Is there a harm to not seeing drug reps?

Now more than ever, the growing consensus among many is that doctors should avoid seeing pharmaceutical sales representatives, otherwise known as drug reps. A position statement from the AAMC, the head organization of all US medical schools and residency programs, recommends that all academic health centers avoid having drug reps on their campuses, hospital and clinics. Many medical institutions including the VA and Kaiser have also enacted similar policies banning drug reps. In fact, the number of doctors willing to see reps has declined about 20 percent since 2008. In 2010, about 11 percent of American physicians had “severe” or “no-see” restrictions on drug rep access, while 34 percent had “some” restrictions.

The rationale for such bans is that drug reps are really marketing agents for the drug companies they represent, and their mere presence will cause physicians to write unnecessary prescriptions. It is not only the sales pitches that certain stakeholders are concerned about, but also drug samples and often times food that comes with them. The idea is that gifts from the industry (which other than meals have not been around for some time) as well as samples of medicines, marketing material and sales pitches from drug reps will influence physicians to write medications that they might not normally write.

There is certainly some data to support this rationale. It is indisputable that marketing from drug companies increases sales of their products. Not only are there studies to back this up, but also at face value, if it didn’t work, the industry wouldn’t do it. The real question is whether or not this is good or bad for patients. Certainly, if a doctor writes for an expensive brand name medication, when a generic medication would have worked just as well for a lot less money, then pharmaceutical marketing is harmful.

On the other hand, if a doctor is not prescribing a medication that he should be writing for or the current cheap, generic medication the patient is taking is not working or is causing unnecessary side effects, then drug company marketing which would change those prescribing practice might actually be helping the patient. There are probably several examples of both extremes. For example, Singulair is a $3 billion dollar product for Merck and the single best selling controller medication for asthma, but it doesn’t work any better than over the counter generic medications for allergies, and the NIH guidelines consider Singulair alternative therapy for asthma (inhaled corticosteroids are first line, yet rarely prescribed). Marketing and subsequent sales of Singulair are probably not good for patients. On the other hand, cardiovascular disease is the single leading cause of death in the US.

However, many physicians had been prescribing less effective, generic statins to patients at risk for heart attacks, and in many cases not meeting therapy goals and causing side effects. Recently, the FDA released warnings about using higher doses of generic simvastatin. Thus, the Pfizer rep promoting branded Lipitor (it has since gone generic and is no longer promoted) with their $4 coupon cards was probably helping patients.

The overall benefit or harm of pharmaceutical marketing is unclear. At issue is whether or not a pretty drug rep, with slick marketing material, a drug sample and a slice of pizza is enough to sway a physician to write for a prescription that is not in the patient’s best interest. Despite many claims that this is indeed the case, there is no real evidence to back this up. Part of the reason for this is such studies are incredibly challenging to design and implement. The one review paper that is often quoted in support of this claim actually never really showed this. Their one example was a study done in the Netherlands where physicians read hypothetical marketing material and picked a therapy.

However, what about the harm of not seeing drug reps? Do the restrictive policies enacted in the last few years have any unintended consequences? Though there is no question that the motivation of the drug reps and the industries they represent is to sell prescriptions, they also provide physicians with information about new products and new data on existing products. Given the complexity of medicine and the vast amount of new data available each day, it is difficult for physicians to keep up to date, especially in primary care. Thus, a benefit of the drug reps is providing physicians with important new information. Therefore, the potential risk of not having drug reps is not having, or more importantly doctors not acting on, new information.

Though it has (surprisingly) drawn very little attention, a recent study looked at this very issue. In a study recently published in The Journal of the American Society of Hypertension called “Can Access Limits on Sales Representatives to Physicians Affect Clinical Prescription Decisions? A Study of Recent Events With Diabetesand Lipid Drugs,” the authors used a very sophisticated methodology and study design to look at the potential harm of physicians not seeing drug reps. They decided to look at three prescribing practices:

  1. Adoption of a new, first in class diabetes medicine (Januvia) in 2006 (sample size over 65,000 physicians)
  2. Decreases in prescribing Avandia after the FDA placed a box warning on it in 2007 (sample size over 58,000 physicians)
  3. Decreases in prescribing Vytorin (a combination of simvastatin and Zetia) when a 2008 study was released that showed no benefit over simvastatin alone in a large, randomized trial (sample size over 72,000 physicians).

The researchers used IMS data of actual physician prescriptions to analyze prescribing patterns of the specific drugs in questions. They used a consulting firm data base of how many times a drug rep saw 300,000 physicians to determine access level (drug reps keep very careful records of their sales calls, since this is how they are paid), and divided physicians into four categories: very low access, low access, medium access and high access. They also only used docs who were high prescribers of diabetes and cholesterol medicines to control for the fact that low prescribing doctors are often not targeted by sales representatives. They also controlled for other variables such as specialty and geography.

What they found were that physicians with very low access to representatives had the lowest adoption of the new diabetes medicine, taking 1.4 times longer to prescribe than the low access physicians and 4.6 times longer to prescribe than the medium access physicians. In response to the Avandia box warning, docs with very low access were 4.0 times slower to reduce their use of Avandia than those with low access. Similar numbers were seen with prescriptions of Vytorin after negative data was released.

The study also showed that the physicians who were most sensitive to the effects of the pharmaceutical reps were primary care physicians. Cardiologists were least affected. In other words, docs who didn’t see drug reps were about 4 times less likely to respond to either positive (new drug available) or negative (safety issues, lack of efficacy) information than docs who allowed some access to pharmaceutical representatives.

Bottom Line: Pharmaceutical marketing increases pharmaceutical sales which ultimately increases what we spend on health care. Whether or not this is good or bad for the individual patient or society is debatable. While there may be overuse of some branded prescription products, there is certainly under use of branded products as well. After all, prescriptions drugs do cost money but they also save lives. Unfortunately, there is no clear evidence to determine the overall risk or benefit of pharmaceutical marketing one way or another.

However, while restricting drug reps may decrease pharmaceutical sales, it may also have the unintended consequence of decreasing access to new and important information for physicians. In this first of its kind study, docs who didn’t see drug reps were more likely to prescribe less effective and potentially more dangerous drugs to their patients after new data was available.

Medical information comes from many sources. Though information provided by drug companies is intended to increase sales, it doesn’t mean that it is not valuable. The question is whether you want your physician to have the most up to date information and trust him or her to interpret the data, regardless of who is providing it, and use it in the best interest of the patient; or whether you don’t trust physicians (especially when pizza or pens are involved) with any information provided by drug companies, so you restrict access to this information. We at least have one study suggesting that there are some potential harms to restricting access to information that drug companies provide, and so maybe we should trust doctors a little more.

Matthew Mintz is an internal medicine physician who blogs at Dr. Mintz’ Blog.

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  • James deMaine

    Systems like Kaiser research best practices, study the drugs with their P&T Committee, and use their pharmacists to educate their doctors.  Surely this is better than a sales rep.  It’s kind of like using the Consumer Report magazine vs. a trade journal when buying a car or any other product.  I’d like to see a study comparing pharmacist educators and sales reps – looking both at the message and outcomes in terms of sales.  Doctors need to rely on unbiased information, not a sales pitch.

    • annefrates

      Plus, as a patient, I find that many doctors blame the drug reps for making the wait times for us longer. I’d love to see all the reps corralled into a specific slot, and stop interrupting the doctors attention to patients needing treatment.

      • MarylandMD

        This is in line with Dr Salwitz’s comment above.  When I did see drug reps, I insisted that NOTHING they did would interfere with patient care activities.  I wouldn’t even sign for samples if I was seeing patients or doing other patient-related work.  Nothing drives patients crazy like sitting in the waiting room to see the doctor (who is usually behind schedule) and watch the drug rep come in the door and go right in to see the physician without delay!  I hear complaints about it all the time.

        The easy answer is to not see the drug reps at all.  Since we stopped, things have only improved, and the patients don’t think we are in the thrall of the drug reps and their freebies.

        As a patient, you have the choice to only see those physicians who no longer allow drug reps in their office.

  • MarylandMD

    Given the significant negative effects of drug reps (e.g., over-utilization of newer, more expensive medicines at the expense of older medications that are effective but much cheaper) I find these few “negative” effects to be unpersuasive.
     
    Rapid adoption of a new, first in class medication is not aways the smart move.  What about Avandia?  This one statistic seems to prove those with less exposure to drug reps are smarter, holding off jumping on a bandwagon they may later regret.

    Finally, just posting *relative* differences instead of *absolute* differences is not helpful.  It reminds me of the techniques drug reps use: playing up the benefits of what you are promoting by pushing relative differences which exaggerate minimal absolute effects!

    One note: as of now, your link to the study in question is broken (it goes to a KevinMD page titled “Full Body Scams”.  Can you perhaps fix it, so we can review the study ourselves?

  • DavidBehar

    The Commie campaign is working. It is to deprive poor, dark skinned people of brand name medications, and to feed them generics left wing officious intermeddlers would not give their dogs. The arrogance of the AAMC is appalling and racially motivated.  I plan to start to intervene in those DOJ witch hunts. Thank the Commie for the empty pipeline. If I led a drug company, I would abandon the hostile USA and move to China, Korea, and India. If you believe in prayer, pray, the Commies at the AAMC get sick and have to take a generic because there are no more brand name medications. Pray they suffer, as they want our poor patients to suffer.

  • Matthew Mintz

    @MarylandMD:disqus - Don’t know why the link to the study is broken in this posting.  Here is the exact URL:
    http://onlinelibrary.wiley.com/doi/10.1111/j.1751-7176.2012.00651.x/full
    There is no question that pharmaceutical marketing increases the number of branded prescriptions written.  It is also possible that this lead to “over-utilization of newer, more expensive medicines at the expense of older medications that are effective but much cheaper.”  However, there is no data to prove this point, i.e. that the patients of docs who prescribed Lipitor (when branded) or Crestor had the same outcomes (at a higher cost) then the patients of the docs who prescribed simvastatin or pravastatin.  This study is fascinating in that it is the fist study of its kind (that I am aware of) to actually show the negative impact of not having reps, i.e. docs who did not see reps were more likely to stop prescribing known less effective medications (in the case of Vytorin). 

    I am not trying to imply that all pharmaceutical marketing is wonderful.  However, I think we need to look at the data and policies critically and recognize the situation is not always black and white. You are correct, that “rapid adoption of a new, first in class medication is not aways the smart move;” however, in the case of Januvia (which was studied in this study) it probably was.  There is now consensus among the diabetes community (US and Europe), that though metformin is clearly first line, sulfonylureas (the only other generic diabetes medication) is probably not the go to second line therapy because it generally causes beta cell failure, causes weight gain and causes (in some cases severe and life-threatening) hypoglycemia. 

    @James deMaine: you are correct that integrated systems like the VA and Kaiser have P and T committees and pharmacists that can educate physicians.  However, 1) most physicians currently do not practice in these systems, though this is obviously changing rapidly and 2) while the reps clearly have a bias to sell their products, the P and T committees also have a bias, which is to keep costs down.  Thus, systems like the VA and Kaiser almost always heavily favor generics, and restrict many branded products.  This clearly saves money.  Whether or not it is of benefit to patients is unclear. 

    • MarylandMD

      You are sounding like a drug rep every time you speak!  Your notion of “the consensus among the diabetes community” is hardly that, unless you talk to a drug reps who are pushing Januvia or Onglyza!  I have consulted with and had talks from endocrinologists recently, and Januvia is still relegated to second or third line use, and everyone who I have discussed Januvia with agrees it is a very weak medication which does not bring about a robust improvement in A1c, especially given its cost.  Again, jumping on the bandwagon of a new, first in class medication is in my (and many other physicians) opinion an unwise idea, and does not inherently show good judgement.  Your notion that Januvia now has value is only evident **in retrospect**.  Again, haven’t you heard of Avandia?  Were those who jumped on Avandia early the smarter docs?

      This study is a retrospective analysis, a very weak kind of study, and certainly not one I would base ANY changes in practice on.  Futher, there are no outcomes data associated with this study.

      In addition, this is an INDUSTRY SPONSORED study.  Imagine that: AstraZenica puts money into a study that suggests drug reps might be a good thing!  How many studies did they have to do (and spike before publication) to get this weak study with the results they wanted us to see?

      I see this as a “disinformational” study.  A weak study with questionable conclusions that only serves to try to generate doubt on a well-established consensus.  This reminds me of studies done by cigarette companies trying to cast doubt on the fact that cigarettes cause lung cancer.  You do not do yourself much credit in touting this insignificant paper.

      • http://twitter.com/drmintz drmintz

        Both the American College of Physicians diabetes guidelines and the ADA/European consensus state, both just recently released, are now in-line with the AACE/ACE guidelines which essentially state that metformin is first line (as I stated above), but there is no clear winner for 2nd. However, there are clear concerns with SU’s given that they do not maintain glycemic control, cause weight gain, and cause hypoglycemia.  This is a major change from the official ADA guidelines which suggested SU’s as a second line agent and didn’t even include the DDP4 inhibitors.  Use of DPP4 inhibitors is not “jumping on the bandwagon) when the prevalence of diabetes is increasing and goals are not being met and a new and novel agent is introduced to the market.
        I do not mean to imply that this is a robust study that should change the way all physicians practice medicine. However, there is virtually no way of doing a blinded randomized trial and the data, though retrospective is quite a robust size. In addition, there is no similar (stronger or weaker) study that I am aware that shows that interacting with pharmaceutical representatives harms patients. The “well-established consensus” is not evidence based. The assumption that representative interactions increase sales of prescriptions (proven true)which in turn increase health care costs (also true) is bad for patients has simply not be demonstrated by any reasonable study, though most just believe it to be true.
        What is needed is an outcomes study (would probably have to be retrospective) that (using similar analytic techniques) compared doc-rep interactions with things like A1c, LDL (surrogate markers) or hard enpoints like MI, retinopathy and death.

        • MarylandMD

          Just because the new guidelines suggest that you maybe possibly can use Januvia 2nd line does not mean that you SHOULD use Januvia 2nd line, nor does it remotely suggest that anyone who hesitates to use Januvia 2nd line (or 3rd line, or at all) is in any way providing a lesser quality of care.  Further, the study in question looks at the adoption of the use of Januvia when it was a new product.  While your 20-20 hindsight is great, it was not at all clear when Januvia was first released that it was worth using AT ALL for type 2 diabetes management.  Even now, as I stated before, Januvia has limited utility for diabetes management given the minimal improvement in A1cs for its high cost.  Adoption of Januvia for management of diabetes could never, ever be used as even a proxy for quality of care, as there are too many other ways to get reasonable control of blood sugars without Januvia.

          You are right there is not a randomized controlled trial PROVING that physician exposure to drug reps increases death rates or other hard endpoints in their patients.  And you know what?  THERE NEVER WILL BE!  I cannot imagine anyone wasting their money on some sort of crazy retrospective trial of drug rep contacts with hard endpoints or even A1cs.  Such a study would have too many holes in it to withstand scrutiny.  There are not randomized controlled trials of the use of parachutes for jumping from airplanes, but we make logical conclusions based on available information to determine that they are useful.  Similarly, we have already plenty of information on drug reps–skewing patients towards higher-cost medications (in the same class!), concerns about physician corruption, and poor perception of the relationship by patients (see the other comments to your article!)–to conclude that the use of drug reps as an educational tool is a bad idea.

          Again, the study you promote is a disinformational tool for drug companies to argue that maybe drug reps aren’t so bad when it doesn’t even come close to proving or even suggesting such a thing.  It is a weak study to the point of worthlessness.

          You even suggest in a earlier comment that since we don’t even have data that proves that using a lower-cost statin (such as Pravachol) is as good (for the same lipid control) than a higher cost name-brand statin such as Crestor, we can’t even conclude that drug reps that get a physician to use Crestor when Pravachol will do are doing the patient a disservice.  Wow.  I would only expect such a dissembling suggestion to come from someone from a drug company.  Do you know the reason why we don’t know whether a particular name-brand statin provides better hard outcomes that the other statins?  **Because the drug companies won’t do the studies!**  They are too chicken, as their drug may not come out on top!  We physicians would LOVE to have hard data to help us select the “best” statin, the “best” PPI, or the “best” ACE-I!  Get the drug companies to do the comparative studies directly pitting their new drugs against the current alternatives (including generics) in the class in an independent trial before the new medication comes to market.  Complaining that we don’t have a study on the drug rep question is really a distraction from the much more important issue of needing direct comparative research on the medications themselves, research which is much easier to design and carry out.

          • Matthew Mintz

            I think that we can both agree that non-biased, comparative effectiveness research would benefit everyone.  Unfortunately, up until now, this simply doesn’t exist. Pharma does in fact fund some comparative studies, including the Vytorin study analyzed in the original article this post is about.  Pharma funds almost all research on pharmaceuticals.  Though the ACA contains funding for some comparative effective research, it simply won’t be enough. Therefore, as clinicians we must rely on industry funded studies. 
            You and I will have to disagree about what the new guidelines mean.  Though they don’t come right out and say use Januvia second line, they do say that we need to consider other options, because the older, generic second line sulfonylureas may not be worth their low cost benefit.  The AACE/ACE guidelines have left SU off their list of first line therapies. 
            I am not saying that we should use Crestor when Pravachol will do.  80% of all meds currently prescribed are generic.  However, it is possible that docs who only or who almost always use generics may not use branded medicines when needed.  Of course, there is no data to prove this, but I would suspect that docs who interact with reps use more branded drugs at a higher cost to the system/insurance companies; however, with better outcomes. I could certainly be wrong, but if you are being objective and evidence bases, one should at least entertain the possibility. 

          • MarylandMD

            I can entertain the possibility of a lot of things, such as that Venus is made of yellow american cheese, but that doesn’t make me spend a lot of time complaining that we haven’t yet sent a mission to Venus to bring back rock samples to PROVE that Venus isn’t made of yellow american cheese.  We have plenty of information on the negative impact on drug reps.  It is now up to the drug companies to prove decisively that drug reps are an overwhelmingly positive contribution to a physician’s practice (AND better than other unbiased educational alternatives) before I will ever let one near my office again.  In light of all we know, the study you cite doesn’t even slightly suggest that drug reps are a positive addition to a medical practice.

            You set up a straw man comparison: a doctor who almost always uses generics (and doesn’t use name-brand meds when appropriate) vs. a doctor who interacts with drug reps and uses more branded drugs “with better outcomes.”  What kind of a crazy comparison is that?  It bears absolutely no relationship to the reality I see in everyday practice.  If you view medical practice through such a distorted lens, then it is no wonder you come to the conclusions you do.  The comparison is all the more crazy, because as you admit you have NO DATA to even remotely suggest that name-brand medications give you better outcomes!  Why is the idea that name-brand meds give you better outcomes than cheaper generics have such value to you over the simpler (and more widely accepted idea) that most medications in a class are generally similar in outcomes?

            The suggestion is all the more crazy, as one of the arms of the study is to see how quickly the physicians get their patients OFF of a brand-name drug that is harmful!  Do you not see the irony here?

          • Matthew Mintz

            Outcome studies are incredibly hard to do and are very expensive. Pharma generally does not do them because the risk is generally not worth it and the government does not do them because we have only recently started to fund comparative effectiveness research.  However, there are a few examples. The PROVE IT study showed that Lipitor (which only recently became generic) decreased CV outcomes in acute coronary syndrome compared to pravastatin (which has been generic for some time).  In addition, the FDA has come out with warnings about high dose simvastatin. The only negative outcome study for statins has been with simvastatin (A-Z Study) whereas all Lipitor outcome studies have been positive.  This suggests a clear class effect between the more potent statins and less potent statins that relates to outcomes.  The NIH BARI-2D study looked at insulin sensitizers (metformin, TZD) and compared them to insulin providing medicines (insulin, SU’s).  Though there was no difference in CV outcomes, diabetes control was better in the insulin sensitizing group and there was significant hypoglycemia with the insulin providing groups. 
            In addition, though outcome studies are hard to come by, there are plenty of studies looking at surrogate markers which suggest there are differences within a class. 
            The newest ARB is definitely superior to some of the older ARBs (some branded and some generic) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3295635/ and though this again is not an outcome study, is enough that might make a difference. 
            Regardless of whether any of the above examples would compel you to use a branded medication over a generic, the potential advantages of branded medications ought to be considered. 

          • MarylandMD

            You can go on and on, but NONE of what you posted proves that using a new, first in class medication always gives you better outcomes and thus not doing so (such as with Januvia) indicates poor practice.  In fact, the experience with Avandia proves the opposite.

            Your few studies do not prove that overall, a doctor who prefers generics and uses name-brand when appropriate is providing measurably poorer care than a doctor who leans heavily towards name brand medications.  You do agree, however, that the second doctor spends much more money.

        • bhai_mian

          Ah the Guidelines.

          Written by doctors on the panel of big pharmaceutical industries and getting paid lot of money to promote their brands. Little wonder that these guidelines don’t mean much to many of us

  • http://twitter.com/DRSALWITZ James C Salwitz, MD

    We banned all drug reps from routine detailing and access more than 12 years ago. The reason was not as much concern about how they would bias our decisions, but how our patients felt about our perceived relationship with pharma.  Our patients were clearly concerned about whether we were making decisions to help them or to sell drugs.  It made a strong statement when we limited those contacts and our patients clearly appreciated our patient centered bias.  In 2012 with all the high quality data sources for ongoing medical education we can not conceive of a gap in our knowledge base that would best be filled by taking valuable patient time to interact with salesman.  No matter how well presented it represents an inefficient and biased information source.  Fortunately we are still being reimbursed at a level that we can afford our own pizza.

    jcs

  • Maurice Bernstein MD

    I generally refused to see drug reps and what was the consequence?  I have never had to take a patient off a drug which was found to have significant but not previously documented side-effects or recalled. There is a genuine value to the use of old established drugs in the vast majority of patients. ..Maurice.

  • Bradley Evans

     This was a study commissioned by AstraZeneca. It was funded by AZ. The lead author was employed by AZ at the time. The sitagliptin data indicates that physicians who saw drug reps less also adopted new therapies slower. This could reflect the preferences of these docs or the fact that the pharmaceutical industry doesn’t fund comparative research, so there usually is no data upon which to make comparisons. Some doctors may be reluctant to prescribe new medicines because phase III studies are designed to test efficacy primarily and may miss side effects. In any case, the authors try to make a cause-effect relation when their data shows only a correlation. I haven’t looked at their “older diabetes drug” data or the combination drug data as yet.

    • Matthew Mintz

      There is no question that this was a drug company supported study.  Almost all research on prescription drugs is funded by the drug companies. I would love it if we had more non-biased research on prescription drugs, but that simply is not the case. The drug companies spend more on research than the entire NIH budget, which rarely looks at prescription drugs. Drug companies in fact do, though rarely, fund comparative research.  One of the studies analyzed in the study this post is about is a comparison of simvastatin vs. Vytorin, which was funded by Merck, who make Vytorin.  Part of the President’s Affordable Care Act funds the comparative research you are talking about, but these trials are just getting started and due to limited funding, it won’t nearly be enough. 
      The study shows exactly what you state , that  “physicians who saw drug reps less also adopted new therapies slower.”  Is adopting new therapies slower a “good” thing or a “bad” thing?  I am not sure, but it’s worth considering. However, it is very unlikely that institutions that created policies that restrict the flow of information, biased or not, even considered that there may be possible negative consequences of such policies. 
      Finally, the only way to show a cause and effect relationship is a randomized control trial. It would be extremely difficult if not impossible to design a trial that randomizes physicians or institutions to drug rep and placebo, let alone generate the kind of volume of prescriptions that one would need to see to determine any significant difference.  You may agree or disagree with the importance of the findings, but the design of the study was appropriate and the methods they used to address the limitations of their non-randomized design was quite rigorous. 

  • MarylandMD

    comment deleted, as was a duplicate post

  • MarylandMD

    From Dr Mintz’s website:

    “Dr. Mintz has served as a speaker for GSK, Astra Zeneca, BMS, Pfizer, Sepracor and Takeda pharmaceuticals.  Dr. Mintz has served as an advisor for GSK, Astra Zeneca, Pfizer, Teva and Sepracor.”

    Yep.  Dr Mintz receives part of his income from drug companies, including AstraZeneca, the company that sponsored the “research” paper cited above!  Why am I not surprised?  The disclosure above should have been prominently displayed with the article.

    • Matthew Mintz

      Kevin of KevinMD, with my permission, copied verbatim this
      post from my blog at http://www.drmintz.com. My financial disclosures are clearly
      listed on my blog’s home page under “more about Dr. Mintz.” I consult
      and have spoken for the industry, and feel no shame in doing so. I am paid for
      services rendered, though at a rate far below what other consultants with
      similar education and expertise would get. I consult because I feel the
      industry will provide better products to patients with input from actual doctors.
      I speak because I think information about new medications is better when it
      comes from actual physicians.

      I try to minimize any bias by working with multiple drug
      companies on multiple diseases, so I am not beholden to any particular product.
      That being said, I certainly recognize that my work with industry can
      potentially bias my opinion.

      Being both in the “ivory tower” of an academic
      institution that tends to view the industry as evil, and having worked with
      many drug companies over the years, I have learned that the issue if
      pharmaceutical marketing is not black and white as some would like to make it
      out to be.  In addition to coming out
      with new products (all the generics we use today were once branded), the industry
      has (and has the potential to do more) done things to educate physicians and
      patients about appropriate prescribing. On the other hand, the industry
      marketing has also caused some expensive prescriptions to be written when a
      cheaper, safer generic would be more appropriate. There are countless examples
      of both.

      As stated in my closing paragraph,  information provided by drug companies is
      clearly biased and intended to increase sales, but that doesn’t mean that it is
      completely useless.  The question is
      whether you trust doctors to interpret and use drug company information in the
      best interest of the patient or whether you want to completely restrict access
      to information that drug reps provide because they can not be trusted to
      interpret and use the information appropriately. I put my trust in physicians.

      • MarylandMD

        You can say what you want, but a disclosure should have accompanied the article.

        Do the right thing: apologize for the oversight, and ask KevinMD to add the disclaimer to the article.

        Or do you not “put your trust in physicians” to give a fair reading to your article in light of such a disclaimer?

  • http://twitter.com/RichmondDoc Mark Ryan

    A couple of thoughts re: whether drug reps improve health care:

    –The author notes that physicians seeing more drug reps were more likely to prescribe a new diabetes medicine.  However, there is no evidence anywhere that I have seen that indicates that this very expensive new medicine actually makes a meaningful difference in diabetes care.  Are we to assume that uptake of a new, expensive, unproven therapy is a positive?  I would argue the opposite: drug rep contact promotes uses of untried therapies in place of long-established, inexpensive therapies.

    –The author also notes that physicians with more contact with drug reps were more likely to stop prescribing Vytorin and Avandia when evidence increased against their use.  However, the author does not note whether or not this was because “high access” physicians (who saw more drug reps) were more likely to have used these newer medications than their “low access” peers.  It could be that more drug rep contact led to more dubious/inappropriate use of the medicines, and these physicians had to backtrack more than their peers who did not buy in to the hype.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Drug representatives pointed out that a new product existed and were willing to provide access to data. It was still up to clinicians to research the product, due their own due diligence and decide whether to include the new product in their own formulary. It required reading peer reviewed journal articles, attending conferences and lectures where the product was discussed, reading pharmaceutical peer reviewed articles and reviews and subscribing to publications like the Medical Letter. You compared that data to the info you obtained from colleagues who used the medication. If it wasnt an orphan drug for a dread condition I preferred to allow one year of  use in the community to go by before I introduced a new drug to my patients.  Whether a pharmaceutical rep dropped off pens and pencils, brought in tuna fish sandwiches for lunch or held a dinner meeting with a speaker had little or no impact on the decision to use it or not contrary to what  many seem to think about us shallow physicians.
    Today there are few reps in my area and fewer looking to call on a small practice like mine. Do the experts and moralists prefer we learn about new medications from the glossy advertisements which help sustain our peer reviewed journals or from the TV ads at prime time? 

  • EmilyAnon

    Do these drug reps have any kind of medical training to be able to answer questions convincingly in proper medical language about the drug they are presenting.  Or are they just reciting from company literature.  What kind of education is required?

    • southerndoc1

      Experience as a college cheerleader is looked upon quite favorably.

  • Kerryanne8

    Physicians can learn about new evidence with regards to medications and other treatments friom much more trusted resources than drug reps. The reps are primarliy held accountable to selling drugs not improving patient health. Drug companies have successfully introduced drugs of little or no benefit into physican prescribing patterns at a huge cost to society. Even when they go generic, the harm remains as we see with the continued preference for poorly efficacious meds that carry high adverse med effect rates like gabapentin being prescribed off label for chronic pain. It is heartwarming to see the requests for better disclosure from KevinMD. You do owe us an apology and I will be less likley to read from this blog or recommend it to others if you do not. Free speech is great and Dr Mintz can say what he wants, but we have duped ourselves as a profession for too long and need to hold ourselves accountable to higher cognitive and ethical standards. A blog that does not recognize that will be more people magazine, and less New Yorker.

    • http://twitter.com/drmintz drmintz

      I am glad you brought up gabapentin. As a physician who has treated many patients with chronic pain, gabapentin has been extremely helpful to many patients where nothing but dangerous and addictive narcotics would work.  Now that we have more data, gabapentin or Lyrica has on label indications for pain and diabetic neuropathy. Also, gabapentin is generic, and now available to patients at a relatively low cost. 
      I don’t mean to imply that the pharmaceutical company is perfect or altruistic. They make useful products for profit.  However, I do not believe they or their representatives are all necessarily evil. I believe black and white opinions, blanket statements, stereotypes, and especially policies that restrict information have potentially negative consequences as this study demonstrated.
      Also, I am sorry if you felt duped by any lack of disclosure.  This post was copied by KevinMD directly from my blog where disclosure is displayed. I will ask that in the future that Kevin not only post the link to my blog but also place the link to my disclosures page to avoid this problem.

      • MarylandMD

        Painting restrictions against drug reps visiting physicians’ offices and hospitals as “policies that restrict information” is a complete farce.  The pharmaceutical industry is one of the most wealthy and powerful industries in the world, and they have their mouth on a bullhorn that spreads their “information” far and wide throughout medicine.  They can publish their research in reputable journals, they can print up pamphlets and mail them to me, they can put ads in the journals I read, they can put ads on TV, they can get my patients to bug me to prescribe their expensive medications, they have academic physicians act as shills who put their names on papers pre-written by the drug company, and they can sponsor bogus throwaway journals posing as scientific publications.  They can even have their minions run throughout the internet and promote weak studies as real science…

        But THEN the drug companies want to impose their drug reps on my office, and if I say no, they whine as if it is somehow a violation of the bill of rights.  They fall back on the fainting couch, shocked that I have the temerity to “restrict information.”  They cry as if somehow they can’t get their ideas across.  The poor, poor drug companies.

        Really, the act gets old after a while.

        • bhai_mian

          Nicely summarized.Couldn’t agree more

  • Elizabeth Belle

    As both a patient and an allied health worker, I’ve noticed some doctors are more prone to prescribing the latest and greatest medication than others. The nonprofit agency I once worked for had allowed drug reps for a period of time. The doctors weren’t particularly excited to see them – contacts were typically two minutes, sign off on receiving samples, and go back to seeing patients while a staff member put medications away. Admittedly the drug reps were easy on the eyes, but their presentations on drugs were liking in useful information. Eventually the director of the agency banned drug reps. While I missed that hot guy from Astra Zenica from time to time, I think a lot of people were pretty happy to not have their work interrupted. These doctors had been in the field for many years and had no issue with prescribing older drugs and Clozaril. Older drugs actually work pretty well and tend to be inexpensive. Minus tricyclic antidepressants, a lot of new psychiatric medications have their own set of safety problems (Diabetes, anyone?) or just aren’t anymore effective than things that have been out for awhile. I’m all for innovation, but “me-too” drugs get a bit ridiculous.

    I had a young doctor who was prone to prescribing new medications. That relationship didn’t last long. I didn’t have the desire to plunk down a hundred bucks a month for Saphris when I could pay four dollars a month for lithium. Some of the primary care physicians at the practice I go to can be just as irritating – some have commented on my medication list when I’ve gone in for stuff like a sore throat. They, too, have suggested Saphris. I found a psychiatrist who has been practicing for thirty years, got a lithium prescription, and have been content for awhile now. The old standbys are great.

    In regards to pharmaceutical advertising – the ubiquitous drug samples that many health centers are trying to avoid – are not the only means of getting low-cost medications. Patient assistance programs and vouchers for those of us who are insured are plentiful. I once had a coupon for a year’s worth of Lunesta for zero copay. The Lunesta ended up not working like every other sedating drug I’ve tried, but getting it for free was great. Had it worked, I would have been sucked into paying for it when the year was up. Those tricky, tricky bastards.

  • Lee Jarm

     For example, Singulair is a $3 billion dollar product for Merck and the single best selling controller medication for asthma, but it doesn’t work any better than over the counter generic medications for allergies, and the NIH guidelines consider Singulair alternative therapy for asthma (inhaled corticosteroids are first line, yet rarely prescribed). Marketing and subsequent sales of Singulair are probably not good for patients.  
    There are a couple of problems with the above sentence – we are mixing and matching diseases here – it is talked about first as a med for asthma – then the next sentence refers to the effectiveness of allergy meds – so are we saying that OTC allergy meds work for asthma?  I am pretty sure that inhaled corticosteroids are prescribed pretty frequently and, if not mistaken, one of the number one products for asthma is likely to be advair which may now be generic.  Point being just this two-sentence section of the opinion pieces is way off the mark leaving me to ask what else may be way off the mark?

    Drug costs are not the only contributing factor to the high cost of health care.  Defensive medicine may also play a role.  People allowing themselves to get fat and sick are also a problem as exemplified by the epidemic of diabetes which is typically associated with comorbid obesity, hypertension, hyperlipidemia, and theoretically could be a contributing factor to the need for joint replacement surgery because heavier bodies wear out joints faster.  It would interesting to figure out how much medical cost saving could be realized if people attempted to maintain their bodies properly.  One hope I’ve always had is that the same percentage of the American populace that participates in mainstream cultural phenomena such as American Idol were as interested in the topic of living a healthstyle.  If folks put as much energy into maintaining their bodies as they did following this type of stuff can you imagine how powerful that would be?

    How about looking to curb excessive eating, being mindful of the types of food one eats, and getting out for some exercise every once in a while.  Everyone is leading incredibly busy lives, myself included, but being in some semblance of physical shape makes it easier to get through the day and has plenty of upside – namely less visits to the doctor and less pills to take. 

    • Matthew Mintz

      Sorry if my Singulair example was not clear. Singualir is a treatment for both asthma and allergies. It is not a very effective for asthma and about as effective as over the counter antihistamines for allergies.  OTC antihistamines do not treat asthm (in fact, may even make asthma worse).
      Based on publicly accessble sources I am aware of, there is no way to separate which part of the $3 billion dollars spent on Singulair was for asthma, which was for allergies and which was for both. However, even if only 50% of Singulair is prescribed for asthma, it is probably too much since evidence shows it is not as effective as inhaled coriticosteroids and the guidelines indicate that it should only be considered alternative therapy. Advair is a combination of inhaled steroids and a long acting bronchodilator. It is indicated for moderate to severe asthma.  It is not, and will probably never go generic due to patents on inhalers and the more difficult approval process from the FDA for inhalers. (Since fluticasone is already generica and salmeterol will soon go generic, we will probably in the next few years see a low cost branded version of fluticasone/salmeterol, but this is not exactly the same thing as generic).  Inhaled corticosteroids, what every expert and guideline believes is the single most important treatment for asthma, by itself is comprises less than 20% of all asthma prescriptions.  Thus, a drug company promoting Singulair over inhaled corticosteroids may be doing harm. A drug company promoting inhlaed steroids as first line therapy is probably doing good. A drug company promoting combination therapy in mild asthma may also be doing harm.  This is why drug company promotions is so tricky.  It’s not black and white.  There is a lot of gray.
      Agree with you that defensive medicine and our unhealthy society contribute to our high medical costs. They also likely contribute far more to medical costs than any pharmaceutical promotions.  80% of all medications prescribed today are generics, and this number is increasing rapidly as some of the blockbuster drugs (Lipitor, Nexium and -wait for it- Singulair) come off patent.

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