Hard Sell: Questions Raised About Pharma Sales Tactics

Hard Sell: Questions Raised About Pharma Sales Tactics
By Charlene Laino, Senior Writer, Gupta Guide
Published: April 12, 2013
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco
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Action Points
Pharmaceutical sales reps rarely mention serious adverse events and other common side effects about medications they are promoting when visiting primary care physicians.
Point out that physicians judged the quality of scientific information they received to be “good” or “excellent” in more than half of cases and indicated readiness to prescribe the medication 64% of the time.
Pharmaceutical sales reps rarely mention serious adverse events and other common side effects about medications they are promoting when visiting primary care physicians, according to the first survey of its kind.

Nevertheless, physicians judged the quality of scientific information they received to be “good” or “excellent” in more than half of cases and indicated readiness to prescribe the medication 64% of the time, reported lead author Barbara Mintzes, PhD, of the School of Population and Public Health at the University of British Columbia in Vancouver.

The findings were published online in the Journal of General Internal Medicine.

“My colleagues and I were shocked that serious risks were mentioned in only about 6% of visits, even though 45% of the promotions were for drugs that carry FDA black box warnings of serious risks,” she said in an interview.

Mintzes stressed that such omissions seriously threaten public health.

Previous attempts to gauge the influence of pharmaceutical sales reps were mixed with many studies concluding that sales pitches did not influence prescribing habits, while other studies concluded that sales reps had a direct influence on physician prescribing.

A 2009 U.S. survey found that 85% of physicians see drug reps, and that these reps are the primary source for information about new drugs, the authors write.

Moreover, the drug representatives often leave the docs with free samples that they in turn pass on to patients, often without knowing if the drugs are contraindicated or could otherwise cause harm, Mintzes said.

In this study, the researchers asked a random sample of 255 family doctors in Montreal, Vancouver, Sacramento, Calif., and Toulouse, France, to fill out questionnaires whenever they were visited by a drug company rep. A total of 1,692 surveys were completed from May 2009 to June 2010.

Mintzes noted that the U.S. and France directly regulate drug promotion, while Canada relies on industry to regulate itself. France has the strictest standards, barring free drug samples and gifts; even free meals are shunned.

The primary outcome measure was the number of reps who provided “a bare minimum” of safety information: mention of at least one indication, serious adverse event, common adverse event, or contraindication, and made no unqualified safety claims or unapproved indications, she said.

“The bottom line,” she said “is that few provided even this minimal amount of information.”

In Toulouse, potential harmful effects were mentioned in 61% of cases, compared with 34% in Vancouver and Montreal and 39% in Sacramento. Mintzes said the higher figure in France may reflect that country’s stricter regulatory standards.

Information on health benefits was provided by reps twice as often as information on adverse effects: 80% versus 41%.

There was “not a single harmful effect mentioned in over half of promotions in the three North American sites,” the researchers wrote.

Overall, adverse events (serious or nonserious) were mentioned in 29% of visits, contraindications in 20% of visits, and potential drug interactions in 3% of visits.

“Laws in all three countries require sales representatives to provide information on harm as well as benefits,” Mintzes explained. “But no one is monitoring these visits and there are next to no sanctions for misleading or inaccurate promotion.”

Physicians not involved with the research were dismayed, though not completely surprised, by the results.

Harlan M. Krumholz, MD, professor of investigative medicine and of public health, at Yale University, said, “We should relegate to the days of the past the time that companies used marketing dollars to entice physicians to prescribe their drugs.

“The interests of patients should be exclusively the basis for what is prescribed, not whether one company provides a better lunch, fancier brochures, or more useful gifts. Meanwhile, physicians need to be avid learners, recognizing where they might be value for patients – and not relying on a company sales force for information about new drugs and devices,” he wrote in an e-mail.

Tom Perry, MD, an internist at the University of British Columbia Hospital in Vancouver, who was not part of the study, said he is not even sure such visits should be permitted. Yale Medical School, Kaiser-Permanente, and the University of California, Davis, are among the centers that prohibit such visits.

And if sales visits are permitted, “the discussions should be subject to strict regulations,” Perry said in an interview.

Continuing medical education about new drugs is key he said, “Doctors learn relatively little about drugs in medical school, and much of their exposure to pharmacology after graduation may be in the form of advertising. If they are unaware of the potential harms from drugs they prescribe, patients inevitably suffer the consequences.”

The bottom line, all agreed, is that new innovative strategies for sharing information about new drugs are needed.

In response to a request for comment, a spokesperson for PHRMA, the trade organization representing the pharmaceutical industry, said PHRMA leadership were at a meeting all week.

In most settings the days of “free lunches” are over, but surveys like this one do raise questions about the ongoing influence of industry on clinical practice. Share your thoughts about ‘repping’ practices by clinking the Add Your Knowledge link at the end of this article. Sanjay Gupta, MD

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