Disclaimer: the article only represents one side of the issue. While the author is speaking from their experience, the article should be viewed as the opinion of the author and thus does not necessarily represent the practice of all involved in the pharmaceutical industry.
We have discussed this issue to some extent in terms of conflict of interest as healthcare providers, but during this discussion I would like us to consider things from the side of the pharmaceutical companies. After reading the article, please consider the following:
Should there be tighter restrictions on the pharmaceutical industry? If so, should they be federally, state or self-imposed?
Is direct-to-consumer advertising effective for educating the consumer or does it simply place prescribers in the position of feeling pressured to satisfy patient requests?
Are sample medications effective at reducing healthcare costs in the short-term? Long-term?
12 comments:
It is difficult to dispute the information that the authors provide in The Policy Forum. Some may agree that the practice of detailing (as described) is unprofessional and even unethical. Others would agree, but say that so what? If physicians practice evidence-based medicine and are ethical practitioners, wouldn't it be prudent to try different medications on their patients and note the results? Wouldn't sampling be better that a 30 or 90 day prescription? I know that if I received a prescription for an ARB or Statin, I would rather try a weeks worth as a sample than filling a 30 day prescription.
One of my mentors always said that pharmaceutical reps always expect something in return for their gifts, food and kindness. He rarely accepted anything. He is correct as the article suggests.
I am concerned that continued restrictions and regulations against pharma will result in a more uneven playing field where the big guys get more and the little guys get less.
Are brand name samples beneficial to the patient when the health care provider is trying the patient on different drugs to see which work best for the patient or is there an underlying motive, that the provider is influenced to give the patient the brand name drug?
In what ways could pharmaceutical companies effectively limit the amount of money spent on "detailing" while still getting the word out about their drug so that this money could be re-directed to more research, lower prices, etc...
Virginia
Do you think the benefits of the information provided by pharmaceutical reps outweighs the potential conflict of interest?
Joey Bero
j.d.bero@wingate.edu
What kinds of situations have you either witnessed or been directly involved with where there was a conflict of interest as a pharmacist?
Claire Anderson
c.j.anderson@wingate.edu
Who do you think has a stronger influence on prescribing physicians, drug reps or clinical pharmacists? Who's opinion does the physician value more?
Lauren Hawkins
l.m.hawkins@wingate.edu
do you think states could hire drug reps. (paid by all of the drug companies) to educate physicians about new drugs is a possible solution to the problem being discussed?
kinjal patel
In response to the question on samples:
I have posted previously on how I use samples in my practice working with a large indigent population. Samples are very important to these patients. I agree with Joe in that it makes sense to use samples to try a new drug in a patient before filling the 30 day Rx. Certainly there could be an underlying physician motive for prescribing the brand name drug but I have not personally witnessed this. The MDs I work with are helping patients afford medications or add/try new medications because a pt has uncontrolled/resistant HTN, DM etc. not because they wish to push a particular brand.
In response to the question on the risk/benefit of drug rep information:
Information from drug reps is not a substitute to keeping up with new literature and guidelines. They have a great potential for COI. As you gain knowledge through pharmacy school you need to begin to develop a system for information/knowledge management. Using eTOC, RSS feeds, readers and MedWatch are just some of the ways to stay up to date…and is a topic for another discussion. Medical liaison’s are a bit different and are able to present a broader opinion based on evidence outside the package insert. Try not to solely rely on CE and drug reps to stay current.
In response to who has a stronger influence of physician prescribing:
Clinical pharmacists working directly with physicians on a daily basis have a stronger impact on prescribing than reps. A good clinical pharmacist can bring evidence, cost and safety into the decision process. In my experience, the majority of physicians seek out and respect this opinion. Of course, not all physician practices and hospitals have access to a clinical pharmacist 24/7 and there are physicians who practice by the PDR and drug reps.
Recently posted NEJM is very interesting. Looks like there is still room for improvement in regards to COI reporting. There are a lot of large studies conducted here at Maryland and many researchers receive funds from pharmaceutical companies for research and speaking engagements etc. I can see where it would be hard to remove oneself fully from bias in these situations.
Zack Deyo
PGY2 Resident
zdeyo@rx.umaryland.edu
As this has become a recent area of concern at my practice site, I'd like to comment specifically on the role of drug reps. In the field of oncology it is of the utmost importance to stay current with the literature. Information is released weekly that has the ability to change our standards of care. As Zack had alluded to, there are numerous mechanisms by which you can stay up to date and I would highly recommend becoming familiar with some of these tools as early as possible.
We have drug reps visit our institution weekly and quite frankly there has not been an instance where they have been able to provide information that I did not already have or could not access on my own. At the end of the day we must remember that their primary role is as a salesman (woman) so the potential for COI is huge! For example, I recently attended a CE dinner on DVT prophylaxis in the medical patient, anticipating a good review on a fairly general topic. The dinner was sponsored by a drug company and the entire presentation focused only on the role of their drug in this patient population. No other agents were discussed, and interestingly the drug they were detailing was an agent we do not currently have on formulary. When I asked questions about the trials that were discussed and how this may apply to my oncology patients the presenter could not answer my questions and I essentially gained nothing from the discussion.
Medical science liaisons are much more valuable because they are permitted to discuss agents off-label. I have found this particularly useful when I want information about ongoing trials (what data is there to date) or what the company plans to research on an agent. I would encourage you to use them as a resource but still remember there is a potential for COI as they are employed by a specific drug company.
Morgan
PGY2 Oncology Resident
msnider@mcvh-vcu.edu
In response to Anh Le:
I have personally seen patients and family members given samples because it was what the rep had given the doctor that week which then resulted in a prescription being written for the same drug. It was a running joke at one site I was stationed at my fourth year that the Lexapro rep, or the Levaquin rep, or the Drug X rep had been by this week as there would be an influx of prescriptions for said drug only to taper off and be replaced by the next drug of the month. Many physicians have no idea what the costs of these drug are to their patients. A recent example of this act is when my Great Aunt complained about how much her Actos was costing her and that she simply could not continue to take it. When I asked her if she had been initiated on metformin as current guidelines suggest, she stated that she had not, that the physician gave her some samples and then wrote a prescription for Actos. I feel that because of drug reps, the physician side stepped current guidelines in an effort to save her some money, not realizing that the drug did not have a generic formulation and that in fact is much more expensive than the drug of choice, metformin. It would have been much more economical to prescribe a 15 day supply to assess her reaction to a medication vs baiting her with samples for an expensive drug not covered by her insurance or on a upper tier.
My personal beef with drug reps is not only the subconscious influence of the prescribing physician, but the fact that the wining and dinning of health care providers only increases the cost of medications for the community.
In response to Joey Bero:
I do not feel that much of the material obtained from reps is reliable. I have noted multiple times that literature was presented in a manner that was simply untrue or skewed to be seen as more beneficial than the study states in reality. My advice to you is to read every study with a fine tooth comb as the reps are trained to spin half-truths. Some will say that their product is superior to product A, for example, yet the study was only designed as a "me too" study. Do your own research on medications you are unfamiliar with, consult your biostat notes if needed, and consult with professionals you respect to discuss information with. Drug reps are sales people, bottom line.
In response to Kinjal Patel:
No. I think that the best information about medications comes from pharmacists. We have the knowledge and education needed to condense highly complicated material into a understandable and patient specific manner for physicians. We have the training to conduct thorough, reliable research from non biased sources. We should be the ones explaining the pros and cons of new medications, new indications and new medical devices. We should be the ones that health care providers think of when they have a drug related question, not the drug reps. Pharmacists need to promote themselves as THE drug resource and demand to be seen in that light.
Lisa DePetris, PharmD
Clinical Pharmacist
St. Vincent's Medical Center
lgdepetris@gmail.com
Anh Le: Drug samples are good "tools" to utilize for determining if a particular medication/class will work for a patient. This also allows them to see if they can tolerate the drug. There is the possibility that if you change to another drug in the same class, however, that it may affect them differently. I think trying a week for free is the best option in this case because you have really lost nothing. Antibiotic samples can be a blessing for an indigent patient as well. Those instances are where doctors may compromise the standard of care just to make sure the patient takes something. Is this right? That is a gray area that definitely depends on the individual patient. I would rather try a drug that might work for free than send them home knowing they will not have the resources to take the medication. This does not help resistance patterns, but sometimes you have no other options.
I have seen situations where patients were given brand medications because of samples or because of drug reps' gifts, and fortunately, I was able to get them to switch the medication to benefit the patient. Sometimes I think physicians are so busy that they look for the quick fix even though they do not mean to. This is why I think limiting their gifting is an essential step the healthcare industry must take to ensure patients receive optimal care and consideration. A pen and an occasional lunch are OK, but I think any gift should be accompanied by new information or updates on the drug.
Clinical pharmacists' opinions would definitely outweigh those of drug reps. Physicians we work with everyday trust us because we earned it. We work with them endlessly to provide excellent patient care. A drug rep every now and again might lead them astray, but our opinions and recommendations will redirect their practices. I experienced this with daptomycin myself one night after a drug rep dinner.
Personally, the last thing on my mind when I am choosing a drug is the lunch, dinner, pen, etc that I might have received from a drug rep. I know a few reps well, and I can say that their name or product never enters my mind unless I feel it is appropriate for my patient. If we all keep the patient our number one priority, we do not have to worry about being biased or having a conflict of interest.
RE: Anh
This probably depends on the situation – you can’t always give a patient an inexpensive drug. Just last week, I had a patient pick up an Rx for Cozaar 25 mg – cash – cost her about $60. She asked if there were any alternatives. Upon further questioning, I found out that she couldn’t take ACEIs or diuretics because she got too dizzy but needed some sort of blood pressure control. After reviewing my company’s $4 list, I couldn’t really come up with a good alternative – beta blockers would probably make her dizzy and CCBs aren’t on the list (well, the good ones anyway). I faxed the doctor and got back a prescription for amlodipine – close to $80. In this case, the patient could very clearly have benefited from the use of samples – prove to her that Cozaar works and doesn’t cause side effects before having her pay for it. The prescriber probably had the same concerns I did in terms of the BB/CCB use and landed on the one with which she was more comfortable. We stuck with the amlodipine and I price matched another company’s generic list for $10. Either way, having drug samples available for patients with trouble finding the drug that works for them is beneficial.
RE: Joey
I think we unfairly assume that reps are the only source of COI. As a pharmacist, I push generic medications as much as possible because we make more money on generics than we do on brand medications. That’s not a secret, so is it a COI that I save a patient money by substituting to a generic (as allowed by law), and in turn, make money? I believe that AB-rated generics are equivalent to brand; does that make me biased toward subsituting to generic? I'll guarantee that when a patient asks for an obscure brand name drug, most pharmacists scoff and say the generic's the same thing and push hard for the generic. COI?
RE: Lauren
I think ANY pharmacist’s word on drugs ought to carry more weight than anyone else’s; we are, after all, the drug experts. Whenever I get a prescription that a patient cannot afford, I call the prescriber, armed with two or three comparable suggestions to discuss (because that question is inevitable – “what can we use instead?”). I’ve never had a doctor not take my recommendation because they wanted to use something a drug rep had been in for.
RE: Kinjal
No – drug reps aren’t educated in scientific nuance – they are salespeople. Plus, it would probably be very difficult – free market theory allows companies to run themselves how they see fit, assuming they aren’t breaking laws and are maintaining minimum standards of practice. If something like this were to happen, it would likely be driven by professional organizations – more readily available guidelines, newsfeeds, emails, presentations, CE, etc.
____________________________
Erica Harms, Pharm.D., R.Ph.
Staff Pharmacist - Target Pharmacy
Charlotte, NC
eharms@carolina.rr.com
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