Promotion overdose

How much influence do drug companies have on what your GP prescribes you?
 
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01 .Introduction

In brief

Our investigation into the promotion and marketing of pharmaceuticals highlights how:

  • GPs are bombarded with marketing and promotions from drug companies. This can influence their prescribing habits — and this isn’t in the best interest of consumers.
  • Pharmaceutical promotion isn’t effectively controlled by the industry-administered Code of Conduct. There needs to be more monitoring and enforcement of the Code by a body outside the pharmaceutical industry.
  • GPs receive far more information from drug companies than from independent sources. The government needs to increase funding to ensure GPs have better access to timely, objective information.

You’re sick, so you go to see your GP who prescribes you the best medication for your condition. You take it and you get better. That’s how things should work but what goes on behind the scenes? Can you trust you’re being prescribed medicines based on the best independent information available?

We surveyed 180 practicing GPs about the extent of industry influence in Australia today. Our research shows that drug companies have a major influence on prescribing, and there's strong evidence that pharmaceutical promotion isn't in the best interest of consumers.

Please note: this information was current as of August 2008 but is still a useful guide today.


The business of selling medicines

Pharmaceuticals are big business. Drug companies in Australia had a turnover of $18 billion in 2006-07. Developing new drugs and conducting the various clinical trials required before they can be brought to market is expensive, so there’s clear incentive for drug companies to market their drugs aggressively.

A company holds a patent over a medicine for up to 25 years before generic versions of the same drug can be manufactured by other producers and offered to consumers at a lower price. So it’s in the company’s interest to generate the highest possible return from their product before the patent expires.

Little information is publicly available on the actual amount drug companies spend on marketing drugs, but some estimates suggest it’s more than they spend on research and development.

Pharmaceutical marketing, like all marketing, is used to stimulate demand and increase the bottom line, so if it didn’t work, they wouldn’t do it. Because the information provided isn’t independent it can lead to inappropriate prescribing practices, which expose consumers to unnecessary risk. It can also increase the cost of the Pharmaceutical Benefits Scheme (PBS), which is funded by taxpayers.

Read on to find out how much contact our surveyed GPs had with drug companies and what they think about the information they receive.

 
 

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Doctors are the key targets of pharmaceutical marketing in Australia, because direct to consumer advertising is prohibited and because doctors have the power to prescribe drugs. We asked 180 GPs about the extent of industry influence in Australia today.

How do GPs get the latest drug info?

Our survey showed GPs use a range of sources to inform their decision about whether or not to prescribe a new drug, including their colleagues’ opinion, medical trade press such as Australian Doctor and Medical Observer and the government-funded National Prescribing Service (NPS), an independent nonprofit organisation for quality use of medicines.



According to our survey, the most commonly used information source, after clinical evidence, is drug companies or their reps — 73% of GPs surveyed use them as a source of information. And they’re the main source of information for 16% of GPs when they’re deciding whether or not to prescribe a new drug.

Given that the pharmaceutical industry reaches GPs through multiple avenues including representatives, direct mail, drug launch meetings, conferences, advertisements in journals and prescribing software, it’s not surprising that as an information source it’s top of mind.

GP contact with drug companies

We asked our survey participants — all practicing GPs — about their contact with drug companies.

  • They received 7 visits a month from drug reps , on average. One visit a week may be more than enough for a busy GP but 65% of GPs are seeing more than one drug rep a week, and 34% of GPs saw 10 or more reps in an average month — that’s at least two drug reps a week. Three per cent of those surveyed said they see 20 or more reps in one month.
  • The NPS provides independent information to doctors, including a small program of educational visiting by NPS drug detailers (the independent equivalent of drug company reps). But only half of the GPs we surveyed were aware of the NPS. And while 67% of GPs who were aware of this service actually saw NPS drug detailers, the frequency of visits from drug company reps was significantly greater as the chart below illustrates.
  • They received 10 promotional mailings a week from drug companies, on average. 62% of the GPs we surveyed receive 10 or more promotional mailings a week — ranging from two to four mailings every day. A mountain of promotion in just one month shows the sheer volume one GP received.
  • 40% of GPs were sponsored by a drug company to attend a conference, seminar or training in Australia — and 3% overseas — in the last 12 months.

Drug marketing known to influence prescribing

Contact with pharmaceutical companies is known to influence GP prescribing of new drugs, and not always in a way that’s beneficial to patients.

  • A UK survey of 1097 practitioners found that GPs who report weekly contact with drug reps are more likely than those who have less frequent contact to prescribe drugs without first checking for published clinical evidence of effectiveness.
  • Another study of 1019 GPs from the Netherlands found that more frequent visits from drug reps were associated with a lower quality of prescribing.
    When correctly prescribed, medicines provide enormous benefits. But used incorrectly or inappropriately, they have the potential to cause significant harm.

There are many players involved in the complex world of pharmaceutical production, from the development of a new drug through to a doctor prescribing it for you, and drug companies influence the players at every level — whether it be during research, licensing or promotion.

Medicines Australia

Medicines Australia administers the Code of Conduct that sets the standard for the ethical marketing and promotion of prescription medicines. It also represents the pharmaceutical industry in Australia, so there’s an obvious conflict of interest.

PBAC

The Pharmaceutical Benefits Advisory Committee decides which drugs are listed on the Pharmaceutical Benefits Scheme (PBS). The government subsidises the cost of the PBS-listed drug to the patient above the prescription charge or co-payment. More than two thirds of the GPs we surveyed use the PBS to assist them in making prescribing decisions. Drug companies can receive considerable financial benefits from having their products listed under the PBS, so they frequently lobby PBAC either directly or via patient groups.

Patients

Although drug companies can’t market prescription-only drugs to patients directly, information about these drugs still reaches them via the media, patient groups and information online. One GP told us, “I dislike greatly the [drug company] practice of promoting new drugs to the public via ‘news releases’ to the media. It may get patients asking their doctors for the drug, but is frustrating to deal with as a doctor trying to give a balanced view to the patient.” In our survey, 37% of GPs said patient requests help them decide whether or not to prescribe a new drug.

Patient groups

These represent the interests of patients suffering various illnesses and offer support services and information to patients, families and carers. But many groups receive funding from drug companies, and while the funding is much needed, it can compromise the independence of the group and the information it provides.

Prescribers

In an environment where information is updated rapidly and there’s so much doctors and healthcare professionals need to know, they have to rely on many sources to prescribe the right drug for you. In our survey, 73% of GPs said they use drug companies or their reps as a source of information.

Medical journals

Published research helps prescribers to choose treatment — 53% of the GPs we surveyed use medical journals such as the Medical Journal of Australia as a source of information. Clinical evidence is most often the main source of information for prescribing decisions made by the GPs we surveyed, but a large proportion of drug trials rely on industry funding, and not all trial results have to be published, so those with inconclusive or negative outcomes may not be seen.

TGA

The Therapeutic Goods Administration (TGA) is the government body responsible for issuing licences and ensuring that drugs and medical devices are safe. It assesses new drugs for quality, efficacy and safety and regulates the manufacture, research and marketing of drugs. The TGA is wholly funded by fees the industry pays to get its drugs approved, so it’s in the TGA’s interest to approve drugs, and in a timely fashion.

We asked our survey participants what they thought about the impact of contact with drug companies:

“It’s a good thing that drug companies provide promotional materials and visits about new drugs.”
  • 86% agree
  • 4% disagree
“I’d rather receive information from drug companies about new drugs in a marketing or promotional format than not receive it at all.”
  • 81% agree
  • 6% disagree
“I often feel pressured by drug company representatives into meeting with them.”
  • 35% agree
  • 41% disagree
“There aren’t enough sources of independent information on new drugs.”
  • 60% agree
  • 19% disagree
“I trust the information I receive from drug companies just as much as independent sources.”
  • 24% agree
  • 55% disagree

GPs in favour of drug company marketing

The survey results indicate that GPs are in favour of drug rep visits because it provides them with up-to-date information in a convenient way. As one GP told us: “[Drug company marketing is] often the only way you get information about new drugs in a timely fashion.”

They’re aware that drug companies are largely profit driven and not without bias: “[Drug companies] play an important role –– including awareness, displaying evidence etc. They’re probably not displaying the evidence without a bias but we as clinicians know and expect that.”

But the reality is GPs receive far more information from drug companies than from independent sources. “[Drug companies] really seem to be the only ones who get out there and do it. More NPS attention would be wonderful!” said one GP.

One in eight GPs unaware of Code of Conduct

Medicines Australia –– the body representing the pharmaceutical industry in Australia –– administers the Code of Conduct which sets the standard for the ethical marketing and promotion of medicines.

The Code sets out rules on pharmaceutical promotion in all forms, including the promotional material produced by drug companies (ads in electronic prescribing software packages, mailings, gifts and offers, for example), drug company reps, sponsorship (of patient groups, for example) and drug company involvement in educational events for healthcare professionals.

But our research found that one in eight GPs weren’t aware of the Code. And compared to its UK equivalent, the Code itself leaves a lot to be desired.

According to the UK’s code of practice, a rep shouldn’t visit a GP more than three times a year. And with many companies promoting products even this can add up. But Medicines Australia’s Code of Conduct is less specific. It simply says ‘Company representatives should ensure that the frequency, timing and duration of appointment, together with the manner in which they are made, are such as not to cause inconvenience to the healthcare professional.’

The UK code of practice also limits the number of mailings companies can send GPs about new drugs within six months of the drug’s launch, and within a year. The Australian Code covers the content of direct mail, but not the quantity.

Drug companies spend millions on events for doctors

Medicines Australia recently announced it was setting a ‘world-first in transparency’ by publishing the details of medical education events held or sponsored by its member companies. In just six months last year drug companies spent more than $30 million on over 14,000 events for doctors and other healthcare professionals.

Under the provisions of the Code lavish meals are banned and meetings ‘must be held in venues suitable for the attainment of the primary objective of enhancing medical knowledge’. But reports reveal that some drug companies are spending $100-plus-a-head wining and dining (and educating) GPs in swanky restaurants such as Jacques Reymond in Prahran, Stefano’s in Mildura, The Manse in North Adelaide and The Argo in South Yarra. There’s also concern about the independence of industry-sponsored seminars and the information doctors receive.

Companies found to have breached the Code face sanctions such as a fine (up to $200,000) or the printing of a corrective letter. Of the 20 complaints received and finalised in 2006/2007, 16 were fined to the tune of $695,000 –– that’s an average of just over $43,000 per fine.

CHOICE believes the Code of Conduct is ineffective, and Australia’s top consumer protection agency, the ACCC, shares our concerns. When it approved the current version of the code, Chairman Graeme Samuel said “it is unclear how effective [the Code] is in actually regulating drug companies’ conduct.”

We asked a GP with a practice in Sydney’s northern suburbs to record all contact with the drug industry he had during April. 

He received:

  • Promotional material11 direct visits from drug reps
  • 17 promotional drug brochures
  • six drug samples
  • five product information leaflets
  • three invitations to functions
  • three invitations to visit drug company websites
  • one patient information booklet
  • one consumer medicine information leaflet
  • one branded pen
  • one magnet
  • one mouse pad
  • one notepad
  • other bits and pieces

In total he was contacted by 18 different drug companies about 33 different drugs.

“Normally a lot of this stuff is filtered into the bin, but this exercise was surprising –– by collecting it over a month it was really interesting to see just how much we get,” he said.

While he doesn’t always refer to the promotions provided he’d rather receive the information than get nothing at all, and doesn’t think it influences his prescribing.

“I think most doctors are savvy enough to realise the drug companies need to market their products. I wouldn’t prescribe a drug if it didn’t benefit my patients or I felt it was inappropriate.”

More objective information needed

Our survey shows that pharmaceutical promotion is abundant while objective, evidence-based information from independent organisations is underutilised in informing prescribing decisions.

  • CHOICE wants the government to invest more money in the NPS independent drug detailing services and other activities to promote the quality use of medicine.
  • CHOICE believes the Medicines Australia Code of Conduct is ineffective. It needs to provide sufficient penalties to deter breaches and there needs to be more effective monitoring and enforcement of the Code. Ultimately it should be administered by a body that’s independent of the pharmaceutical industry.

CHOICE investigation of drug advertising

In a separate investigation, CHOICE examined advertising in medical trade press over a 12-month period, looking in detail at drugs used to treat high blood pressure. We found that promotion focused on medicines which are newer and more expensive but not necessarily more effective. Medicines which are out of patent are rarely promoted, even where their use is considered best practice. These findings demonstrate some of the biases which make pharmaceutical advertising a poor source of information for doctors.

See Drug advertising to read more about this investigation.

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