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.