John D. Abramson was practising family medicine in Hamilton,
Mass., he prided himself on how conscientiously he selected
the drugs that he prescribed. He closely followed pharmaceutical
research. He kept track of the latest medical guidelines.
And he maintained his distance when company salespeople, with
promotional pitches at the ready, appeared at the practice
that Abramson shared with several colleagues during the 1980s
and 1990s. He typically didn't speak to pharmaceutical sales
agents, although he did let them leave behind free samples
of drugs that their companies sold.
Abramson knew that the companies wanted him and his colleagues
to prescribe new and often expensive drugs rather than their
older, less costly alternatives. But he saw no harm in stockpiling
the freebies and banding them out to patients who were without
health insurance and unable to buy drugs on their own.
"I thought I was being Robin Hood," Abramson says.
Before long, however, he grew so familiar with administering
the free drugs that he found himself writing prescriptions
for the same substances for insured patients, whose coverage
would then pay for the medications. For pharmaceutical companies,
Abramson's behavior meant new customers. "That's what
they wanted," he says. "They were playing me like
Abramson left medical practice nearly 4 years ago to write
Overdosed America: The Broken Promise of American Medicine
(2004, HarperCollins), which trains a critical eye on pharmaceutical
companies' influence on medical research and practice. He
now teaches at Harvard Medical School.
At least two pharmaceutical marketing strategies converge
to alter doctors' prescribing habits. On one hand, sales representatives
target physicians with visits and samples, and ads tout drugs
in journals. On the other, mass media advertisements urge
people to ask their doctors about specific brand-name medications.
This direct-to-consumer (DTC) advertising, which is not permitted
in Europe and strictly limited in Canada, has in the past
decade grown into a multibillion-dollar industry in the United
Pharmaceutical companies and some health researchers say
that promotional activities make doctors and patients better
aware of available treatments. Other researchers and consumer
advocates counter that the ads and giveaways goad doctors
into giving patients drugs that may be unnecessarily expensive
or sub-optimal in effect.
If nothing else, says internist Richard L. Kravitz of the
University of Caiifornia, Davis, the consequence of drug promotions
is that the medicines that are most profitable for drug companies
end up being overprescribed.
ASK THE DOCTORS Eighteen actors were dispersed to physicians'
offices by Kravitz and his colleagues during 2003 and 2004.
Such actors are known in the medical literature as standardized
patients; they aren't sick, but they're trained to describe
certain realistic sets of symptoms. Medical schools use standardized
patients to test students' diagnostic skills.
Kravitz had a different test in mind. He and his fellow investigators
instructed the actors not only to fake specific symptoms but
also, in some cases, to ask for a particular drug or a general
class of drugs. The researchers wanted to know how physicians
would respond to supposedly media-driven inquiries. The researchers
recruited 152 family physicians and general internists practicing
in San Francisco, Sacramento, Calif., or Rochester, N.Y. Each
participating doctor was told that he or she would be sent
two standardized patients during the next year. But the doctors
weren't told the study's purpose or how to identify the fake
The actors then scheduled appointments with the physicians.
Once in a participating doctor's office, some of the fake
patients described symptoms of major depression, a long-lasting
mood disorder that's often treated with antidepressant medications.
Other standardized patients complained of symptoms of a less
serious psychiatric ailment, which is called adjustment disorder
with depressed mood. This condition generally disappears within
months without medication.
When standardized patients faking major depression didn't
specifically request an antidepressant, 31 percent received
a drug prescription. However, when others claimed that a television
show about depression had encouraged them to seek drug treatment,
76 percent received a prescription of some kind.
In those two groups, about 6 percent of the actors who received
a prescription got one for paroxetine (Paxil), one of several
drugs in a class frequently used to treat major depression.
However, when members of a third group reporting identical
symptoms asked specifically for Paxil, saying that they had
seen it advertised on television, more than half the resulting
prescriptions were for that drug.
In standardized patients who reported symptoms of adjustment
disorder and didn't raise the subject of antidepressant drugs,
just 1 in 10 got any medication. But nearly half of the actors
who asked for medication got it. Most who asked for Paxil
walked out with a prescription for that drug, while most who
made a nonspecific request were prescribed some other antidepressant.
Ads aren't necessarily having a wholly negative influence,
Kravitz and his colleagues note. "Direct-to-consumer
advertising may have competing effects on quality, potentially
both averting underuse and promoting overuse" of prescription
drugs, the researchers conclude in the April 27 Journal of
the American Medical Association.
"It's probably promoted use of expensive, brand-name
medications, which are more likely to be heavily promoted
... than less expensive generic alternatives," Kravitz
Other studies support the notion that DTC ads translate into
prescriptions. One 2003 investigation found that people visiting
doctors' offices in Sacramento, were twice as likely to request
a new prescription, and twice as likely to receive one, as
were similar patients in Vancouver, British Columbia. The
U.S. patients were nearly six times as likely as were their
Canadian counterparts to have recently seen ads for most of
the half-dozen prescription drugs that the study examined,
reported a team of Canadian and U.S. researchers, including
In a more recent survey of 643 U.S. physicians, many attributed
a double-edged effect to pharmaceutical ads. Nearly three-quarters
of the doctors said that they believe that DTC ads inform
people about medicines that might help them, and two-thirds
of the doctors said that ads improve dialogue. One quarter
of the ad-initiated doctor-patient conversations lead to diagnoses
of treatable problems that might have gone undetected, the
On the other hand, four-fifths of the survey respondents
said that ads encourage patients to seek unnecessary treatments
and don't fully convey the therapies' risks. Joel S. Weissman
of Harvard Medical School and his colleagues posted the results
of the survey on the Web site of Health Affairs in April 2004.
The pharmaceutical industry says that it recognizes its responsibility
to be candid about drug benefits and risks. "Our communication
with patients should really be thought of as direct-to-consumer
education;' said Johnson & Johnson's chief executive officer
William C. Weldon at a March meeting of the Pharmaceutical
Research and Manufacturers of America (PhRMA) in Washington,
D.C. "The framework we call DTC advertising may inadvertently
minimize the importance and power of medicines and their risks,"
In the months since the PhRMA meeting, where Weldon was elected
to head the trade association's board of directors, companies
such as Johnson & Johnson and AstraZeneca have introduced
new television ads that include recitations of circumstances
in which patients shouldn't use the companies' products. Last
week, PhRMA'S board gave preliminary approval to a set of
advertising principles that encourage ads that "reflect
balance between risks and benefits."
The new advertising trend has a backdrop of recent concerns
about drug safety. Since last September, when the sudden recall
of the pain medication Vioxx raised congressional concerns
(SN: 2/5/05, p. 90), the Food and Drug Administration has
sent numerous warning letters to drug manufacturers.
In April, for example, FDA ordered an ad for the impotence
drug Levitra off the air because the agency said that it neglected
to explain potential side effects. Another letter went to
AstraZeneca in December, warning the London-based company
that newspaper ads about Crestor contained "false and
misleading" statements about risks associated with that