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Persuading Prescribers. Adriane Fugh-Berman MD Georgetown University Wilson Lectureship, Albuquerque September 29, 2006. Drugs are important. But so is rational use The most-promoted drugs are not necessarily the best Drugs are not benign. Drug Costs According to the CDC….

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persuading prescribers

Persuading Prescribers

Adriane Fugh-Berman MD

Georgetown University

Wilson Lectureship, Albuquerque

September 29, 2006 (c) A. Fugh-Berman

drugs are important
Drugs are important..
  • But so is rational use
  • The most-promoted drugs are not necessarily the best
  • Drugs are not benign (c) A. Fugh-Berman

drug costs according to the cdc
Drug CostsAccording to the CDC…
  • Between 1997 and 2002 prescription drug expenses increased from 14% to 23% of total health care expenses
  • In 2002, average expenses for Rx drugs were about $1,100 per person (75% higher than 1997)
  • In 2002, average out-of-pocket expenses for prescription drugs were about 50% higher than in 1997 ( (c) A. Fugh-Berman

drug costs according to the gao
Drug CostsAccording to the GAO…
  • Drug costs constitute 10.7% of health care expenditures
  • In 2004, spending for prescription drugs was $188.5 billion, almost five times what was spent in 1990

GAO. Price Trends for Frequently Used Brand and Generic Drugs from 2000 through 2004. (c) A. Fugh-Berman

kaiser family foundation
Kaiser Family Foundation
  • From 1994 to 2004, in the U.S.
    • Population grew 12%
    • Number of Rx purchased increased 68%
    • Retail Rx prices increased 8.3% annually
    • Inflation rate was 2.5% annually (c) A. Fugh-Berman

use of drugs by elders
Use of drugs by elders
  • More than 90% of persons ≥65 years old used a least one medication per week
  • More than 40% used at least 5 medications per week
  • 12% used at least 10 medications per week

Kaufman DW. JAMA 2002;287:337 (c) A. Fugh-Berman

phrma s view
“As use of medications grew between 1980 and 2000, the number of days Americans spent in the hospital fell by 56 percent, representing 206 million days of unneeded hospital care in 2000 alone. Although this study does not show that drugs caused the number of hospitalizations to fall, it is likely that they played a role.”

PhRMA. Pharmaceutical Industry profile, 2006.

PHRMA’s view… (c) A. Fugh-Berman

adr frequency by drug use
ADR Frequency by Drug Use

Frequency (%)





Number of Medications

May FE. Clin Pharmacol Ther 1977;22:322-8.

Slide courtesy of Karim Calis, NIH

promoting the profitable
Promoting the profitable
  • There are more than 10,000 drugs in the US pharmaceutical market
  • More than half of promotional expenditures are concentrated on the top-selling 50 drugs

Ma J et al. Clin Ther 2003;25(5):1503-17 (c) A. Fugh-Berman

promotion includes
Promotion includes
  • Detailing
  • Advertising in journals
  • Meetings and events
  • E-detailing
  • Direct Mail
  • Publications
  • DTC advertising (c) A. Fugh-Berman

docs vs reality
Docs vs. Reality
  • Studies consistently show that promotion consistently increases prescribing of targeted drugs*
  • Studies consistently show that physicians do not believe that promotion affects prescribing**

*Chren MM et al. JAMA 1994 Mar 2;271(9):684-9; Lurie N et al. J Gen Int Med 1990;5:240-243; Wazana A. JAMA 2000 Jan 19;283(3):373-80.

**Sigworth SK et al. JAMA. 2001;286(9):1024-5.McKinney WP et al. JAMA 1990;264(13):1693-7. (c) A. Fugh-Berman

the costs of promotion
The costs of promotion
  • In 2000, total promotion cost for Rx drugs was almost 16 billion dollars
  • About $5 billion spent on detailing
  • Sales force expenditures average $875 million per company (c) A. Fugh-Berman

detailing in a poll of 2608 practicing physicians
Detailing: In a poll of 2608 practicing physicians …
  • 9% said information provided by reps was “very accurate”
  • 72% said information was “somewhat accurate”
  • 14% said that it was “not very” or “not at all” accurate”
  • 15% found information provided by reps “very useful”
  • 59% found it “somewhat useful”

Kaiser Family Foundation National Survey of Physicians, May 2002. (c) A. Fugh-Berman

detailing a rep s view
Detailing: A rep’s view

An official job description for a pharmaceutical sales rep would read: Provide health-care professionals with product information, answer their questions on the use of products, and deliver product samples. An unofficial, and more accurate, description would have been: Change the prescribing habits of physicians.

Reidy J. Hard Sell: the evolution of a Viagra salesman. Andrews McMeel

Publishing, Kansas City: 2005 (c) A. Fugh-Berman

what drug reps cost
What drug reps cost
  • Between 1995 and 2005, the number of drug reps in the US increased from 38,000 to 100,000
  • Pharmaceutical companies spend $150,000 annually per primary care rep and $330,000 per specialty rep*
  • Average annual income for a drug rep is $81,700 ($62,400 plus $19,300 bonuses)**

*Med Ad News 2004;23(3):1; ** Pharm Exec 2005 (January) (c) A. Fugh-Berman

meetings and events
Meetings and events
  • Dinner meetings
  • Rounds
  • Symposia
  • CME (c) A. Fugh-Berman

meetings pharma controls cme
Meetings:Pharma controls CME
  • In 2004, more than half of the $2 billion dollars spent on CME came from pharmaceutical manufacturers
  • Medical Education and Communication Companies (MECs) launder money for pharma
    • 75% of their income is from firms that manufacture FDA-regulated products
  • Medical schools are just as bad
    • Pharma provides almost two thirds (63.8%) of CME income to medical schools (ACCME) (c) A. Fugh-Berman

some universities court pharma
Some universities court Pharma
  • “CCOE and UMDNJ faculty can advise, assist and advocate to propose and position educational activities for product awareness, acceptance, and utilization”
  • Services include “Validation of scientific and promotional messages” UMDMJ Center for Continuing and Outreach Education (c) A. Fugh-Berman

advertising in medical journals
Advertising in medical journals
  • 5 of 6 physician organizations raised at least10% of annual revenue from advertising in affiliated medical journals
  • More than 95% of ads in JAMA are for Rx drugs
  • Pharma companies also purchase “sponsored” subscriptions
  • And are the largest purchaser of reprints

Fugh-Berman A, Alladin K, Chow J. PLoS Medicine 2006;3(6):e130 (c) A. Fugh-Berman

what about r d costs
What about R&D costs?
  • Between 1970 and 2005, research and development accounted for between 8.5% and 17. 3% of sales(PhRMA Annual Membership survey 2006)
  • Pharma spends 3 times as much on marketing as it does on research (c) A. Fugh-Berman

physicians are not the only prescribers
Physicians are not the only prescribers
  • Physician assistants and advanced practice nurses have not received much attention …
  • But will in the future (c) A. Fugh-Berman

  • More rational prescribing, including increased use of older drugs with well-established benefits and risks, would reduce drug costs
  • Reducing inappropriate drug use will also decrease adverse effects and benefit our patients
  • Pharma should not participate in continuing education of health care practitioners (c) A. Fugh-Berman


Recommended Books

Abramson, John. Overdo$ed America

Angell, Marcia. The truth about the drug companies

Avorn, Jerry. Powerful medicines

David, Healy. Let them eat Prozac

David, Healy. The antidepressant era

Elliott, Carl. Better than well

Goozner, Merrill. The $800 million pill

Kassirer, Jerome P. On the take

Moynihan, Ray. Selling Sickness

Mundy, Alicia. Dispensing with the truth

Reidy, Jamie. Hard Sell

Washburn, Jennifer. University, Inc

  • No Free Lunch
  • Healthy Skepticism
  • Health Care Renewal
  • GoozNews
  • PharmaWatch
  • Center for Science in the Public Interest Integrity in Science Project
  • American Medical Student Association
  • Health Action International
  • Consumers International
pharmedout org
  • Coming soon!
  • Funded by the Attorney General Prescriber and Consumer Education Grant Program
  • We’ll provide news and resources, list pharma-free CME, and provide CME (and hopefully CE) modules on pharmaceutical promotion (c) A. Fugh-Berman