When you’re sick 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, right? But there’s more going on behind the scenes than you may be aware of. Can you really trust that you’re being prescribed medicines based on the best independent information available?
In 2008 we surveyed 180 practising GPs about the extent of the pharmaceutical industry's influence in Australia. Our research showed then that drug companies have a major influence on prescribing, and there's no reason to expect that things have changed greatly since. There has been some tightening up in the Medicines Australia Code of Conduct that covers this area of medical practice, but nevertheless there’s strong evidence that pharmaceutical promotion isn't in the best interest of consumers.
The business of selling medicines
Pharmaceuticals are big business. Drug companies in Australia had a turnover of approximately $22 billion in 2009-10, and it's only been on the rise since then. Developing new drugs and conducting the various clinical trials required before they can be brought to market is expensive, so there's a 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.
Very little information is publicly available on the actual amount drug companies spend on marketing their wares, but some estimates suggest it’s more than they spend on research and development, which in 2008-09 was over a billion dollars.
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.
Doctors are the key targets of pharmaceutical marketing in Australia, because direct-to-consumer advertising is prohibited here and only doctors have the power to prescribe certain drugs.
How do GPs get the latest drug info?
GPs use a range of sources to inform their decision about whether or not to prescribe a new drug, including their colleagues' opinions, medical trade press such as Australian Doctor and Medical Observer, and the government-funded National Prescribing Service (NPS), an independent non-profit organisation for quality use of medicines.
Fortunately, according to our survey, the most commonly used information source is clinical evidence. However, the next most common source 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 the info it wants doctors to hear is often top of mind.
GPs’ contact with drug companies
We asked our survey participants — all practicing GPs — about their contact with drug companies.
They received seven 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, totalling at least two 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 visits 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.
They received 10 promotional mailings a week from drug companies, on average; 62% of the GPs we surveyed received 10 or more promotional mailings a week.
Forty per cent of GPs were sponsored by a drug company to attend a conference, seminar or training in Australia — and 3% overseas — in the previous 12 months.
Drug marketing is 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.
Under the influence
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 administers the Code of Conduct that sets the standard for the ethical marketing and promotion of prescription medicines. But it also represents the pharmaceutical industry in Australia, so there’s an obvious conflict of interest. The Code of Conduct does not cover generic and over-the-counter drugs, though these are probably not marketed as heavily to doctors, so are of less concern.
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.
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 online channels. 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.
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.
In an environment where information is updated rapidly and there's so much information 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 this information.
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.
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.
What do GPs think about drug marketing?
We asked our survey participants what they thought about the impact of contact with drug companies. The great majority agreed that it’s a good thing that drug companies provide promotional materials and visits about new drugs, and that they’d rather receive information from drug companies about new drugs in a marketing or promotional format than not receive it at all.
Only a minority felt that they were often pressured by drug company representatives into meeting with them, or that there aren’t enough sources of independent information on new drugs. And most didn't trust the information they receive from drug companies as much as from independent sources.
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.
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. Our survey found that one in eight GPs were unaware of the Code of Conduct.
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.
The Code doesn't allow promotional material such as pens and notepads to be branded with particular drug names, but does allow these items to be branded with the pharmaceutical company’s name.
Unfortunately, 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 so many companies promoting products, even this can really 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
Every year, drug companies spend several million dollars on events for doctors and other healthcare professionals. Thousands of these events – primarily focused on education – are held each year. As an example, in just six months of 2013, over $44 million was spent on over 16,000 educational events.
In August 2012, Medicines Australia established a working group to develop measures to improve transparency of payments between healthcare professionals and the pharmaceutical industry. One important step has been the regular reporting of educational events and their costs. This is a welcome step forward.
Under the provisions of the Code lavish meals are banned, and meetings must be in "venues that have suitable facilities to support the provision of education''. Reports in the past have revealed that some drug companies spend over $100 a head wining and dining (and, apparently, educating) GPs in swanky restaurants. There are moves to increase the transparency of transactions, although the proposed system of disclosure will be self-regulated by the industry and will allow doctors to opt out. Obviously, the ones whose accepted ''gifts'' start to look embarrassing will consider opting out in time too.
A mountain of promotion
As part of our 2008 survey we asked a GP with a practice in Sydney’s Northern Suburbs to record all contact with the drug industry he had in one month. He received:
- 11 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, this doctor said 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."
Our survey showed that pharmaceutical promotion is abundant, while objective, evidence-based information from independent organisations is underutilised in informing prescribing decisions.
We want the government to invest more money in the NPS independent drug detailing services and other activities, to promote the quality use of medicine.
Despite important steps forward, such as the transparency reporting mentioned above, we believe the Medicines Australia Code of Conduct still needs improvement. 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 2008 investigation, we 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.