Blurring the Boundaries - New Trends in Drug Promotion

Affiliations: *MD,** MPharm Dept.of Clinical Pharmacy,KIST Medical College,Imadol, Lalitpur.(Nepal)

‘There is an enormous imbalance in the financial resources available to produce commercial and promotional information on drugs, as opposed to the limited resources available for comparative and independent information and assessments.’ The book has this sentence prominently displayed in the ‘Introduction’ section. This book about new methods in drug promotion, and blurring the boundaries between illness and health, has been written by Barbara Mintzes, an international authority in the field of rational use of medicines. As faculty members involved in promoting rational use of medicines (RUM), this discrepancy in resources has often struck us. In certain developed nations like Australia, the government and the National Prescribing Service (NPS) invest a good amount of money in providing unbiased, objective information to prescribers, but in developing countries like Nepal, the funds available for promoting RUM are extremely limited.

This book produced by Health Action International (HAI), examines promotion targeting five main audiences e.g. consumers, prescribers, pharmacists, health care providers and researchers. The book starts by examining in detail, promotion targeting consumers. At present, direct to consumer advertising (DTCA) is legal only in the United States (US) and New Zealand, but moves are afoot to make it legal in Europe. The main theme of DTCA, according to the author, is to promote anxiety among consumers that serious illness is lurking around the corner, and that drugs are available to either treat or prevent this illness. DTCA is not common in South Asia, but companies occasionally place advertisements in newspapers targeting consumers. The issue of spreading fear among the public about future ill health, was covered in detail at the first international conference on ‘Disease Mongering’, held in Newcastle, Australia in 2006. The industry had advertised to consumers in some countries, to insist that generic substitution be not carried out, and to ensure that they get the same brand which has been prescribed according to the author. With the problem of substandard and counterfeit medicines in South Asia, there may be some justification. However, even well known brands have been counterfeited. The chapter concludes by categorically stating that DTCA should not be allowed.

The author also recommends guidelines for Over-the-Counter (OTC) drugs. The list of information that advertisements for OTC drugs should follow, is similar to those recommended in the WHO Ethical Criteria for Medicinal Drug Promotion. The authors state that consumers have access to information on risks only after purchasing the medicines, when they read the package inserts and advertisements concentrate only on the benefits. However, in Nepal, package inserts are not mandatory either for OTC or prescription drugs, and very few companies consequently include package inserts with their products. In South Asia, most medicines are available OTC, and pharmacists often serve as the first contact of patients with the health care system.

Pharmaceutical companies often fund patient groups for particular disease conditions, institutes and societies, and even journals. Much of this is indirect or disguised sponsorship for products, according to the author. This issue was covered in detail during presentations and discussions at the inaugural ‘Disease Mongering Conference’ (www.diseasemongering.org). The book describes certain initiatives taken by the industry for educating consumers. The emphasis is more on enhancing consumer compliance with prescribed regimens, and there is little emphasis on risks of medicines. In France, a kit for school children asks the questions ‘What medicine did the doctor prescribe?’, and not ‘Did the doctor prescribe a medicine?’ The issue of drug promotion on the internet has also been discussed, but the information is dated at places, and recent initiatives like ‘HealthInSite’ and the ‘QUICK guide’ are not mentioned.

The second chapter concentrates on promotion targeting prescribers. Sales representatives have been shown to be very effective in promoting medicines, and the salaries of sales representatives are the single largest marketing expenditure of pharma companies. Doctors and other prescribers are in the unique position of being able to decide for their patients without any financial burden. The one who decides does not pay, and the one who pays, does not decide! The guidelines which doctors give to sales representatives regarding how to discuss or present their product, is useful. This will help representatives promote their products in a more scientific manner. A similar issue is discussed in the ‘Guide to Good Prescribing’ under the heading, ‘How to optimize the time spent with medical representatives’. Group presentations have been shown to be more effective in providing reliable, unbiased information, compared to one to one detailing. There have been few studies on the impact of medical representatives on the prescribing of physicians and on the quality of information provided by them. Companies have advertised that they would be contributing a certain proportion of the sales revenue of a particular drug to a charitable organization or a social cause. Companies are free to contribute to society, but advertising the fact to doctors and tying it to sales of a particular drug can lead to unnecessary prescriptions. Prescribing data about individual doctors has often been sold to pharmaceutical companies, and as revealed in a recent issue of the journal ‘PLoS Medicine’, companies use it to target and fine tune their promotional campaigns and develop strategies to effectively modify the prescribing behaviour of individual doctors.

The third section concerns itself about ‘Incentives for drug sellers’. The section on ‘Research and the industry influence’ makes for interesting reading. Pharmaceutical industries promote a lot of clinical research, but questions about the quality and motivations of industry sponsored research have always remained. A study had found that 35% of agreements between researchers and drug companies allowed the sponsor to delete information from publication, 53% allowed delays in publication and 30% allowed both delays and deletions. A few suggestions to reduce bias in publication are, that registries for drug trials should be set up, all trials should be registered and all data from drug studies should be published and not just the positive findings. Some of these recommendations have now been implemented.

The book concludes by making general recommendations and recommendations for specific forms of drug promotion. The language of the book tends to be bureaucratic in places, and makes for difficult reading. The examples of advertisements discussed, however, are very interesting and relevant. The book discusses a very important topic, and will be of interest to all prescribers, pharmacists, pharmacologists, policy makers and everyone interested in promoting the more rational use of medicines. The book has been well produced, and the printing is of the highest quality. I would strongly recommend this book to readers!

About The Book
Mintzes B. Blurring the boundaries New trends in drug promotion. Health Action International–Europe 1998. ISBN: 90-74006-09-4.
Copies are available from HAI Europe

Acknowledgement

The authors would like to express their thanks to Margaret Ewen of Health Action International for providing them with a free copy of the book.