Physicians need to understand subtle marketing manipulation

There is do doubt that the way pharmaceutical companies market drugs to both doctors and consumers sways prescribing and drives up health costs.  Prescription drug costs have outpaced other health care spending and are predicted to exceed the growth rates for hospital care and physician services going forward from 2010-2019.

Two researchers (Howard Brody, MD, PHD, University of Texas Medical Galveston and Donald Wright, PhD,  University of Medicine and Dentistry of New Jersey) have outlined 6 things that have a large effect on physicians and lead us into prescribing drugs that may not be needed.   It’s not just the pharmaceutical marketing that has led us to this place … it is also how journals publish literature that physicians rely on for changing medical practice.

Here are the 6 strategies that influence us:

  •  Reducing thresholds for diagnosing disease.  For example, a diabetes diagnosis used to be fasting blood sugar above 130.  Now it is glucose above 100.  There is no evidence that tight control leads to improved outcomes in preventing stroke, total mortality, blindness or renal failure.  Early detection  is a good thing if it helps with diet and exercise but recent data shows that the intensive therapy (HbA 1c-<6%) group did worse.
  • Relying on surrogate endpoints rather than outcomes as goals.  We know that Statins lower cholesterol.  From 1994-2006 the use of Statin drugs by adults 45 and older increased 10 fold.  In a meta-analysis of 11 clinical trials involving 65,229 participants of high-risk patients without prior cardiovascular disease, the Statin use did not lower all- cause mortality.  Surrogate endpoints make it easier for marketers to make claims that the drug will benefit the patient.
  • Exaggerating safety claims.  When drugs are initially tested, the test population is usually homogeneous and small.  As a larger number of patients take the drugs, the potential for adverse effects increases.  We need to always be aware of this.
  • Exaggerating efficacy claims.  Marketers often emphasis that a new drug is better than an established (lower cost) drug when actually the drug performs no better than the old one.  New drugs might have an advantage for a smaller subset of patients but marketers emphasize the benefit for everyone.
  • Creating “new”  diseases.  Social anxiety disorder (aka: shyness),  Erectile Dysfunction (aka: aging men), Pre-diabetes etc. creates millions of new customers who might benefit, but will also be exposed to high cost and potential side effects.
  • Encouraging unapproved uses.  It is illegal for a pharmaceutical company to market a drug for a non-indicated condition, but that doesn’t stop physicians who are on the honorarium payroll from shilling for dollars.  This has been a common practice that has just lately had a light shown on it.

I am not bashing Big Pharma here.  They have a product to sell and patients and physicians are the customer.  It is up to physicians to understand the subtle marketing manipulation and published research.  We need to remember that epidemiological data linking a risk factor to a bad outcome does not prove that changing the risk factor by taking a drug will reduce the risk for an individual  patient.

Modern pharmaceuticals are lifesavers and have increased longevity and good health for millions.  But we should always stop and think before we start a patient on a “lifetime” drug if they have no complaints and make sure we are really preventing an outcome, not just a lab test.

Toni Brayer is an internal medicine physician who blogs at EverythingHealth.

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  • Anonymous

    Outstanding overview here, Toni – thanks for this. The pharmaceutical industry MUST attempt each of these strategies in order to satisfy their shareholders.  For each strategy, and for each drug company, the intent is clear: get docs to prescribe my drug to more patients. And sometimes the steps they need to take are hardly “subtle”.

    Doctors on the take from Big Pharma are courted by being called “thought leaders” – who can then help influence their colleagues to help sell more drugs. More on this at http://ethicalnag.org/2010/10/31/is-your-doctor-a-thought-leader/

    Dr. John Santa,
    former medical director of the Drug Effectiveness Review Project in
    Oregon, explained the pervasive influence of drug companies directly on the daily lives
    of physicians in a ‘Consumer Reports Health’ interview recently:

    “Doctors deny it, but the evidence is
    clear that these relationships lead to significant increases
    in prescribing and sales. If they didn’t, the drug companies wouldn’t
    spend an estimated $20 billion a year attempting to influence physicians.”

  • http://www.freshwhitecoat.com Jin Packard MS/MPH

    I agree with most of those points, but I disagree a little about “creating new diseases” and “surrogate endpoints.” It’s up to the physician to recognize patients who are suffering from debilitating disease or disability. Fibromyalgia and ADHD are relatively “new disaeses” as are a bunch of other psych conditions. Some may be uncommon, or more common than we think. On surrogate endpoints: those are frequently important diagnostic markers, and easy to document, whereas true outcomes are influenced by a bajillion other factors and loss to followup is also a real problem in studies. Physicians often rely on surrogate endpoints to make treatment decisions. From a biostats point of view, it’s unrealistic to expect the majority of drugs to demonstrate efficacy beyond surrogate endpoints because of extraneous (soioeconomic, geographic, etc) influences on true outcomes.

    • http://notwithstandingblog.wordpress.com/ The Notwithstanding Blog

      I agree with everything that Jin wrote above, and would add one more point about “creating new diseases.” That conditions such as erectile dysfunction are considered “treatable diseases” where they would previously have been considered “part of aging” is a red herring. Does the drug improve quality of life or functionality, even if we had until now learned to live without it? It might not be saving lives and curing “real” (however we define that) illness and suffering, but it still adds real value to real lives.

  • Anonymous

    Thank you for a great column – and the comment are insightful also, especially Carolyn Thomas’s quote of Dr. Santa on the efficacy of pharma marketing: if it didn’t influence doctors, they wouldn’t do it. Same with direct-to-consumer (DTC) drug advertising. The U.S. is one of only two countries on the planet that allows DTC drug ads. Just as with any product, let the buyer (and prescriber) beware.

  • http://twitter.com/MarilynMann Marilyn Mann

    I agree with your general point about the danger of relying on surrogate endpoints, but I think the example you chose is not really very illustrative of your points. The fact is we have lots of data that shows that statins lower the risk of cardiovascular events in both primary and secondary prevention. Cardiovascular events are clinical endpoints

  • http://twitter.com/MarilynMann Marilyn Mann

    I agree with your comment about the danger of relying on surrogate endpoints. However, in the case of statins we have lots of data that statins reduce the risk of cardiovascular events in both primary and secondary prevention. Cardiovascular events are clinical endpoints, not surrogate endpoints. In addition, there is good evidence that statins lower total mortality in secondary prevention. The only argument has been over whether statins lower total mortality in primary prevention. In the meta-analysis you cite, total mortality was 9 percent lower in the statin group as compared to placebo and the upper bound of the confidence interval was 1. Although the result was not statistically significant, it still seems likely that statins lower total mortality slightly in primary prevention. In any case, the reduction in risk of heart attacks and strokes is a clinical (not surrogate) benefit.

    The problem in terms of total mortality is not with statins but with certain nonstatin cholesterol drugs that increase noncardiovascular mortality (see fibrates).

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