It’s okay for drug companies to spend oodles on advertising because they spend even more making sure their drugs are safe and effective, right? Not so much, according to a study in PLOS Medicine.
The study shatters the accepted myth that pharmaceutical companies spend more on research than on marketing. In reality, drug companies pour $57.5 billion into marketing, dwarfing the comparably paltry $31.5 billion devoted to research.
Billions of marketing dollars go toward television ads that implore us to “ask our doctor” about drugs we don’t need to treat ailments cultured by public relations firms. Yet even more money is spent convincing doctors to prescribe costly medicine—an astounding $61,000 in “promotion per physician.”
For the last 50 years, say the authors, there has been an ongoing debate as to which image of the drug industry is most accurate. The industry promotes a vision of itself, say the authors, as “research-driven, innovative, and life-saving,” but the industry’s critics contend that the drug industry is based on “market-driven profiteering.”The study confirms the more cynical view that drug companies are out to profit first, and save lives second. And there’s nothing wrong with that.
We think there is something severely wrong with a system that emphasizes marketing over research. Profit is good, but profit at the expense of the public health is dangerous.
Don’t be ashamed to ask your doctor if a drug company recently paid for any meals or ski trips. Instead of mentioning the latest drug splashed across the screen, ask how they would use their expansive medical knowledge to treat your condition. Ask how they would treat their child.
Do drug companies do more marketing or research? [SciGuy]
The Cost of Pushing Pills: A New Estimate of Pharmaceutical Promotion Expenditures in the United States [PLoS Medicine]
(Photo: rabbit.marshall)
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@Hambriq: “Here’s my stance: New drugs are almost invariably better than old drugs.”
I will agree with that (and you’re sweet for liking me!), with one caveat: New drugs are almost invariably better than old drugs FOR A SPECIFIC SUBSET OF PATIENTS. Vioxx is CLEARLY better than naproxen … for patients who don’t respond to naproxen. For the majority of osteoarthritis patients who respond perfectly fine to naproxen (or ibuprofin, for that matter), Vioxx simply wasn’t necessary … and as it turned out, had dangerous side effects that weren’t anticipated, and the drug should have been confined to the patients who didn’t respond to the older, safer drug. But it wasn’t, largely because of advertising.
“Why? Because any doctor worth his salt is going to prescribe the best possible medication within reason.”
One hopes this is true, but countless studies show that doctors also respond to drug advertising. It’s honestly only natural, because if they’re already working a 60-hour week, they’re probably not reading and closely comparing every single drug study in every English-language journal; they’re going to respond to drug reps who provide them with timely, topical information, and they’re likely not going to have seen any (very limited) studies that may suggest side effects outweigh benefits. Add that to drug companies buying studies, buying doctors’ names to put on studies, and suppressing data on negative effects … it’s seriously problematic.
Even if they’re only seeing excellent, third-party studies of a Brand New Drug (BND), it takes years for adequate side-effect and long-term use data to become available on BND. If older treatments are effective for a patient, there’s no good reason to expose them to the risk of the BND until there’s a substantial body of real-world data on the BND. It’s when existing treatments are NOT effective that BNDs become an excellent idea.
@courtneywoah: “I believe that research shows that new drugs are not better than old drugs and this is because new drugs are tested against a placebo NOT against the old drug its supposed to be replacing“
Then you need to read the research.
“Also, when a patent is about to run out on a drug the company will come up with a “new drug” to extend the paten life and to get new customers, the best example of this is Prozac. which is now used to treat women who suffer from PMS.”
This is just patently false. Yes, Prozac (and all other SSRIs) is being used now as a line of treatment for women with severe PMDD. But Prozac has been generic for quite some time. Tacking on another indication to a medicine does not extend the life of the patent. You can still get generic Fluoxetine for 4 dollars and the only people who profit from that are the generic drug manufacturers and Wal-Mart, not Big Pharma.
@Eyebrows McGee:
Here’s where I disagree. As I mentioned in an earlier post, if a patient has high cholesterol, I cannot think of a single reason to prescribe an older statin over Crestor/Lipitor besides cost. I wouldn’t say Crestor/Lipitor is better only for patients who don’t respond adequately to Simvastatin. It’s better, period.
Now, regarding Vioxx specifically, I think it’s a huge stretch to say that Vioxx is unnecessary. Taking an NSAID (especially Naproxen) every day is going to wreck severe havoc on your GI system, especially in the age group of patients who tend to have arthritis. COX-2 inhibitors, on the other hand, have a significantly lower incidence of disturbances. By taking an NSAID daily, you are basically forced to tack on a PPI like Nexium every day in order to prevent a GI event, and the costs of that are going to end up being about equal to what it would cost to just pay for the Vioxx or whichever COX-2 you’re using.
Now, the increased risk of MI is truly unfortunate, and obviously it represents a risk disproportionate to the reward. But to say that COX-2 inhibitors are unnecessary, considering the huge GI issues that stem from long-term NSAID use? I really have to take issue with that.
Also very true. I think this stems more from the fact that doctors are constantly searching for better medications and better options to treat their patients. Despite this, they still have to remain prudently skeptical, to a point. So when a rep comes in touting the latest, greatest treatment option, the doctor is obliged to play the role of devil’s advocate. Of course, this is a losing proposition. Even the most well-informed doctor will not have the kind of off-hand knowledge to go toe-to-toe with a good sales representative. A doctor’s job is to know about everything out there. A sales representative’s job is to know absolutely everything about the one or two medications they are selling.
Unless the doctor researched everything before hand and developed the same level of familiarity with the drug that the rep has, there’s no way he’s going to “beat” them. Therein lies the other problem. The doctor isn’t looking to prove the rep wrong. He’s looking for the best medicine out there. So if a rep can address all of the doctor’s potential misgivings in a satisfactory manner, then why not prescribe the medicine? Again, the doctor isn’t looking to show the rep why Simvastatin is better than Lipitor, or even why Crestor is better than Lipitor. He’s looking for the best possible medication to prescribe his patients.
@Eyebrows McGee:
I’m not sure I agree with that. The average patient at our pharmacy who regularly uses Viagra or Cialis goes through about 4 to 5 in a month. They both cost about $13 a pill, so the companies are making about 60 to 75 dollars a month off of these regulars. Now, compare:
Viagra/Cialis: ~$60-75 a month.
Crestor/Lipitor: ~$110-150 a month.
Nexium: ~$190 a month.
Diovan/Cozaar/Benicar: ~$120-130 a month.
Granted, these figures are just off the top of my head, and when I go into work today I can figure out exactly how much more money pharmaceutical companies are making off of maintenance medicines over lifestyle medicines.
The main reason behind it is, maintenance medicines have to be taken every day for the rest of your life. Get a customer stuck on a statin, and you have a customer for life. Lifestyle medicine, on the other hand, is taken on an as-needed basis. And when people start to cut costs, the first things that go are the lifestyle medicines, not the maintenance ones.
@NickRB: So what exactly has Moore made up in Sicko? I get the feeling that he’s hiding something in that bit about the trip to Cuba, but what?
I had to watch it in my high-school Economics class (“the Economics of Health Care” was the unit being covered) and the teacher was an American immigrant to Canada, so he probably knew both sides of the issue when he showed it…
@NickRB: I recently went to a presentation by an advocate for support for kids with cancer (NOT Saint Judes or whatever). The drug companies spend less than 1 percent of children’s cancer. They spend most of their 10% budget for cancer on easily curable cancers that are common. The drug companies are NOT researching the proper drugs. AIDS drugs that cure AIDS are not the attention of the drug companies, drugs that will treat the symptoms are the ones getting the development.
Topgun nailed it earlier in the thread…why bother curing anything when you’d just cut off the money train that just keeps on giving?
@catnapped:
Sounds like you’ve identified a significant market niche. Start a pharmaceutical company that will develop drugs that will actually cure disease. Clearly there is a conspiracy among the existing drug companies to keep patients on drug maintenance regimens without curative intent. Instead of pens and notepads, your drug reps can provide doctors with tinfoil hats with your company logo.
The thing about the for-profit drug model can best be encapsulated in a hypothetical. Imagine tomorrow, a $5 pill came out that cured AIDS, deep in a Big Pharma lab someplace.
Which company, needing to exceed shareholder expectations, could, in good conscience, roll it out to the market at a price of $10?
None. WAY too much money to be paid treating AIDS versus curing it. It would be “irresponsible” for them to do so.
@Hambriq: @Eyebrows McGee: Great exchange guys
+1 each
@trai_dep: wow that is incredibly cynical. Especially since you would have to assume that every research scientist, lab assistant, executive, and cured test subject would have to keep it silent (real tough, as weve learned from EVERY OTHER PIECE OF EVIDENCE that secrets dont stay that way).
More likely, they would release the cure, benefit greatly from customer good will, see a massive influx of research grants, then move on to other problems. If someone cured cancer tomorrow, there are still millions of other deseases that can be cured/treated. Plus if people live longer there are going to be more chances to sell Crestor/Cialis/other drugs like that.
The only time that I see a true effort to treat rather then cure desease are in the mental health field. GSK would obviously lose a big chunk of income if suddently Welbutrin (which they reformulated to extend patent) wasnt needed. Psych drugs are lifetime-use, and a big chunk of the money pharmas make.
When I worked for a group of surgeons, we would have lunch brought in from these reps every now and then. Our doctors would almost never show up, and we would usually tell these reps the doctors more than likely wouldn’t be there. They kept bringing us food anyway. What astounded me the most is that a primary care office across the hall was served a full spread of breakfast and lunch literally every day of the week. Starbucks coffee, too. I find it very difficult to accept the prices these companies charge for their drugs in light of all this waste. It wasn’t just drug companies either. Home health agencies pursued our office more agressively than drug companies. They were relentless!
The surgeons I worked for didn’t seem to give a crap who was pushing their goods. Patient satisfaction was what made their decisions, at least where I worked. I doubt many physicians prescribe any differently because of food and swag, but I just can’t imagine why these drug companies continue to spend huge amounts of money on this “bribery” if it isn’t working. The practice should be banned, or at least curtailed. Consumers shouldn’t have to pay for this kind of crap.
@MellowCat:
I doubt the bribery is what is working. Would you compromise your values and your efforts to do your job well for a free lunch? Even more so for health care professionals where patients’ lives and their quality of life is at stake.
The value of the drug reps is more likely their ability to get literature and up to date information on drugs to physicians. Also the free samples give the office the ability to get drugs in the hands of patients that may have financial or insurance issues.
Physicians sometimes have several drugs that are designed to treat a given condition. If all are known to be effective, which is the doctor likely to prescribe? Probably the ones that he is most familiar with and for which he has seen the latest studies.
The free lunches may help the rep establish a good relationship with the office staff which may be a prerequisite to getting their literature and samples to the physician.
@johnva: The interesting thing about the drug ads is all that small print. Or if audio, much fast talking about side effects.
@ClayS: Actually there was an article a few days ago which said most of the samples were going to people who would have no problem affording the drugs (insured people) and most of it wasn’t getting to those who really did need them.
Today I got to see firsthand the results the what I have been hearing about so much in the media, that our nations kids are becoming hooked and ODing on the plethora or prescription pain medication that Doctors today hand out so freely to their parents and other adults. My best friends 16 year old son died this morning at 6:30 from what was most likely an overdose of Methadone.
If you watch TV or read any magazine anymore you would think we Americans are totally unable to eat, sleep, have sex, pee, not pee, function in public, not stop eating…………………….without the help of the pharmacutical companies. At $150.00 for a 30 day supply of said medicine, of course.
We have to keep the direct to consumer marketing. If it was not for the commercials I would not know that 70% of the people that get genital herpes did not know their partner was having an outbreak, or as I like to see it, 30% hit it when it was all nasty.
I would also not know that a certain restless leg drug will turn you into Britney Spears. (sexual and gambling impulses)
I also would not know that a 4 hour erection was a problem called priapism and it needs medical treatment and not another BJ.
Marketing = Lobbying US Senate and Congress.
@JustRunTheDamnBallBillick.: There’s at least something to what trai_dep says, although in a slightly different direction.
For example, there’s some very promising work being done on arthritis “vaccines” (for the auto-immune varieties like rheumatoid arthritis, not for the osteo kind that’s a result of running out of cartilage when you’re old). However, it’s extremely difficult to get funding for this research, and most drug companies have shown little or no interest in the work.
On the other hand, drug companies are delighted to fund arthritis TREATMENTS. Which isn’t a bad thing — advances in arthritis treatments in the last 10 years have been pretty spectacular and allow sufferers to live far more normal, less-painful lives — but every auto-immune arthritis sufferer I know would much rather have the CURE than the treatments.
Some of the treatments run $1600/month, every month, for the rest of your life. The cure would be a one-shot deal. There is definitely a financial incentive to developing the treatments that doesn’t exist for the cure, which is part of why most of the research on the vaccines is being done in academic laboratories, not by drug companies.
Still, that doesn’t necessary mean this is a BAD way of doing things, except for two things: First, it can be very difficult to get “orphan” drugs (needed by only a few people) or high-liability, low-profit drugs (e.g., vaccines) MADE by drug companies even once they’re perfected. Second, substantially more research dollars flow to drug companies than academic research, and “cure” research tends to occur in academia. (For a few reasons, not least of which is that “cure” research is often more experimental and has far less of a chance of panning out than research which tweaks existing drugs to come up with better maintenance/lifestyle drugs, and that is a fair reason for a public company to avoid “cure” research; hardly anybody since AT&T was a monopoly has allowed research with no apparent commercial applications.)
So perhaps the solution would be to redirect government grant money away from drug companies (it bugs the heck out of me that they get to patent drugs discovered using US gov’t grants anyway and then charge so much for them, while other countries pay less!), or, in exchange for allowing direct-to-consumer advertising, require them to put X% of their ad budget towards producing orphan drugs or low-profit vaccines, which the federal government could parcel out among the companies to ensure adequate production. (They’re already willing to hand out liability waivers in the desperation to keep vaccines coming!)
@ClayS: “If all are known to be effective, which is the doctor likely to prescribe? Probably the ones that he is most familiar with and for which he has seen the latest studies.”
The problem there is that studies have been forged, fudged, and manipulated, since typically the drug company pays for them. There was a series of scandals a few years ago when it was revealed they commonly did their own research, fudged the bad numbers, then paid MDs huge chunks of cash to put the MD’s name on it when submitting it to an academic journal, to make it look like a 3rd-party study.
The practice is better-known these days, and some of the journals actively guard against it, but it still happens, and it still happens a LOT.
It’s not that drug companies “bribe” doctors; it’s that there are a lot of subtle ways they use to influence doctors, who are just as prone to being influenced by advertising as the rest of us (I myself am Pavlovianly trained to order pizza whenever a pizza commercial comes on), and a lot of ways to present them with falsified data that leads them to making less-than-optimal treatment decisions.
@Eyebrows McGee:
“The practice is better-known these days, and some of the journals actively guard against it, but it still happens, and it still happens a LOT.”
A lot? I really hope you’re wrong, because that is beyond scandulous. If mainstream medical journals are being duped, then what truly reliable source do doctors have for efficacy data and side effects for drugs?
Are you in the healthcare industry?
@ClayS: “Are you in the healthcare industry?”
I teach medical ethics. This article is outdated, but shows the scope of the problem:
[medicine.plosjournals.org]
The CSPI’s been continuously reporting on it; here’s an instance from two years after that article:
[www.cspinet.org]
The issue has become far more prominent since the WSJ’s story, but the problem does continue. And it is a very real question about whether there IS a truly reliable source of drug data for medical professionals; many GPs prescribe with this in mind. (Specialists have fewer problems with this, for a variety of reasons — they’re more likely to be involved in drug research/trials, they read specialized journals that aren’t targeted as heavily by drug companies, they prescribe (say) gastrointestinal drugs to 1,000 patients a year instead of 10 so have a good idea of the side effects simply from their own practice — but it is still a problem.) In some classes of drugs (luckily, mostly lifestyle drugs) that are heavily dominated by advertising, there simply isn’t much if any clearly valid data available.
It’s a terrible thing, because there ARE fair players in the industry, but it paints them all with the same brush. If I’m a drug rep who genuinely is interested in getting good, valid information to doctors about a new drug, in the hopes they’ll prescribe it when appropriate, and the other drug rep visiting today has falsified studies in hand and is just interested in selling as much as possible … well, we both get tarred with the same brush, and my decent data is thrown out with his crap data.
@Eyebrows McGee:
I think there’s a fair amount of financial incentive involved with producing a cure rather than a treatment, especially if you are the first out of the gate. See Merck’s Gardasil (the HPV vaccine).
The biggest issue is that it has to work, and it has to be worth the side effects. The problem with all the -mab drugs being explored as an option for arthritis is that they haven’t been shown to really “cure” arthritis on a long-term level… yet. So right now, they are basically just another treatment option. A treatment option that not many people will look at because 1.) They are expensive as hell and most insurances require you to jump through many hoops to pay for it, if they even pay for it at all. 2.) It’s an injection, which most people are inherently resistant to, and 3.) The -mabs are basically systemic immunosuppressants, which can lead to a lot of serious side effects considering that most people with arthritis are elderly and therefore already have a compromised immune system.
I believe that once they perfect those medicines, there will be a LOT more research dollars being thrown at them. But at the current stage in the game, there’s just too much wrong with them and not enough right for it to be worth it…
…And therein lies the Catch 22. A drug won’t be researched if it isn’t promising, but most of the time it can’t be shown to be promising without a fair amount of research.