American College of Physicians: Internal Medicine — Doctors for Adults ®

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Butterflies, happy couples and prescription decisions

From the June ACP Observer, copyright 2007 by the American College of Physicians.

By Stacey Butterfield

SAN DIEGO—Think about how many hours you spend with one of your patients in a year, Matthew F. Hollon, FACP, instructed the audience at the "Best Drug or Best Advertised Drug?" session at Internal Medicine 2007.

Matthew F. Hollon, FACP


Matthew F. Hollon, FACP



While you may spend only a few 15-minute visits with a patient, "The average American sees as many as 16 hours of prescription drug advertisements per year," said Dr. Hollon.

The intensity of direct-to-consumer (DTC) advertising is one of the factors responsible for a recent dramatic rise in the number of prescriptions written in the U.S., Dr. Hollon said. Between 1994 and 2004, American use of prescription drugs increased by about 50%, and U.S. patients now take as much as twice as many prescriptions as residents of other industrialized countries.

"I don't think anybody questions that marketing has contributed to this," said Dr. Hollon, citing ads that have butterflies carrying sweet dreams, happy herpes couples frolicking on the beach, and other images that drive patient requests and growing sales for branded drugs.

Ads vs. evidence

Because advertisements rely almost entirely on emotional appeals (used in 95% of DTC commercials, according to a recent study), the scientific evidence for brand name drugs vs. generics is often missed by physicians, as well as patients, he said.

For example, atorvastatin (Lipitor) is currently the brand-name drug most frequently prescribed by internists, even though summary reports have shown that other, less expensive generic statins are equally effective for most patients.

Proponents of drug advertising argue that marketing informs patients about signs and symptoms of disease, encouraging them to seek care for undiagnosed problems and preventive treatment. "That is a haphazard way of bringing people to treatment," countered Dr. Hollon. "Marketing is never a force that draws people not to treat."

As a defense against prescription marketing, Dr. Hollon encourages physicians to concentrate on the number needed to treat in studies, as well as the cost of a drug. For example, a manufacturer-sponsored study suggests that valacyclovir (Valtrex) is effective in preventing herpes infections in the partners of infected patients. However, said Dr. Hollon, based on the number needed-to-treat, you would have to treat 24 people for eight months at a cost of $32,256 to prevent one infection.

Dr. Hollon also warned physicians to be wary about marketing that targets them specifically, noting studies showing that only about 25% of marketing claims presented to physicians are based on the gold standard of randomized controlled trials.

Plenty of sway

Even when physicians try to rely on evidence-based data, reading journals and searching PubMed, the manufacturers' positive publication bias will slant the findings, Dr. Hollon said. He cited two meta-analyses which found that studies funded by industry are four times more likely than other research to report positive conclusions.

Continuing medical education (CME) and ghostwriting are two other effective means by which drug manufacturers influence prescribing habits, Dr. Hollon noted. Industry funding for CME has been steadily increasing in recent years, hitting $1.35 billion in 2005.

"This is leading us to prescribe in a way that runs counter to our responsibilities," Dr. Hollon said. "I think avarice, of which drug marketing is symptomatic, is probably the most overlooked problem in the U.S. health care system today."

Physicians can combat the problem by maintaining "a fence between our practices and the pharmaceutical industry," he said. He urged physicians to limit their contact with pharma reps—by not accepting gifts, including lunch, and not using samples. Studies have shown a direct relationship between physician contacts with the pharmaceutical industry—including sample use—and prescribing habits.

If physicians make an effort to prescribe fewer drugs and more generics and use evidence-based resources to support their decisions, patients will go along in most cases despite advertising pressure, Dr. Hollon said. Especially after the Vioxx recall, "Patients appreciate that these drugs have potentially serious consequences."

Congress has also taken note of the consequences of drug advertising, with proposed legislation to enforce a moratorium on direct-to-consumer advertising of newly approved drugs. Dr. Hollon urged internists to get involved on the political side of the issue by advocating for more independent funding of CME and research, and greater disclosure of pharmaceutical influences.

Pharmaceutical companies will always be in the business of selling more drugs, so physicians need to be aware of how that goal conflicts with their own, he said. "My business, our business, is patient well-being."

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