Ties That Bind
Drugmakers spend billions a year wooing doctors with gifts and free
trips.
Critics say these relationships aren't healthy.
But breaking up is proving hard to do.
By Barbara Basler
January 2008

For years, pharmaceutical companies have courted America's doctors
with an ever-growing intensity, showering them with billions of
dollars' worth of gifts, consulting fees and trips to persuade them to
prescribe their drugs. But now, patient advocates and lawmakers are
out to break up those relationships, arguing that physicians--working
amid the clutter of the drug industry's free samples, pens,
clipboards, calculators and pizza boxes--often lose sight of the
patient's best interests.

Even some doctors are speaking out against these gifts and favors on
websites such as No Free Lunch and PharmedOut. The Institute of
Medicine at the National Academies is drawing up conflict of interest
guidelines for doctors, while leading medical schools are tightening
their policies on accepting gifts. And legislators in Congress and in
statehouses across the country are drafting laws to require drug
companies to report these gifts publicly so patients can find out
which doctors took what from the industry.

Several states, including Pennsylvania and South Carolina, have hired
their own representatives to call on doctors and discuss older drugs
and generics. The idea is to counter the sophisticated pitches and
gift giving of drug industry sales reps who are promoting their
company's latest, most expensive drugs.

"There are signs of a building momentum to restore a sense of medical
ethics, a sense of service to the patient, to our profession," says
Howard Brody, M.D., director of the Institute for the Medical
Humanities at the University of Texas Medical Branch in Galveston.

But Brody points to a national survey published last year in the New
England Journal of Medicine, in which 94 percent of the doctors polled
said they had "direct ties" to the drug industry. "So you can see the
position we are starting from and how far we have to go."

The drug industry maintains that its voluntary guidelines recommend
only "modest" meals and gifts and says that the sales representatives
provide vital information to doctors.

But reformers point to the sheer momentum of the industry's massive
spending on marketing to doctors--up 275 percent from 1996 to 2004--
along with the rising costs of health care and the safety problems of
such drugs as the painkiller Vioxx.
While few would deny that new drugs have saved lives, new medications
are typically more expensive than older or generic versions and can
have adverse side effects that were not apparent in initial clinical
tests. Prescribing new drugs for older patients is even more
problematic because most drugs are approved based on trials in which
older patients were woefully underrepresented, says Jerry Avorn, M.D.,
of Harvard Medical School.

Whether they know it or not, "many doctors have been prescribing
according to industry profits rather than the patient's needs," says
Brody of the University of Texas.
Sales reps aggressively promoted Vioxx, minimizing unfavorable
findings on the drug. Doctors wrote millions of prescriptions for it--
right up until the drug was pulled from the market, in 2004, because
it raised the risk of heart attack and stroke.

"I stopped seeing all drug reps when the problems with Vioxx hit the
news," says Jonathan Mohrer, M.D., a family practitioner in Forest
Hills, N.Y., who is one of a small but growing number of physicians
swearing off drug reps. "Like every other doctor, I had a closet full
of Vioxx pills--free samples for my patients. The Vioxx reps came by
every two or three days with samples and other stuff because they were
in a marketing war against Celebrex." Reps, he says, would call his
office in the morning to see what the staff wanted for lunch: "Nothing
fancy--pizza, sandwiches."

Despite a slight dip in spending in 2005, drugmakers still spend about
$7 billion a year to win the hearts and minds of doctors and another
$18 billion on free drug samples for doctors, according to data
compiled by the Prescription Project, an effort funded by the Pew
Charitable Trust to curb the drug industry's influence.

"I've had doctors say, 'I can't be bought with a slice of pizza,' "
says Adriane Fugh-Berman, M.D., a Georgetown University associate
professor who has studied industry tactics. "In fact, one drug
industry study, for instance, showed that when a drug rep got one
minute with a doctor, the doctor's prescriptions for that drug
increased 16 percent. With three minutes--52 percent."

Each day more than 101,000 drug company reps--one for every five office-
based physicians--call on the nation's doctors. Primary care
physicians, on average, have 28 interactions a week with drug reps,
according to a 2005 report by the Health Strategies Group, a
consulting firm for manufacturers of health care products.
"I go to medical conferences and ask, 'Why do you think the
pharmaceutical companies are spending all that money and giving you
all that free stuff?' And I get blank stares," says Jerome P.
Kassirer, M.D., former editor of the New England Journal of Medicine.
"Doctors," he says, "continue to insist they can't be bought."
Even so, Congress is considering a bill that would require big drug
companies to report gifts to doctors worth $25 or more, or face
substantial fines. The legislation would set up a national website so
patients could learn which doctors were taking gifts and fees from the
drug companies.

"Right now the public has no way to know whether a doctor's been given
money that might affect prescribing habits," said Sen. Chuck Grassley,
R-Iowa, who, with Sen. Herb Kohl, D-Wis., introduced the measure last
year.

The industry is vehemently opposed to marketing-disclosure
legislation, which the Pharmaceutical Research and Manufacturers of
America says "offers no extra value to patients and is a costly,
unnecessary burden for innovative" drugmakers.
"In the end, pharmaceutical marketing is one of several important ways
for physicians to receive information they need to make sure patients
are safely and effectively treated," Ken Johnson, PhRMA senior vice
president, said in a statement to the AARP Bulletin. Others disagree.

"I think all the trend lines are pointing in one direction, showing us
we have real problems," says Harvey V. Fineberg, M.D., president of
the Institute of Medicine. An IOM committee of consumer, medical and
ethics experts is drawing up guidelines for the medical community,
which should be ready by the end of the year, he says. While the
guidelines are nonbinding, experts say the prestige of the IOM could
give them real clout. In the meantime, the effort to curb industry
influence is progressing very slowly.
"Doctors say they see the reps for the latest information, but it's
also for the food and toys and flattery," says Georgetown's Fugh-
Berman, who helped organize PharmedOut.org to counterbalance industry
influence. The site aims to offer doctors unbiased drug information
and insight into drug company marketing strategies. It's funded by
money from a 2004 settlement with 50 states and the District of
Columbia of a case alleging improper marketing by the drugmaker
Pfizer.

Vermont, Maine, West Virginia, California and Washington, D.C., now
have drug company gift disclosure laws. And since 2005 Minnesota has
limited giving to $50 worth of meals or gifts a year per doctor. The
effect of the restriction is dramatic:

Primary care doctors there have been seeing far fewer drug reps,
according to a firm that tracks pharmaceutical marketing.

But in New York, for example, the state Assembly passed one of the
toughest disclosure bills in the country in 2006 and again in 2007,
only to have the bill die in a Senate committee after what one
supporter called "an army of lobbyists" descended on Albany. The
measure, supported by AARP and other consumer groups, will be back
this year.

New Hampshire passed a law in 2006 prohibiting drug companies from
purchasing information about doctors' prescribing habits, information
they use to tailor their sales pitches. The industry challenged the
law, and it was overturned in federal court last year. But the state
is appealing. Maine and Vermont passed similar laws that also are
being challenged in federal courts.

Altogether last year 17 states drafted legislation that would regulate
gifts to doctors or require their disclosure, according to the
National Legislative Association on Prescription Drug Prices, a
nonpartisan organization of state legislators who work on ways to
reduce drug costs. Not one of these bills became law.

http://www.aarp.org/bulletin/yourhealth/drug_rep_ties_that_bind.html