock music,” wrote
Ahari and Adriane Fugh-Berman, a Georgetown University physician, in
an article published by the Public Library of Medicine in April.

Small practices and family physicians are most intensively courted.
And doctors whose prescribing practices are not circumscribed by
healthcare companies or hospital formularies get extra attention as
well. According to the New England Journal of Medicine survey
published last April, family practitioners reported they met with
pharmaceutical-company detailers, on average, 18 times per month, more
than four times the average for all doctors that was reported in a
2000 study. Trailing not far behind them were internists (10 meetings
per month), cardiologists (nine) and pediatricians (eight).

Outside the confines of a doctor’s office, pharmaceutical marketing
efforts become more extravagant.

At physicians’ association meetings and at conferences and seminars
that provide “continuing medical education” for doctors, drug-company
sponsorship is substantial. Both have become important venues for
courting physicians over meals and in appealing venues. Both provide
opportunities for drug companies, indirectly, to pay speaking fees to
favored physicians. And a recent Senate Finance Committee report
concluded that, in spite of efforts to stem the practice, both are
used by pharmaceutical companies to boost physicians’ prescribing of
their products.

Sponsorship of seminars
AT a recent hearing of the Senate Committee on Aging, Dr. Jerome
Kassirer of Tufts University School of Medicine described meetings of
medical societies and associations as “mini-circuses, replete with
enormous glittering displays and hovering attractive personnel.
Although couched as education,” he added, “these marketing efforts are
thinly disguised bribes.”

UCLA internist Shapiro, who as president of the Society for General
Internal Medicine in 2002 sought to limit drug company sponsorship,
calls it “the walk of shame.” At almost every major medical meeting he
attends, he said, “there are these opportunities to get free things
that are questionable — and that clearly are not intended to sharpen
the rational decision-making skills of a physician, but to have an
impact . . . on how they prescribe medications.” It’s not enough, he
added, to close your eyes and walk past them: Pharmaceutical company
money has largely underwritten the programs doctors will attend and
the administration of the professional association that organizes the
event.

Medical societies “have become dependent on the infamous ‘unrestricted
grant’ from numerous pharmaceutical companies,” Dr. J. Gregory
Rosenthal, a Toledo, Ohio-based retinal surgeon, told the Senate
Committee on Aging in June. “In this context, ‘unrestricted’ means,
‘Use this for whatever you want, but if you ever want another, don’t
displease us.’ ”

Physicians’ “continuing medical education” requirements also have
provided drug companies ripe marketing opportunities, experts say. In
2005, drug companies spent $1.12 billion to fund sessions that
physicians attend to maintain their license to practice.

In recent years, new guidelines have sought to distance those grants
from companies’ marketing departments. Still, the Senate report noted,
“drug companies routinely fund educational grants to support programs
that favorably discuss the companies’ newer and more lucrative
products, thereby encouraging physicians to prescribe these products
and, ultimately, driving sales.” Where doctors are typically a
skeptical audience for direct pitches, “when the favorable message is
delivered in the context of education — even if corporate sponsorship
is disclosed — there is an imprimatur ofcredibility and
independence,” investigators noted.

Some of those programs appear to have been forums for pushing
“off-label” uses for prescription drugs, a back-door means of
expanding its market. About one-fifth of prescriptions that doctors
write are for off-label uses — to treat a condition other than that
for which FDA has found a drug safe and effective. Although it’s legal
for doctors to write off-label prescriptions, it is illegal for a drug
manufacturer to market its drugs for off-label uses.

In 2004, Warner-Lambert (now a division of Pfizer Inc.) paid $430
million to settle claims that it was using continuing education grants
to promote off-label uses of Neurontin, an epilepsy drug. In 2005,
Serono Laboratories paid $704 million to settle claims in a case that
alleged it was using educational programs to boost sales of the AIDS
drug Serostim for off-label uses.

The 50 state attorneys general who accepted the settlement of the
Neurontin case have used $21 million to establish the Consumer and
Prescriber Grant Program, www.ohsu.edu/cpgp/, designed to provide
healthcare professionals and consumers information related to
prescription drugs and their marketing.

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FOR many Americans, a doctor’s decision to prescribe medication is
something of a sacred transaction. A physician considers the patient
and symptoms and chooses the best drug for the job, drawing upon years
of training and clinical experience. It is an exchange conducted in a
hushed sanctuary, far from the heat and noise of the marketplace — a
place where cool judgment reigns.

That sanctuary has been breached. Today, drug manufacturers do
everything in their considerable power to ensure that their brand-name
prescription medications are on the lips of patients and in the minds
of physicians every time the two meet across an exam table. A growing
chorus of critics says their efforts have begun to rewrite the
dialogue between patient and doctor, influence physicians’ judgments
and open the act of prescribing to forces more profit-minded than sacred.

In 2006, drug-makers spent almost $5 billion to reach out to consumers
with direct advertising. But the glossy magazine ads and
buzz-generating TV spots are just the most visible parts of a campaign
to build and nourish markets for brand-name prescription products. The
world’s pharmaceutical companies spend an estimated $19 billion
annually to woo doctors. They sponsor teaching programs and research
at universities across the country, gaining goodwill along the way.
They give money to patient groups. They hire public relations firms to
share patient stories of illness and triumph.

In a nation that consumed $279-billion worth of prescription
medications in 2006 — spending 80% of that on brand-name products –
their efforts appear to be paying off. Americans filling a
prescription choose brand-name products 37% of the time, even though
three-quarters of all prescription drugs in the U.S. are available in
cheaper generics.

“The most effective marketing is the marketing you’re not aware of,”
says Dr. Peter Rost, a one-time pharmaceutical company marketing
executive who has become an Internet-based industry watchdog. “If you
see an ad, you know it’s marketing. But if a friend or your doctor
talks to you about a drug, you don’t.”

Now the size, scope and apparent effectiveness of drug companies’
marketing efforts has begun to prompt cries of foul even from within
the medical establishment, which has long been silent about its
growth. In a handful of state legislatures across the country,
lawmakers already have acted to blunt drug-company marketing, and many
more are considering similar measures. Lawmakers on Capitol Hill have
suggested that federal legislation may come next.

At stake, critics say, are patients’ health, the nation’s healthcare
budget and, ultimately, the trust and esteem in which Americans hold
their physicians. Costs rise as more doctors prescribe brand-name
drugs when cheaper, older or more effective drugs might be available.

Under-treated conditions that threaten the lives and wellness of large
swaths of the population — illnesses such as diabetes and high blood
pressure — may get less attention than conditions such as erectile
dysfunction or insomnia, for which pharmaceutical firms have new and
potentially more profitable offerings. And patients may be steered
toward newer drugs with risks and side effects that are less
well-known, in lieu of medications with a longer history of safe use.

“There is nothing fundamentally wrong with advertising products,” Dr.
Jerome P. Kassirer, a former editor of the New England Journal of
Medicine, told a Senate committee recently. “But when financial
incentives yield inappropriate or dangerous care, when they
inordinately raise the cost of care, when they risk patients’ lives in
clinical trials, and when they damage the profession, they have gone
too far.”

The pharmaceutical industry counters by arguing that its marketing
efforts are needed to recoup the cost of drug development and that
they introduce Americans to medicines that can save lives and improve
well-being. The industry’s sponsorship of research and education
pushes the process of drug discovery and development forward,
drug-makers say. Companies’ marketing to physicians keeps busy
clinicians abreast of new therapies and scientific advances in a
fast-changing landscape. And their advertising of drugs in mass-media
outlets educates patients and improves their communication with
doctors, they add.

And drug marketing improves the economic vitality of the nation, a
representative of the drug industry’s largest trade group, PhRMA, said
at a recent Senate hearing. Prompted by drug industry marketing, more
patients in recent years have sought out a doctor, and more doctors
have looked for signs of under-treated conditions such as depression,
diabetes and asthma among patients, Marjorie E. Powell, an attorney
for PhRMA, said to the Senate Select Committee on Aging in late June.
Citing a pair of studies published in 2003, Powell said that in the
long run, increasing treatment of such chronic conditions should drive
down the nation’s healthcare bill.

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A jury awarded $25.8 million Friday to the family of a cancer patient
who was given a wrong prescription, had a stroke and died several
years later, lawyers said.

Beth Hippely was prescribed Warfarin, a blood thinner, in 2002 to
treat breast cancer. The prescription filled at a Walgreens pharmacy
was 10 times what her doctor prescribed, court documents said.

The Polk County Circuit Court jury found the prescription error caused
a cerebral hemorrhage resulting in permanent bodily injury, disability
and physical pain. The mother of three died in January at the age of 46.

A 19-year-old pharmacy technician, with little training, misfiled the
prescription, according to court documents.

The lawsuit was filed in 2003 by Hippely, her husband Deane Hippely
and their children against the Deerfield, Ill.-based Walgreen Co. for
negligent breach of duty and wrongful death.

“Beth Hippely died unnecessarily because this tenfold overdose with
Warfarin by the pharmacy she trusted caused her cancer to come back
with a vengeance and it interrupted all of her cancer treatments,” her
lawyer Chris Searcy said. “They have been seeking justice for almost
five years and this was a case that screamed out for justice.”

A statement released by the company expressed sympathy for the Hippely
family.

“We’re truly sorry for what the Hippely family has been through, and
we’ve personally apologized to them,” Walgreens spokeswoman Carol
Hively said in a statement. “We have been, and continue to be, the
leader in pharmacy safety initiatives. We had hoped the verdict would
have been fair and reasonable.”

Hively said the company had not decided if it would appeal the decision.

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I understand that right now is ‘hump time’ as the kids are going back to school and because of other health issues in my/OUR community
right now both the ‘DOCS’ and the ‘PHARMACIES’ are understaffed and SWAMPED.

I understand and have empathy/sympathy for those that are upest/REALLY MAD at the ’system’ whether it be ‘HEALTHCARE’ in
genereal or that it took them ‘TOO LONG’ to get to ‘MY PHARMACY’ as we ‘offer’ many ‘products/services’ that are not available anywhere within a 200 mile radius of Corpus Christi, TX.

‘I’m sorry that Dr. ‘SOANDSO’ wrote BRAND MEDICALLY NECESSARY on your SALEX lotion script and that even with ‘good’ insurance, your Salicylic Acid Topical Lotion is going to cost you a $55.00 Co-Pay when the generic is $10.99 SELF-PAY price…’

AND…

‘NO, I CAN NOT GIVE YOU THE ‘GENERIC’ BECAUSE YOUR DOCTOR HAS ‘WRITTEN’ THAT THE ‘BRAND NAME’ IS ‘MEDICALLY NECESSARY’ AND I CAN NOT ‘KNOW’ ‘WHY’ THIS DOCTOR WROTE THIS PRESCRIPTION THIS WAY BUT I CAN NOT GIVE YOU THE GENERIC WITHOUT HER/HIS AUTHORIZATION. I CAN UNDERSTAND WHY YOU ARE UPSET! WE’LL CALL HER IN THE MORNING.’

No, Ms. ‘USUAL MONTHLY B/C GAL’:

“This birth control pill now has a GENERIC and it will not be the SAME CO-PAY as the BRAND-NAME if you CHOOSE the BRAND vs the GENERIC! I KNOW that this is a very PERSONAL medication and of all ‘THINGS’ you might ‘doubt’ the ‘ABILITY’ of a B/C pill ‘NAMED’ LESSTHANA but…”

YOUR CO-PAY WILL NOT BE THE ‘SAME’ or YOUR INS. JUST WILL NOT PAY MORE THAN 10% for DAW 2.

I can try to ‘understand’ other special cases when because of our ‘FORMULARY’, I’ll have to ‘TAKE’ the ‘FRUSTRATIONS’ of the mother
of a person with Hansen’s who has been on Greyhound for 2 days to get to my Pharmacy from the Colonia where she lives 300+ miles from the ‘BORDER’.

She knows she has 1 more day to wait for the PA, and then 2 more days on Greyhound back to the place where she lives where there are NO DRIVE-THRUS and we are the closest Pharmacy that sells Thalomid!

I feel really ‘good’ about both what I am doing now and what I strive to be in the future when I am able to work with Hospice Nurses
and ‘Specialists’ to ‘USE MY SKILLS’ to make peoples’ lives…

‘BETTER!’

And, of course, not everyone is going to be HAPPY.

Folks get upset.

Such is human nature.

Some are upset because they have been ‘promised’ too much:

“ANY prescription you bring to the Pharmacy will be filled in 15 minutes or we’ll give you a $1001010101.00 ‘GIFT CARD’ even if its a
COMPOUND and would you like FRIES WITH THAT?”

This is how I often ‘FEEL’ as a ‘NORMAL’ issue with folks that ‘THINK’ that for whatever reason that ‘WE’ have made them ‘WAIT
TOO LONG’ and that because of OUR ‘MISTAKE’ as they ‘PERCEIVE IT’ WE owe them something ‘EXTRA’ other than the fact that they got what they were prescribed CORRECTLY and WE’LL WORK HARD FOR THEM TO ASSURE THEY GET EVERYTHING THAT THEY ‘DESERVE’…

We ‘bill’ correctly.

We contact them in the most timely manner if we have information that needs to be updated.

We work with DOCS to try to get ‘DIFFERENT/MORE AFFORDABLE/AND MORE SAFE’ medications as a part of what we consider a ‘complete’ healthcare ‘team’, not just a…

(In the Taco Bell Dog’s Voice)

“Welcome to …, can I take your order?”

As a very ‘busy’ Pharmacy, we are also the target of folks that would like to pull a ‘fast one’ on us.

I have had to give ‘information’ to law enforcement more in the past year as a CPhT than I ever did working for TABC (Texas Alcoholic
Beverage Comm) liscenced ‘On Premise’ establishments.

I find it kind of strange that I could ‘OWN’ a liscense to sell alcohol in TX for more than 2 years and I only had to ‘CALL’EM’ 1
time!

So now when I feel that I ‘MAYBE’ ‘SHOULD’…

‘CALL THEM’… (LAW ENFORCEMENT)

I DON’T WANT TO feel that I might be becoming kind of a ’scardey-cat’

BUT:

When faced with the following situation, what would any of us DO?

At just after 10:00 PM last night I went to ’service’ a DRIVE-THRU customer as I had noticed had ‘DRIVEN-UP’ to the side of my Pharmacy.

I am really too darn busy right now to ‘judge’ folks by the kind of car that they drive or who they ‘ARE’ even if I ‘KNOW’ them unless
there is something ‘SPECIAL’ that I ‘KNOW’ ahead of time that is ‘GOING ON’ with them so in all honesty, I really don’t pay too much attention to the ‘CAR’ or the ‘PERSON’ in the car or what they are ‘picking up’ as long as I have no reason to be uncertain about what a customer needs.

So I really was just not ‘ready’ with my ‘usual defenses’ when I was ‘confronted’ with a REALLY TATOOED UP GUY in a late model CADDY that had some ‘ROAD WEAR’….

BOTH THE CAR AND THE DRIVER WERE ‘WORN’…

And I guess I must have ‘looked twice’ when the the driver asked…

“C’C'C’OULD YOU GET ME SUM WATER?”

Stuttering always makes me ‘look’ twice.

Then the guy who I was now sharing an uncomfortable moment with as he had decided to bring himself to ME ‘NOTICED’ that I was paying some ‘attention’ to…

TOLD ME:

“GIVE ME SOME WATER AND A BAG OF U-100 SY”

I cut him off in mid sentence.

I said, “I absolutely don’t sell syringes through the ‘window’ and I need you to come inside.”

This guy just ‘looked’ paranoid. If you have Clozaril patients, then you know what I mean when I say that this man’s eyes are lifeless.

He had lost voluntary control of his jaw muscles and was ‘chewing Columbian cud’.

I didn’t get to the point where I could even ask if he needed insulin when he told me:

“We’re here in town, and we’ll be buying syringes! Are you not going to…”

I cut him off again and told him that I absolutely will not sell anything to him through the DRIVE-THRU.

I hope you folks don’t read this message later and have to think:

Gee…

Christian’s ‘example’ was something that ‘WE’ should have thought of before we…

DID NOT TELL ‘SOME SORT OF AUTHORITIES’ about SOMETHING!

This turkey pretty much told me that I would be ‘NEXT’ which I ‘KNOW’ from past experiences is BS stupid ‘BRAVADO’ from a coke/speed FIEND who I want to keep away from my ‘LEGITIMATE’ customers who are upset because their children are DYING and a ‘SHOOT-OUT’ is not what the WORLD NEEDS…

AND THIS TURKEY WENT AWAY AS THESE TURKIES NORMALLY DO…

But I most definately looked ‘both ways’ when I walked out the front door this past evening.

And I will NOT let FEAR make my professional judgements for me.

I hope that we can all have the ‘guts’ to be this ‘way’ in any situation in which we feel ‘challenged’!

I don’t mean that you should put yourself in physical danger just that we should we should NEVER feel that we are helpless.

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