Pushing Pills


How Drug Companies Spin Doctors

Americans pay up to 1000% more to fill their prescriptions than consumers in other countries - that is an alarming statistic.

- Ken Salazar

Between 2001 and 2011 drug spending growth will exceed total health spending growth
by almost 5% per year on average. (Health Affairs, March/April 2002).
State-administered Medicaid programs reported pharmaceutical expenditures annual increases for FY 2000
as follows: Arizona: 29.8%; Hawaii: 30.5%; Nevada: 29.6%; North Carolina: 29.4%; Oregon: 32.0%.
Data from HCFA-2082 Reports as compiled by CMSO.

The industry's semi-secret weapon is prescriber reports, weekly lists of every prescription written by each of the 600,000 doctors in the United States.  Relatively few physicians know about prescriber reports, also known as prescriber profiles.  But their existence makes it far more difficult to imagine that pharmaceutical marketing has no effect on the doctors it targets...

The weekly prescriber reports can show the names of the doctors in a rep's territory and what each doctor prescribed and how much of it.  Reports provide reps with up-to-date feedback on just how effective they've been in persuading their doctors to prescribe the 2 or 3 drugs each rep pitches.  The reps are schooled for weeks in a variety of sales techniques.  They memorise tightly crafted speeches and volumes of data on their products, and some are even trained in personality profiling, to help them guess whether a physician is more likely to respond to reams of scientific research or to schmoozing.  Prescriber reports play a key role in helping reps boost sales - they're like weekly focus groups that help reps shape their pitches to individual doctors.  If Doctor A increased her prescriptions after being treated to a facial and full-body massage, more expense-paid spa excursions are in order for her.  If Doctor B didn't respond to a courtesy 5-course meal, then maybe it's time to try football tickets, or up the free drug samples, or plug clinical research that touts the proffered drug's benefits.

Prescriber reports also allow reps to identify and target their top prescribers.  The reports rank doctors into 4 tiers, based on how many scripts they write.  Reps focus most of their energy on the upper ranks - the doctors who write hundreds of prescriptions per month.  That's because a rep's bonus depends on increasing market share, the sales of his drugs in his territory compared with competing medications.  Getting top prescribers to increase their prescriptions by even a few percentage points can give the rep that needed boost...

One study published in the New England Journal of Medicine in 2001 revealed that patients who used the painkiller Vioxx were 5 times more likely to suffer a heart attack than users of the generic drug, naproxyn.  Yet that year, Merck & Company, Vioxx's manufacturer, managed to make the drug's sales rise faster than the top 10 drugs in the industry, with revenues topping $2.6 billion.  How did that happen?  Merck documents submitted to Congress after Vioxx was withdrawn from the market last fall show that the company taught sales reps how to deflect doctors' questions about the painkiller's safety...

Source: slate.msn.com Slate May 2005 via prorev.com/health.htm

How Medical Marketing Influences Doctors and Patients

by Ben Harder

When John D Abramson was practicing family medicine in Hamilton, Massachusetts, he prided himself on how conscientiously he selected the drugs that he prescribed.  He closely followed pharmaceutical research.  He kept track of the latest medical guidelines.  And he maintained his distance when company salespeople, with promotional pitches at the ready, appeared at the practice that Abramson shared with several colleagues during the 1980s and 1990s.  He typically didn't speak to pharmaceutical sales agents, although he did let them leave behind free samples of drugs that their companies sold.

Abramson knew that the companies wanted him and his colleagues to prescribe new and often expensive drugs rather than their older, less costly alternatives.  But he saw no harm in stockpiling the freebies and handing them out to patients who were without health insurance and unable to buy drugs on their own.  "I thought I was being Robin Hood," Abramson says.  Before long, however, he grew so familiar with administering the free drugs that he found himself writing prescriptions for the same substances for insured patients, whose coverage would then pay for the medications.  For pharmaceutical companies, Abramson's behaviour meant new customers.  "That's what they wanted," he says.  "They were playing me like a violin."

Abramson left medical practice nearly 4 years ago to write Overdo$ed America: The Broken Promise of American Medicine (2004, New York: Harper Collins), which trains a critical eye on pharmaceutical companies' influence on medical research and practice.  He now teaches at Harvard Medical School.

At least two pharmaceutical marketing strategies converge to alter doctors' prescribing habits.  On one hand, sales representatives target physicians with visits and samples, and ads tout drugs in journals.  On the other, mass media advertisements urge people to ask their doctors about specific brand-name medications.  This direct-to-consumer (DTC) advertising, which is not permitted in Europe and strictly limited in Canada, has in the past decade grown into a multibillion-dollar industry in the United States.  If nothing else, says internist Richard L Kravitz of the University of California, Davis, the consequence of drug promotions is that the medicines that are most profitable for drug companies end up being overprescribed.  Eighteen actors were dispersed to physicians' offices by Kravitz and his colleagues during 2003 and 2004.  Such actors are known in the medical literature as standardised patients; they aren't sick, but they're trained to describe certain realistic sets of symptoms.  Medical schools use standardised patients to test students' diagnostic skills.

Kravitz had a different test in mind.  He and his fellow investigators instructed the actors not only to fake specific symptoms but also, in some cases, to ask for a particular drug or a general class of drugs.  The researchers wanted to know how physicians would respond to supposedly media-driven inquiries.  The researchers recruited 152 family physicians and general internists practicing in San Francisco, Sacramento, California or Rochester, NY.  Each participating doctor was told that he or she would be sent two standardised patients during the next year.  But the doctors weren't told the study's purpose or how to identify the fake patients.  The actors then scheduled appointments with the physicians.  Once in a participating doctor's office, some of the fake patients described symptoms of major depression, a long-lasting mood disorder that's often treated with antidepressant medications.  Other standardised patients complained of symptoms of a less serious psychiatric ailment, which is called adjustment disorder with depressed mood.  This condition generally disappears within months without medication.

When standardised patients faking major depression didn't specifically request an antidepressant, 31% received a drug prescription.  However, when others claimed that a television show about depression had encouraged them to seek drug treatment, 76% received a prescription of some kind.  In those two groups, about 6% of the actors who received a prescription got one for paroxetine (Paxil), one of several drugs in a class frequently used to treat major depression.  However, when members of a 3rd group reporting identical symptoms asked specifically for Paxil, saying that they had seen it advertised on television, more than half the resulting prescriptions were for that drug.  In standardised patients who reported symptoms of adjustment disorder and didn't raise the subject of antidepressant drugs, just 1 in 10 got any medication.  But nearly half of the actors who asked for medication got it.  Most who asked for Paxil walked out with a prescription for that drug, while most who made a nonspecific request were prescribed some other antidepressant.  "It's probably promoted use of expensive, brand-name medications, which are more likely to be heavily promoted ... than less expensive generic alternatives," Kravitz and his colleagues note.

Other studies support the notion that DTC ads translate into prescriptions.  One 2003 investigation found that people visiting doctors' offices in Sacramento, were twice as likely to request a new prescription, and twice as likely to receive one, as were similar patients in Vancouver, British Columbia.  The US patients were nearly 6 times as likely as were their Canadian counterparts to have recently seen ads for most of the half-dozen prescription drugs that the study examined, reported a team of Canadian and US researchers, including Kravitz.  In a more recent survey of 643 US physicians, many attributed a double-edged effect to pharmaceutical ads.  Nearly 3/4 of the doctors said that they believe that DTC ads inform people about medicines that might help them, and 2/3 of the doctors said that ads "improve dialogue."  One quarter of the ad-initiated doctor-patient conversations lead to diagnoses of treatable problems that might have gone undetected, the doctors report.  On the other hand, 80% of the survey respondents said that ads encourage patients to seek unnecessary treatments and don't fully convey the therapies' risks.  Joel S Weissman of Harvard Medical School and his colleagues posted the results of the survey on the website of Health Affairs in April 2004.

As influential as advertising drugs to consumers may be, it represents only a small fraction of pharmaceutical companies' promotional efforts.  The industry spent $3.2 billion in 2003 on consumer-oriented marketing, according to the health-industry research firm IMS Health.  By contrast, IMS Health's latest data show that the pharmaceutical industry spent about $5.3 billion in 2003 on detailing - a term for the face-to-face promotional activities directed toward physicians - and it distributed $16.4 billion worth of free samples that year.  The companies also spent $448 million on advertising in medical journals.  PhRMA doesn't dispute these estimates.  A survey of physicians published in 2001 found that 92% had accepted free drug samples.  Most doctors had received other freebies, too, including meals, travel, and entertainment tickets.

Citing cost-control measures, Donohue says, hospitals have increasingly restricted detailing.  Some have also imposed limits on free samples and other items.  Last year, for example, Affinity Health System of Wisconsin barred pharmaceutical companies from distributing to its employees free meals, clocks, calendars, and other handouts, and it restricted the distribution of free samples.  The notion is that physicians will feel more comfortable prescribing cheaper alternatives to brand-name medicines when they feel they don't owe a return favour to a drug company.  "It's a wonderful idea," says Abramson.


Abramson, J.D. 2004.  Overdo$ed America: The Broken Promise of American Medicine.  New York: HarperCollins.

Donohue, J.M., et al. 2004.  Effects of pharmaceutical promotion on adherence to the treatment guidelines for depression.  Medical Care 42(December):1176-1185.  Abstract available at lww-medicalcare.com/pt/re/medcare abstract.00005650-200412000-00004.htm.

Kravitz, R.L., et al 2005.  Influence of patients' requests for direct-to-consumer advertised antidepressants: A randomized controlled trial.  Journal of the American Medical Association 293(April 27):1995-2002.  Abstract available at jama.ama-assn.org/cgi/content/abstract/293/16/1995.

Mintzes, B. ... R.L. Kravitz, et al. 2003.  How does direct-to-consumer advertising (DTCA) affect prescribing?  A survey in primary care environments with and without legal DTCA.  Canadian Medical Association Journal 169(Sept. 2):405-412.  Available at cmaj.ca/cgi/content/full/169/5/405.

Weissman, J.S., et al 2004.  Physicians report on patient encounters involving direct-to-consumer advertising.  Health Affairs - Web Exclusive 23(March/April):w4.219.  Available online at dx.doi.org/10.1377/hlthaff.W4.219.

Further Reading:

Berndt, E.R. 2005.  To inform or persuade?  Direct-to-consumer advertising of prescription drugs.  New England Journal of Medicine 352(Jan. 27):325-328.  Extract available at content.nejm.org/cgi/content/extract/352/4/325.

Donohue, J.M., and E.R. Berndt. 2004.  Effects of direct-to-consumer advertising on medication choice: The case of antidepressants.  Journal of Public Policy and Marketing 23(Fall):115-127.  Available at kff.org/rxdrugs/upload/Effects-of-Direct-to-Consumer-Advertising-on-Medication-Choice-the-Case-of-Antidepressants.pdf.

Gardner, D.M., et al 2003.  Direct-to-consumer advertising in Canada: Permission by default?  Canadian Medical Association Journal 169(Sept. 2):425-427.  Available at cmaj.ca/cgi/content/full/169/5/425.

Harder, B. 2005.  Dangerous practices.  Science News 167(Feb. 5):90-92.  Available at sciencenews.org/articles/20050205/bob10.asp.

Kaiser Family Foundation. 2003.  Impact of Direct-to-Consumer Advertising on Prescription Drug Spending.  Kaiser Family Foundation report. (June).  Available online at kff.org/rxdrugs/6084-index.cfm.

Majumdar, S.R., et al 2004.  Promotion and prescribing of hormone therapy after report of harm by the Women’s Health Initiative.  Journal of the American Medical Association 292(Oct. 27):1983-1988.  Available at jama.ama-assn.org/cgi/content/full/292/16/1983.

For further information about IMS Health, go to imshealth.com.

For information about the Pharmaceutical Research and Manufacturers of America organization, go to www.phrma.org.


John D Abramson
39 Spring Street
Ipswich, MA 01938-1357
Julie M Donohue
Department of Health Policy and Management
Graduate School of Public Health
University in Pittsburgh
130 DeSoto Street, A653 Crabtree Hall
Pittsburgh, PA 15261
Richard L Kravitz
University of California, Davis
Center for Health Services Research
Department of Internal Medicine
2103 Stockton Blvd, Suite 2224, GB
Sacramento, CA 95817

Source: sciencenews.org Science News, Vol. 168, No. 5, July 30, 2005, p. 75

It is worth noting the fact that prescription costs have increased 12 - 15% per year over the past 5 years.  An incredible 91% of Americans report having taken a prescription drug in the previous year and 54% regularly take them.  An average American consumes 6 prescriptions per year (for those over 75, it’s 11).  Last year, doctors wrote 20 million prescriptions for ADHD medications alone and a further 68 million Americans have taken at least one SSRI for depression.  Many patients come across as gullible, many doctors as greedy, and drug companies as nothing short of voracious.  Meanwhile, costs are spiralling out of control...

Eli Lilly And Company Introduces Reconcile For Separation Anxiety In Dogs

Eli Lilly and Company (NYSE: LLY) announced today it has received approval from the FDA to market Reconcile™ (fluoxetine hydrochloride), the first selective serotonin reuptake inhibitor (SSRI) class of antidepressants approved by the FDA for treatment of canine separation anxiety in conjunction with behaviour modification training.  Reconcile™ is the first Lilly product approved by the FDA for dogs and is now available to US veterinarians.

"Lilly research shows that 10.7 million, or up to 17% of US dogs(1) suffer from separation anxiety," said Steve Connell, DVM, manager of technical, academic and consumer services for companion animal health at Lilly.  "We're thrilled that our first product for dogs can help restore the human-pet bond, which can be compromised when dogs suffer from separation anxiety."

Reconcile™ is a once-daily, chewable, flavoured tablet that may be prescribed by a veterinarian in weight-specific doses for use in conjunction with behaviour modification training to treat canine separation anxiety.  The drug is proven safe for dogs and puppies 6 months or older.

In field studies of approximately 600 dogs, 73% of dogs receiving Reconcile™ showed improvement in separation anxiety-related behaviour within 8 weeks when compared with dogs receiving behaviour modification training alone.  Within one week of starting Reconcile™ treatment and behaviour modification training, 42% of dogs showed improvement.  During trials, the most common adverse reactions to Reconcile™ were calm or lethargy, reduced appetite, vomiting, shaking, diarrhea, restlessness, excessive vocalization, aggression and - in infrequent cases - seizures.

Reconcile™ allows dogs to be more receptive to your training to help with anxiety

Canine separation anxiety is a prevalent and often misunderstood behaviour problem, according to Connell.  It amounts to undesirable behaviour that occurs when the dog is left alone even for short periods of time.  The resulting anxiety may cause the dog to engage in inappropriate behaviour, such as destruction, excess vocalization and inappropriate elimination.  Anorexia and depression also may be observed in some cases.  "Your family veterinarian may recommend certain tests before diagnosing separation anxiety," Connell added.  "Such tests are used to rule out other potential physiological causes of inappropriate behaviour."

For dogs affected by separation anxiety, Reconcile™ reduces inappropriate behaviours, minimises the pet's distress and increases receptivity to a simple training plan called the BOND™ modification training plan.

The BOND™ behaviour modification program is an easy-to-implement, at-home training plan developed by Lilly and a team of veterinary behaviourists as well as veterinarians.  The simple plan allows dog owners to take an active role in the treatment of their pet's separation anxiety to help restore the human-pet bond.  Dog owners whose veterinarians have prescribed Reconcile™ receive educational materials to enable them to follow an easy 4-step training plan to reinforce positive pet behaviour which helps to reduce or eliminate inappropriate responses to anxiety.  Components include a take-home DVD, printed materials and in-home reminders so the whole family can reinforce behaviour modification training for the dog.

Debra F Horwitz, DVM, and a diplomate of the American College of Veterinary Behaviourists, was among the veterinary behaviourists involved in developing the BOND™ program.  "Learning and memory are important in the formation and maintenance of anxieties," said Horwitz.  "Decreasing anxiety can help pets learn and, through training, they can learn new responses to stimuli that have triggered separation anxiety in the past.  The development of the BOND™ behaviour modification plan is an important complement to Reconcile™ in the treatment of separation anxiety."

For more information about Reconcile™ and the BOND™ behaviour modification program, which are available only through veterinarians, visit reconcile.com.  Important safety information and the product label also can be found there.

Lilly, a leading innovation-driven corporation, is developing a growing portfolio of first-in-class and best-in-class pharmaceutical products by applying the latest research from its own worldwide laboratories and from collaborations with eminent scientific organisations.  Headquartered in Indianapolis, Lilly provides answers - through medicines and information - for some of the world's most urgent medical needs.  Additional information about Lilly is available at lilly.com.  Information about Lilly products for pets is available at lillypet.com.

(TM) Reconcile and BOND are registered trademarks of Eli Lilly and Company.

(1) Lilly Research 2006, Eli Lilly and Company

Source: medicalnewstoday.com 26 Apr 2007

First, while this drug is called Reconcile, it is also known as Prozac.  Second, at the end of 8 weeks, yes, 73% of the drug-treated dogs showed improvement - but 51% of the dogs treated with behaviour modification alone also were improved.  This drug can cause seizures in some dogs and these seizures, while rare, can be fatal.  Now that Eli Lilly has lost patent protection on Prozac, they need a new revenue stream.  People pamper their pets more than ever and Eli Lilly is going to take full advantage of it.  A Los Angeles vet estimates that 5% of the 8,000 cats and dogs seen at the clinic are now taking drugs for behaviour modification and the number is rising.  Much of animal behaviour is normal but not acceptable.  Pets who once had space now live in close urban quarters - the animals haven't changed but our expectations have.  To begin with, it is important that breeds appropriate for one's lifestyle are chosen.  Doping the family pet is a lazy way out.  Pets require attention, exercise, and proper handling and training.  (I feel similarly about young boys and Ritalin...)

This dog needs help

See also:

bulletMarketing Madness (the next page in this section) - three articles about Prozac including the fact that it's called Sarafem if you're female and take it for PMS, can be administered weekly and it becomes patent protected again, and can cause violent and suicidal behaviour in some people...

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