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The Pharmaceutical Industry and Its Influence on Doctors and Medical Students


By Tom Jaconelli
The Lancet
March 20, 2009


The pharmaceutical industry and the medical profession are uneasy bedfellows.

It would be hard to imagine a functioning healthcare system without medicines.
Even outside the system many of us frequently take over-the-counter drugs for
common ailments: in the USA 50 billion aspirin tablets are consumed each year.
(1) Also, it is difficult to think of any kind of human experience that doesn’t
come with a health warning. (2) This medicalisation of society explains why
pharmaceutical companies such as GlaxoSmithKline and AstraZeneca rank in the top
10 share prices in the UK economy. However, the nature of pharmaceutical
companies as profit-driven businesses in contrast to their role as health
providers heralds a seemingly intrinsic problem: is their priority health or wealth?

There are three focal points involved in this situation-the industry, the doctor
and the patient. By regulating each of these it is possible to exercise some
control over the situation. I wish to concentrate on the relationship between
the clinician and the pharmaceutical industry, though I will also look briefly
at the position of the industry and the patient.

The industry is regulated in the UK by various bodies. The Association of the
British Pharmaceutical Industry (ABPI) is the industry’s trade association and
annually publishes codes of practice on how companies should act. It is worth
noting, however, that membership to the ABPI is voluntary. The Pharmaceutical
Price Regulation Scheme (PPRS) which operates under the Department of Health
caps the profits companies can make. Again participation in the scheme is
voluntary. The PPRS says that all scheme members will have a common Return on
Capital target of 21%. (3) These policies should be made mandatory as they are
effectively window dressing unless they are explicit and vigorously observed.

(4) The National Institute for Clinical Evidence (NICE), as the government’s
rationing tool which assesses cost-effectiveness, has since its inception, made
pharmaceutical companies more aware of their pricing methods in order to make
any new drugs viable in the UK public market. However, it has its own
limitations as not all clinical practice has changed in line with NICE guidance.
(5) NICE needs to do more to increase compliance of its guidelines.

Patients are regulated in various ways as in the UK there is a standard charge
for prescriptions, although certain groups such as the elderly are exempt. It
is worth noting that the elderly are the major consumers as they have multiple
morbidities. More recently many prescription-only medicines (POM) have been
switched to over-the-counter (OTC) drugs, which shifts expenditure from the
public to the private sector. In the UK patients are, on the whole, not
informed about drugs, as new drugs are targeted at doctors, thereby creating a
paternalistic relationship between doctor and patient. However in the USA
‘Direct to consumer advertising’ through the media is commonplace. Finally,
doctors have to abide by budgetary controls. In the UK this applies both in
hospitals and in general practice and limited lists of drugs are produced,
effectively limiting the drugs a doctor can prescribe.

Despite the aforementioned regulatory procedures in place, there are still
problems that exist with the direct relationship between the pharmaceutical
industry and clinicians. These interactions are omnipresent and due to vast
investment (greater than that spent on the production of medicines) in marketing
and the generation, collation and dissemination of medical information. (6)

Clinical Influence

Since commencing my clinical training I have been surprised by the significant
amount of contact my colleagues and I have had with the pharmaceutical industry.
Contact includes being given free lunches and gifts such as pens and medical
equipment with branded drug names clearly printed on them.

Pharmaceutical companies make themselves known to students in many other ways
such as sponsoring medical facilities and lecture halls and subsidising travel
to medical events (thereby instilling their names in the minds of students).
Indeed the influence does not stop at undergraduate level. The widespread
influence of drug manufacturers on postgraduate medical education activities
makes more stringent regulation necessary. (7) The interesting factor is that
many medical students, when asked, express the belief that pharmaceutical
industry contact does not have any influence on them. However social science
literature suggests that it would be surprising if doctors were not influenced
by small and large services and tokens of appreciation. (8) Gifts create
relationships: they create a subconscious indebtedness and the feeling of a need
to reciprocate. (9) This reciprocation is well documented in the form of
increased prescribing of the heavily marketed drugs, even if those drugs are no
more efficacious than other generics in that particular therapeutic area and do
not display cost-effectiveness.

Apart from the intensive marketing that pharmaceutical companies deliver, they
often claim that their clinical trials are an important source of readily
available information for the busy clinician. Indeed this is true to an extent
but we must realise the flaws in their processes. Many new drugs are compared
to a placebo drug or ineffective doses of established drugs rather than the
gold-standard equivalent as a comparator. This results in the new drug being
shown in a more favorable light. Studies sponsored by the industry are four
times as likely to have outcomes favouring the sponsor than are studies funded
by other sources. (10) There is also widespread evidence of negative results
from trials being suppressed-a clear form of publication bias. Also, in the
realm of clinical trials erroneous data result from insufficient documenting of
adverse outcomes. This prejudices patients, as in the case of the revolutionary
COX-2 selective inhibitor drugs which came on to the market a few years ago. On
release they were heavily marketed as revolutionary anti-inflammatory drugs
without the gastric side effects common in the COX inhibitor class of drugs.

Yet they were later found to have detrimental effects by increasing the number
of thrombotic events. These consequences were not revealed in trial findings.
Once a trial has been written up it is usually published in a major medical
journal. However, 75% of clinical trials published in major journals are funded
by the industry11. An additional number of these have further bias from the
professionals conducting the trials who have conflicts of interest (e.g. as
shareholders). Even though they have to declare any interests, this is not
always complied with. Richard Smith, former editor of the British Medical
Journal, told BBC news that the journal was too dependent on pharmaceutical
industry advertising revenue to be considered impartial. This means that
industry-sponsored trials and the journals they are displayed in should be
regarded with considerable scepticism.

How does this affect medical students?

The above entanglements between the industry and doctors apply even more so to
medical students, as they have the longest “prescribing life” and so are key
targets for pharmaceutical representatives. (12) With the advent of nurse and
pharmacist prescribers this dimension can only increase. Medical students are
also at their most naďve, as they are formulating views on the industry and
rapidly expanding their drug knowledge. As such, medical students need to think
actively about their relationship with the industry, in the same way that they
consider the doctor-patient relationship. They need clear guidance on how to
interact with the pharmaceutical industry from an early stage. With regard to
the above issues, a non-exhaustive list of guidance would include the following:
Approach the pharmaceutical industry with caution in all dealings with it. As
profit-driven companies their priority is not that of health, but wealth.
Realise that free gifts, however useful, are targeted at medical students for
the sole reason of modifying future prescribing behaviour and are an example
of marketing and product placement.

Understand that, however much you believe that incentives and gifts will not
modify behaviour, research shows that they subconsciously change prescribing behaviour.

Industry-sponsored clinical trials should be analysed critically and not taken
at face value. They should not be the sole source of information for
evidence-based decision-making.

Use relatively less biased publications such as BMJ Clinical Evidence. If
possible, the raw published data from clinical trials should also be viewed.
I believe medical schools should take a more active role in ensuring medical
students are educated about the pharmaceutical industry. In particular, they
should publish polices to provide a point of reference for occasions when their
students have dealings with the industry (e.g. sponsorship of sporting events).
I contacted five UK medical schools at random and none had an active policy in
place about how medical students should interact with pharmaceutical companies.
Evidence suggests that these entanglements should be explicitly addressed at the
level of policy and education. (13) This would enable standardisation in any
dealings with the pharmaceutical industry and control the industry’s influence
over medical students.

Get Involved

There are many organisations which have been set up to increase awareness about
the industry. If you are interested please support the following organisations:

PharmAware UK

This organisation is part of Medsin and aims to change health care
professionals’ relationships and interactions with the pharmaceutical industry
and educate and raise awareness of worldwide pharmaceutical issues. There are
branches at most UK medical schools. Visit www.pharmaware.co.uk

No Free Lunch

This is an American organisation committed to raising awareness about the
influence of the pharmaceutical industry on prescribing habits. The website
encourages healthcare professionals to hand in their drug branded pens in the
‘No Free Lunch Pen Amnesty Program’. This is a very good website with a lot of
resources. Visit ww.nofreelunch.org

No Free Lunch-UK

This is the British branch of the above organisation. It campaigns for complete
transparency through a public register of all contact, hospitality and payments
received by health professionals from the industry. Visit

www.nofreelunch-uk.org

Healthy Skepticism

Healthy Skepticism (formerly known as MaLAM) is an international non-profit
organisation for health professionals and everyone with an interest in improving
health. It aims to improve health by reducing harm from misleading drug
promotion both in developed and developing countries. Visit

www.healthyskepticism.org

Tom Jaconelli

Fourth Year Medical Student
Hull York Medical School,
UK
thomas.jaconelli@hyms.ac.uk

Competing interests: None declared.

(1) A.S. Harding. Milestones in Health and Medicine. Phoenix Oryx Press, 2000.
(2) F, Furedi. Conference: Health: An Unhealthy Obsession. London. Feb 2005.
(3) Medicines, Pharmacy And Industry Group Summary Of The Pharmaceutical Price
Regulation Scheme 2005 Department of Health
(4) Kamran Abbasi, Richard Smith. No more free lunches. BMJ 2003;326:1155-6.
(5) Sheldon TA, Cullum N, Dawson D, Lankshear A, Lowson K, Watt I, et al. What’s
the evidence that NICE guidance has been implemented? Results from a national
evaluation using time series analysis, audit of patients’ notes, and interviews.
BMJ 2004;329:999-1004.
(6) Collier J, Iheanacho I, The pharmaceutical industry as an informant. Lancet
2002;360:1405-9.
(7) Lurie N, Rich EC, Simpson DE, et al. Pharmaceutical representatives in
academic medical centers. JGenIntern Med. 1990;5:240-243.
(8) Blumenthal, David MD. Doctors and Drug Companies. New England Journal of
Medicine. October 28, 2004.
(9) Katz D, Caplan AL, Merz JF. All gifts large and small: toward an
understanding of the ethics of pharmaceutical industry gift-giving. Am J Bioeth
2003; 3: 39-46
(10) Lexchin J, Bero LA, Djulbegovic B, Clark O. Pharmaceutical industry
sponsorship and research outcome and quality: systematic review. BMJ
2003;326:1167-70.
(11) House of Commons Health Committee The Influence of the Pharmaceutical
Industry-Fourth Report of Session 2004-05 The Stationary Office Limited
(12) Chawla, R. First Pharmfree Day launched studentBMJ 2005;13:1-44
(13) Wazana A. Physicians and the Pharmaceutical Industry: Is a gift ever just a
gift? JAMA. 2000;283:373-80

 

 

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