Doctors and Drug Ads

Washington Post staff writers Shankar Vedantam and Marc Kaufman were online Wednesday, April 27, at 2 p.m. ET to discuss Wednesday's article, " Doctors Influenced By Mention Of Drug Ads ."

Vedantam and Kaufman report:

"Actors pretending to be patients with symptoms of stress and fatigue were five times as likely to walk out of doctors' offices with a prescription when they mentioned seeing an ad for the heavily promoted antidepressant Paxil, according an unusual study being published today.

The study employed an elaborate ruse -- sending actors with fake symptoms into 152 doctors' offices to see whether they would get prescriptions. Most who did not report symptoms of depression were not given medications, but when they asked for Paxil, 55 percent were given prescriptions, and 50 percent received diagnoses of depression."

The study adds fuel to the growing controversy over the estimated $4 billion a year the drug industry spends on such advertising. Many public health advocates have long complained about ads showing happy people whose lives were changed by a drug, and now voices in Congress, the Food and Drug Administration and even the pharmaceutical industry are asking whether things have gone too far."

Nearly every industrialized country bans such advertising, and physicians said the new study raises new questions."

A transcript follows.

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Denver, Colo.: Who funded this research? What was the funding source's interest in the results?

Would the study have been more valid had the "patients" (in a control group) mentioned another medication for yet another malady? If a patient, for example, had complained of indigestion and heartburn and mentioned "the purple pill," would the physician have prescribed it, instead, or as well??

What are the analytical (or?) processes used by physicians in making a diagnosis?

from a doctor, who is not a physician

Shankar Vedantam: Greetings all. Thanks for joining us for this online chat. I will handle the first few questions and then turn the ball over to my co-author Marc Kaufman. I'm juggling a couple of things, and may be back later.

Excellent questions here: The research was funded by the National Institute of Mental Health, which is part of the federal National Institutes of Health.

It is not absolutely clear what would happen if we weren't talking about depression but about allergies or heartburn. At an intuitive level, it would seem the same effects would occur, but that will have to be tested.

Physicians are supposed to use a checklist before making a diagnosis of depression; the checklist involves the number of symptoms, their severity, length and the extent to which they interfere with functioning.

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Washington, D.C.: I am wondering about how accurate the study is ... first, the use of actors seems strange. Also, are 152 people enough to get a real idea of whether or not there's a problem?

Shankar Vedantam: The use of actors or standardized patients allowed the researchers to make sure that doctors were hearing the same symptoms across the entire study. That is the way you can compare apples to apples - and make sure the effect you are seeing can be tied to the ads, not to differences in patient presentation.

As the story noted, the study was published in a highly regarded peer reviewed journal, The Journal of the American Medical Association, and the results were proven to be statistically significant.

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Chicago, Ill.: I'm a nurse practitioner. My husband is constantly turning to me during ads for any and all meds and saying "what's that for?" How effective are the ads that tell you to ask your doctor but don't really tell you what patients they are useful for? By the way, I work in pain management and isn't it true Vioxx was one of the first drugs to be marketed primarily to pts not Nps and Mds and that approach made them Huge money? I know that when I get a good clinical pitch from a drug rep, I listen and it can influence my practice. Ads on TV and pt requests don't really. But I will listen if a pt asks me about a drug they heard about or read about, and if they seem worth a try, have prescribed them.

Shankar Vedantam: The purpose of these ads is to get a conversation going between patients and doctors. From the point of view of undertreated diseases, that is a great thing. From the point of view of people going in seeking care that they don't need, it seems to result in overdiagnosis and overtreatment. The pharmaceutical industry calls the ads educational, but of course the point of most of these ads is to highlight a particular product.

As the story notes:

"The study found that the ads did help patients with a stigmatized illness such as depression get treatment, even as they prompted overmedication of people who did not need treatment. Such marketing in effect exploits the diagnostic gray zone that characterizes many conditions in medicine, including heartburn, arthritis and allergies."

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Southern Maryland: I've long suspected that the advertising and promotion of prescription drugs may be a big factor in the rising costs of the drugs. Is there any evidence for this?

One time on vacation, one of my children contracted pink eye and we went to the local doctor. We waited for almost an hour and a half before seeing the doctor. While we were waiting, a man in a suit carrying a briefcase shows up, and the receptionist shows him right in to see the doctor. My wife turns to me and says, "Drug rep."

Marc Kaufman: Yes, there is some respected data suggesting that DTC advertising does indeed increase the nation's healthcare budget. The National Institute for Health Care Management did studies a few years ago that found a significant correlation between advertising and sales of new and more expensive versions of drugs. Some will argue that the newer drugs are better or more convenient, but others say they are often me-too drugs with little additional value and sometimes don't have a proven track record. Yet people want them, and that desire is to some extent fanned by the advertising.

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Arlington, Va.: Do you think the AMA and other organizations will attempt to educate doctors about biases resulting from pharmaceutical advertising? Also, is there anyone on Capitol Hill who cares enough about this issue to do something?

Shankar Vedantam: The AMA is interested in this issue, as are Congress and even some voices within the pharmaceutical industry. There have been hearings where this issue has come up, such as the recent Education, Labor and Pensions Committee hearing on March 1, 2005. There are clearly complicated issues about commercial speech involved, and there is also a proposal by the industry to come up with a voluntary code of conduct regarding ads. It remains to be seen what such a code would look like, and whether people believe that the industry can police itself. Here's where the Pharmaceutical Research and Manufacturers of America stands on the issue.

"We can do a much better job with the advertising," agreed W.J. "Billy" Tauzin, president and chief executive of the Pharmaceutical Research and Manufacturers of America (PhRMA). "The ads can do a great job making sure people who need medications and are undertreated get help. We can also make it clear that a particular product is meant for people with this particular problem and for those people only."

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Hartford, Conn.: The issue of drug advertising needs to be looked at from an additional, broader perspective. How much do pharmaceutical companies spend on marketing? How does that compare to what they spend on R and D? And what do the costs of marketing do to the cost of health care? I think it's insane that a sizeable chunk of our health insurance premiums pays, not for health care, but for advertising and lobbying.

Marc Kaufman: I've seen recent estimates that the overall advertising and promotion budgets for big Pharma are greater than the overall budgets for research and development. Given the fact that the drug companies often say that their high prices in the U.S. are needed to pay for research into innovative new drugs, the heavy expenditures on marketing rub some people the wrong way. Others will argue, however, that the advertising expenses represent the company's assessment of how to remain profitable and productive. Most of the advertising is directed at doctors rather than patients, but I think it's fair to say that the 15-20 percent of drug advertising that goes to direct-to-consumer pitches is the most controversial.

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Alexandria, Va.: This is a little off topic but does W.J. "Billy" Tauzin insist that his name be published in this manner? I never see him referred to as Billy Tauzin or W.J. Tauzin.

Shankar Vedantam: This has more to do with newspaper style than with Mr Tauzin's preferences. His press release yesterday called him Billy Tauzin. The Post's style protocols dictated how we published the name. Thanks for the question!

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Meshoppen, Pa.: What indications are there, if any, that PhRMA Pres. Billy Tauzin -- in his former capacity as the powerful chairman of the House Commerce Committee -- helped pave the way for the ad-driven overprescribing of pharmaceuticals?

Marc Kaufman: I don't think that Tauzin was an especially a major player regarding DTC advertising when he was in Congress, except as a leader of the Republicans--who generally favored the idea. But the real impetus behind DTC was a series of Supreme Court decisions regarding commercial speech, which gave it greater protection than it had in the past. As a result, the FDA was faced in 1997 with a request to allow DTC on television and a legal climate that said it was probably unconstitutional to say no.

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Burke, Va.: How much do drug makers spend on advertising as opposed to R and D for new drugs.

How many new drugs are sent to the market because the patent has run out on the old one?

Marc Kaufman: Marcia Angell, the former editor of the New England Journal of Medicine and author of "The Truth About Drug Companies," writes that in 1990, 36 percent of sales revenue in the top ten drug companies went to marketing and administration, while 11 percent went to R and D. She writes the R and D went up to 14 percent in 2000, but is still much smaller than promotion. To me, one of the most amazing statistics regarding drug trends is that about half of the world's $500 billion in drug sales occurs in the U.S. Since we're something like 5% of the world population, that suggests something remarkable is going on, and it seems fair to suggest that some of the vast usage here may well be related to DTC advertising.

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Marc Kaufman: Thanks for your questions. The FDA and the drug industry are actively grappling with the issues surround DTC now, so I suspect there will be more news on this subject in the future.

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