The Pharma-psychiatry tango: necessary evil or dance with the devil?

This is a follow-up to a recent post on why I think direct-to-consumer advertising of prescription drugs is wrong. This post is going to look specifically at marketing by drug companies aimed at health care professionals.  Primarily this marketing targets physicians, since they’re doing the majority of the prescribing.

There are multiple different forms this marketing can take. One example is the drug reps that go around to medical offices. They’ll schmooze with physicians and do things like provide written information about the drug, give samples, and hand out assorted merch like pens and notepads so that their product name is in front of the prescriber’s eyeballs more often.  While drug reps receive training on their particular set of drugs, in most cases they don’t have health professional training.

Drug companies will also sponsor educational activities. They may sponsor a hospital’s departmental grand rounds, providing free lunch for an event that would have gone ahead with or without sponsorship.  A drug rep would often be there, happy for the opportunity to schmooze.

A pharmaceutical company might also bring in a speaker, typically a psychiatrist, to give a talk about the company’ drug.  This might be a local psychiatrist who the audience will already know and presumably trust, or someone who’s brought in from elsewhere and has strong credentials.  Typically there is food involved, because who doesn’t love free food, right?

Another strategy is to sponsor continuing education activities that are geared at a broader audience, which may take the form of a free webinar.  All health professionals have some form of continuing education requirements they have to meet every year, and the opportunity to get free continuing education hours can be attractive.

There are pros and cons with all of this.  Health professionals do need to learn about new drugs that are on the market.  Just because a talk is being sponsored by  a drug company does not necessarily mean that the speaker will be heavily biased.  Sometimes the featured speakers at drug company sponsored events are widely recognized as experts in their field.

Sometimes health care organizations will put restrictions on sponsored activities occurring onsite.  I remember earlier in my career going to grand rounds at the hospital I worked at and munching on drug company-funded lunch.  A few years later the healthy authority I worked at put the kibosh on sponsored events at any of the health authority’s sites.  I’ve been to a couple drug company-sponsored dinners, one with a speaker they’d brought in from elsewhere, and one with a local psychiatrist I really respected.  I fairly regularly do continuing education webinars that are free because of drug company sponsorship.  I like to think that I’m enough of an informed consumer of information to be able to evaluate what’s being given to me, and recognize that, sponsored or not, one particular talk is never going to give me the whole picture on the topic.

This is pure speculation, but I wonder if the most potential iffy part of what I’ve talked about so far is drug reps going into family doctors’ offices.  Psychiatrists are only really keeping up to date about new psychiatry meds, and the same is true with other specialties. General practitioners often have little free time, and they have to learn about a much wider range of new drugs.  Chances are, they’re going to be relying a little more on what they’re getting from drug reps.  Still, a health professional should have the background information to put new info from drug reps into a proper context, something that’s just not possible when it comes to direct-to-consumer advertising.

All of this is small potatoes compared to the potential for corruption at higher levels.  Drug companies’ primary objective is to generate profit for their shareholders.  Yes, it would be nice if they were concerned about the wellbeing of the people taking their drugs, but that’s not the reality of capitalism.  It may not be very nice, but it is what it is, and there’s no point pretending otherwise.  The problem really comes if the drug companies are getting in bed with regulators or with major medical organizations.  In an ideal world, the drug companies would be at not just arm’s length from regulators like the U.S. Food and Drug Administration (FDA), but more like football field length.  Of course, we don’t live in an ideal world, and that kind of thing can be difficult to enforce.  What if John Smith worked at the FDA for years, and decides he’s ready to make some big bucks and takes a position at a drug company.  It’s pretty tough to regulate away that influence John Smith is still going to have with all his old buddies at the FDA.  It’s the old boys’ club at its finest.

Concerns have been raised about drug companies having undue influence with the American Psychiatric Association’s committee responsible for developing the most recent edition of the Diagnostic and Statistical Manual (DSM-5).  The fact that the people on the committee have received either research funding or speaking fees from drug company doesn’t inherently mean they’re biased.  Often, prominent figures within a specialty field are particularly sought after by drug companies for that kind of thing; it doesn’t mean they’re necessarily drug company flunkies.  Yet the old boys’ club appearance is still there.

I think sometimes arguments in that area go a bit too far and throw the baby out with the bathwater, so to speak.  Sometimes GlaxoSmithKline, the makes of Paxil, are accused of inventing social anxiety disorder as a way to sell more Paxil.  Whatever role they did or did not play in the inclusion of social anxiety disorder in the DSM, there are many sufferers who would attest that social anxiety disorder is all too real and all too debilitating.

Of all of these areas, the relationships between drug companies and regulators like the FDA are most likely to cause damage, and that damage can occur on a very broad scale.  If alarming research results are being hushed up because the drug companies are too cozy with the FDA, that’s dangerous.  What is the answer, though?  I wish I knew.

 

psych meds made simple

 

My first book, Psych Meds Made Simple: How & Why They Do What They Do, is now available on Amazon as an ebook or paperback.  It’s everything you didn’t realize you wanted to know about medications!

Should pharmaceutical advertising be banned?

In many countries, direct to consumer advertising (DTCA) of prescription drugs is either prohibited or tightly restricted.  The United States is a notable exception, along with New Zealand.  For tv ads, the standard pattern is to talk about the illness, talk about the amazing benefits of the drug, and then provide the required long list of side effects in an upbeat tone of voice while cheerful music plays and people are shown happily living their wonderful lives.  The ad closes with something along the lines of “ask you doctor if _____ is right for you”.  If you haven’t seen one of these ads before, there are a couple of examples at the end of this post.

Drug company marketing to health care providers is a related but distinct issue that’s deserving of its own post, so I’ll set it aside for the sake of this post and focus solely on issues around DTCA.

Wikipedia cites a study that reported expenditures in the U.S. grew from $1.1 billion in 1997 to $4.2 billion in 2005.  In the last ten years, four major pharmaceutical companies have reached settlements of greater than $1 billion with the U.S. Food and Drug Administration (FDA) over allegations of illegal marketing.  Psychiatric medications were among the drugs involved in all of these settlements.  Prescription drug ads do not need to be pre-screened by the FDA before they can be printed or broadcast, so even if an ad is later found to be in violation of the laws, it will have already been seen by large numbers of consumers.

In Canada there’s a loophole of sorts that allows marketing of drugs as long as there’s no mention of what medical condition the drug is used for.  In 2006 the independent Health Council of Canada published a report looking at at the public health implications associated with direct to consumer advertising of prescription drugs.  They recommended closing this loophole and prohibiting all DTCA of prescription drugs.

What are the potential benefits?

Clearly the winner here is the drug companies themselves.  But what are the supposed benefits to consumers from this kind of advertising?  According to the Health Council of Canada report, some of the benefits that are claimed are consumer education, increased autonomy in health care decision making, earlier diagnosis of illnesses, and increased medication compliance.

Public service announcements may be educational, but commercial advertisements are not.  Whether its drugs or laundry detergent, the purpose is to sell a product.  Any information that is gained through commercial advertising is only to support the primary sales purpose and will likely heavily biased.

In terms of autonomy, I’m not sure that going to the doctor and requesting drug X truly represents autonomous decision making.  In fact, if patients are forming spurious judgments about the state of their health and the treatment they need, they lose the true autonomy that comes from getting a well-reason diagnosis and being presented with appropriate treatment options in a way that allows them to make informed decisions.

As for earlier diagnosis, this brings to mind issues with misleading Paxil advertising that essentially claimed that everyone (and probably their dog too) had social anxiety disorder and needed to be medicated.  Social anxiety is a very real and potentially debilitating condition, but the makers of Paxil were casting a much wider net than that.  People who are unwell will make their own decisions about whether or not to seek medical help, but there’s no need for the masses to go rushing to their doctor asking for drugs because pharmaceutical marketing campaigns told them they were most likely sick.

I fail to see how compliance could be improved, unless the line of thinking goes that if a patient asks their doctor for drug X (whether they need it or not), they’re more likely to take drug X?  Or does seeing a Pristiq ad on tv remind someone that they forgot to take their medication that morning?  It all seems like a rather flimsy argument.

What are the potential harms?

According to studies cited in the Health Council of Canada report, direct-to-consumer advertising influences both patient demand and physician prescribing.  A study of general practitioners in New Zealand found that almost 70% felt pressured by their patients to prescribe medications.  A study conducted in the U.S. and Canada found that when patients went into an appointment requesting a drug, they were 17 times more likely to be prescribed a drug by the end of that appointment.

Pharmaceutical ads that claim Drug X is wonderful for condition Y are targeting consumers who likely don’t have the medical knowledge base to determine whether Drug X is in any way appropriate for them, and may have no idea if they actually have condition Y or not.  If they go to their doctor requesting Drug X, a prescriber may order Drug X rather than the more appropriate Drug Z in order to appease the patient, or they may try to appease the patient by giving them Drug X even though they don’t actually meet the full diagnostic criteria for condition Y.  While this may seem like poor practice on the part of physicians, it’s certainly not unheard of.  As an example, overprescribing of antibiotics is driven in part by patients who are going in to see their doctor and demanding antibiotics even though they most likely have a viral illness that antibiotics will do nothing for.  Doctors are busy enough without having to spend time trying to re-educate patients who have been misinformed by drug company ads.

 

Decisions about an individual’s medication treatment should be made by that person and their healthcare providers based on their specific health concerns.  Pharmaceutical companies should not have the opportunity to interfere in that process.  The whole reason drugs are prescription only is that medical professionals need to determine whether or not they are appropriate for a given patient.  If patients are going into their medical appointments having actually researched treatment options, that’s great, but watching a pharmaceutical ad is not research.  It’s a sales pitch.

A 2013 opinion piece in the New York Times says that “biased pill-pushing messages are a public health menace.”  I agree, and it would be nice to see regulators in the U.S. and New Zealand stand up to the powerful pharmaceutical lobby and put an end to direct to consumer advertising.  Sales tactics have no place in mental health care.

 

What are your thoughts?

 

Sample ads posted on Youtube:

 

psych meds made simple

 

My first book, Psych Meds Made Simple: How & Why They Do What They Do, is now available on Amazon as an ebook or paperback.  It’s everything you didn’t realize you wanted to know about medications!

Where did our meds go?

pills spilling out of a bottle

nosheep on Pixabay

I recently saw an article on the Canadian news site cbc.ca.  It warned that there was a manufacturer’s shortage of the antidepressant bupropion, both brand name and generic.   No reason was given for the shortage, and Health Canada doesn’t require this information.  The brand name manufacturer told CBC that the shortage had been resolved and the medication would be appearing in pharmacies “imminently”.  Earlier this year, there was a Canadian shortage of Epi-Pens, the life-saving medication to treat anaphylaxis.

Canada is certainly not the only country to have drug shortages.  The blog Vision of the Night has mentioned shortages of the antidepressant clomipramine in the UK.  A 2017 article in The Lancet said that the antipsychotic haloperidol was one of the most commonly shorted medications in South Africa.  A 2017 study in the Saudi Pharmaceutical Journal found that over half of the community pharmacies surveyed had shortages of  psychiatric medications including amitriptyline, aripiprazole, bupropion, buspirone, duloxetine, haloperidol, and lithium.

Unlike Health Canada, the Food and Drug Administration (FDA) in the United States requires that manufacturers report the reasons for drug shortages.  2017 statistics from the FDA show that the reasons given were manufacturing (30%), supply/demand (8%), natural disaster (3%), raw material (2%), discontinuation (2%), and the most common reason unknown (53%).  It seems rather unlikely that more than half the time someone suddenly woke up at the factory and realized they’d stopped producing pills, and called the Ghostbusters to come investigate.

Sarcasm aside, it doesn’t seem as though the pharmaceutical industry is very motivated to address this issue.  Presumably there is a business case for this, although at first glance it would seem that the best way to make money is to actually sell the product.  While I’m not strongly anti-Pharma overall, the frequency at which drug shortages are occurring has a rather unpleasant smell to it.

Drug shortages impact health conditions across the spectrum, but I think the potential impact of psychiatric medication shortages is quite high.  Medications are often grouped into classes based on their mechanism of action, such as selective serotonin reuptake inhibitors (SSRIs).  For some classes of medication, a person can switch between drugs in the same class without much difficulty.  It’s not that simple with psychiatric meds.  Someone might respond well to one SSRI, but have poor effect and considerable side effects with another.  For some psychiatric medications, like bupropion, mirtazapine, and lithium, there are no other medications that have exactly the same mechanism of action.

Aside from hoping that our meds won’t be shorted, there’s not a lot we can do.  If you hear about a shortage, coverage issues can make it hard to follow the example of Elaine on Seinfeld in her quest to buy up every remaining Today sponge from every pharmacy in the area.  I don’t know what the answer, but I think our national health regulators need to lean on Big Pharma a little harder than they’re doing right now.

Have you ever experienced a shortage of your medication?  How did you manage?