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Prohibition of drug advertising to promote health

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New Zealand and the US are notable for allowing consumers to receive direct mail for medicines, but the impact on patients and doctors is negative and should be limited, writes Joel Lexchin of York University in Toronto

Promoting new drugs is effective, but often leads to inappropriate prescriptions. To protect the health of their citizens, countries should ban this.

Many, but certainly not all, drugs are extremely useful in controlling symptoms and preventing or curing diseases. The companies that make them are generally expected to make a profit, increase sales with higher prices, or larger sales volumes.

But almost all wealthy developed countries impose price restrictions on drugs, so this option is not always available. And so companies spend huge sums of money on advertising to increase sales. In 2016 alone, US $ 20 billion was spent persuading doctors to prescribe branded drugs.

The funding is not only aimed at doctors. Both the US and New Zealand allow direct mail to consumers, with the name of a drug appearing in a single advertisement alongside the problem it is designed to treat. Businesses in the US spend nearly $ 10 billion annually promoting medicines to consumers.

Evidence shows that advertising affects patients. Three-quarters of respondents in an American survey said they would likely ask a health care provider about advertised drugs, and 26 percent said they had already done so. Almost a quarter would see another doctor if their doctor refused to prescribe a branded drug they wanted. This influence continues, although accumulated evidence strongly suggests that the information patients receive through advertising does not result in a better prescribing – such advertising has more negative than positive consequences.

A randomized controlled trial, the strongest form of evidence, examined the impact of patient inquiries about the antidepressant paroxetine using actors who pretended to have standard symptoms. These pseudopatients described either symptoms of depression or a less severe transient illness called an “adjustment disorder” that was related to life problems and did not require antidepressant treatment. If patients requested an advertised brand-name drug, they were equally likely to receive an antidepressant, regardless of whether they had symptoms of depression or an adjustment disorder.

A systematic review of 20 studies examining consumer advertising and testosterone replacement use concluded that advertising was linked to prescribing testosterone replacement therapy without adequate testing. Direct marketing to consumers can also promote overdiagnosis of high cholesterol and over-therapy in populations where the risks of statin use may outweigh the potential benefits.

Canada shares general and medical cultural similarities with the United States, but does not allow direct mail to consumers, which makes it a useful comparison. However, some U.S. media outlets are reaching Canadian audiences with advertisements for prescription drugs, which are illegal under Canadian law. Barbara Mintzes and her colleagues surveyed patients and doctors in Vancouver, Canada and Sacramento, USA to compare prescribing decisions. In Sacramento, patients were much more likely to ask about a drug because of advertisements. However, doctors in both countries were just as likely to fulfill requests when patients asked for a prescription by name, even when doctors were ambivalent about the suitability of the desired drug.

Another group of researchers looked at three drugs advertised in the US media and compared prescribing rates in English-speaking Canada to Quebec, which is mostly Francophone and less influenced by the US media. They found increased prescription rates for one product, tegaserod, a drug approved for use in irritable bowel syndrome and later withdrawn from the market for safety reasons.

The solution to such advertising and its effect on prescribing is straightforward in most regions of the world. If it’s not allowed, don’t let it start. In countries where disease awareness ads are already in place, governments should ban them.

Promoting doctors is not that easy.

A little over a decade ago, researchers (including myself) analyzed 58 studies and looked at three dimensions of prescribing – how often doctors prescribed, how expensive the prescription was, and was the right drug chosen. The conclusion: “With rare exceptions, studies of exposure to information provided directly by pharmaceutical companies have found associations with higher prescribing frequency, higher cost, or lower prescription quality, or no significant associations. We found no evidence of net prescribing improvements. “

The problem needs to be tackled in two ways: better regulating transport and making doctors less susceptible to it. Leaving regulation to the drug companies, as is the case in Australia, or to independent bodies dominated by groups that benefit from the promotion, as is the case in Canada, is not a solution.

At least when it comes to advertisements in medical journals, direct government regulation is much better. But the zeal with which government agencies approach regulation can be subject to the ideology of the ruling party. In addition, government agencies are often underserved. In 2016, the Food and Drug Administration’s Office of Prescription Drug Promotion, with just over 70 employees, received nearly 100,000 prescription drug promotional materials annually. Only a non-governmental organization that is legally protected and has a stable source of income can proactively monitor the funding.

We should not be fooled into believing that fining drug companies will stop their practices. In December 2005, Eli Lilly pleaded guilty to misleading Evista, an osteoporosis drug, and fined $ 36 million. Just over three years later, the same company pleaded guilty to misleading its antipsychotic drug, Zyprexa, and paid a fine of $ 1.415 billion. Lilly had sales of $ 36 billion from the sale of Zyprexa.

As much as some people would like drug company executives to be jailed for the way their companies advertise, it can’t work either. In the early 1980s, Australian criminologist John Braithwaite found that at least two companies were paying people to take what he called “vice presidents responsible for prison sentences.” What would really hurt a drug company, and make it think twice about the way it is advertising, is the loss of patent rights – generic manufacturers could make and sell the drug at lower prices and enter the market.

Even a $ 20 meal can affect the way doctors prescribe. But doctors generally believe that they are individually invulnerable to drug company flattery. What works is separating medical students and pharmaceutical company representatives, as well as training medical students and registrars on conflicts of interest. Once these aspiring physicians, trained to recognize drug maker incentives, go into open practice, they are less likely to prescribe heavily promoted drugs, are less likely to prescribe newer but no more effective drugs, and have less confidence in what drug manufacturer sellers have to do to say.

Direct mail to consumers and other forms of sales promotion are corrosive to the prescription. It is up to governments and the medical community to remedy this problem.

Originally published under Creative Commons by 360info ™

Joel Lexchin received his PhD from the University of Toronto in 1977. He is Professor Emeritus at York University’s School of Health Policy and Management in Toronto, Canada, where he taught health policy until 2016. In addition, he worked in an emergency. Department at the University Health Network, also in Toronto, for more than 33 years.

Disclosure Statement
In 2018-2021, Joel Lexchin received payments for writing a brief on a drug side effects lawsuit for Michael F. Smith, attorney, and a second brief on the role of advertising in creating prescriptions for Goodmans LLP. He is a member of the Board of Trustees of Health Action International and the Board of Canadian Doctors for Medicare. For books he authored, he received royalties from the University of Toronto Press and James Lorimer & Co. Ltd.

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