Drug Advertising

The use of Vioxx and other NSAIDS such as aspirin, ibu- profen, and naproxyn, has resulted in dramatic rises in ulcers, bleeding, even death. Approximately 16,500 people die every year from NSAID-induced bleeding. There are over 100,000 hospitalizations annually in the U.S. for this side effect of NSAIDs, at an estimated cost of $2 billion annually. 

The cost of the medication is another problem: A three-month supply of Vioxx costs $206, while the same supply of acetaminophen can be purchased for just under $40. In elderly patients who often take eight or nine different drugs daily, the cost difference can be overwhelming. 

DTC ads for Vioxx worry Sasich, “Acetaminophen is not only cheaper, it doesn’t cause bleeding like NSAIDS. [This] puts patients at risk, not just physically—but it causes them financial harm as well,” says Sasich. 

Despite its huge costs and risky side effects, Vioxx skyrocketed to first place in sales among all drugs promoted by DTC ads in 2000. Its use increased 331 percent between 1999 and 2000. Merck ploughed $146 million into DTC ads for Vioxx in 2000, beating out ad spending for Budweiser beer and nearly matching Dell Computer’s ad spending for its top computer. Merck’s reward? Over $1.5 billion worth of Vioxx sold in 2000. 

Altogether, drug companies plunked down $2.8 billion on DTC ads in 2001, up from $2.5 billion in 2000 according to the NDCHealth. The 50 most heavily promoted drugs in 1999 through 2000 experienced a hefty 25 percent rise in sales—compared with an increase of 4 percent for all other drugs combined. 

IMS Health, an “information partner to the pharmaceutical industry” says DTC ads “empower” patients. In an article titled “Power to the People, Reaching the ‘Smart Market’ of Empowered Consumers,” IMS spins the ads as “education” that help patients make smart choices. Other advocates say DTC ads provide an important counterweight to the paternalistic world of medicine in which patients are often kept in the dark about their medical care. Playing the “power to the people” card hit pay dirt when several patient groups testified in U.S. Food and Drug Administration hearings in 1995 in defense of DTC ads. 

But Madison Avenue slogans work best when money follows. Drug company money is everywhere. The National Consumers’ League, one of the three non-profit groups that testified in the FDA hearings in support of DTC ads stated in the hearings that it received approximately 2 percent of its funding from drug companies that do DTC ads. They did not address the question of how much drug company money they received in all. The NCL did not respond to requests for documentation of the funding they receive from drug companies. 

The second group to testify, the Allergy and Asthma Network/Mothers of Asthmatics, Inc., (AANMA) did not disclose their financial ties during the hearings. However, a visit to their website shows that they have received funding from AstraZeneca Pharmaceuticals, Merck & Co. Inc., Pfizer Inc., and Proctor & Gamble Company, among others. An AANMA representative acknowledged that the group was receiving drug-company funding at the time of the FDA hearings. 

The third group, the National Kidney Cancer Association, now known as the Kidney Cancer Association, received in excess of $300,000 from drug companies in 1995, according to their federal tax report. They did not respond to questions about their funding at the time of the hearings. 

Besides empowering patients, advocates say DTC ads bring large numbers of patients in for under-treated conditions, like high blood pressure and elevated cholesterol. They also argue that DTC ads create competition, driving down drug prices. 

Critics say the ads don’t promote good medicine and that the newer drugs promoted in DTC ads have poorly defined risk profiles, a point made evident by a rash of recent drug withdrawals after patients died or suffered serious side effects, including liver failure and muscle breakdown caused by drugs such as Rezulin, Posicor, Duract, Baycol, and others. 

Critics also challenge the idea that DTC ads drive down costs. Prescription drug sales increased by 17.9 percent in 2001 and comprise the fastest growing health care expense. Much of the increase was concentrated among those drugs promoted by DTC ads and coincides with 12 to 46 percent increases in DTC ad expenditures every year since 1998. This at a time when the pharmaceutical industry enjoys a 19 percent profit margin, the highest of any business—eclipsing the 5 percent median profits of all Fortune 500 firms. 

Drug companies, faced with the increasing use of formularies (lists of drugs an institution recommends or supplies as cost effective) have found that creating patient demand can be more effective than supplying doctors with scientific evidence that their drug is more effective or safer than another drug. Dr. Philip Alper of the University of California at San Francisco wrote in the Journal of the American Medical Association, “What could be simpler than doing an end run around the cost- containment efforts of health managers and physicians by going directly to the patients to create demand that will be difficult to refuse?” 

Caught between patient satisfaction surveys and ever-pressing time constraints, doctors feel they are under the gun when confronted with a patient clutching an ad for a drug they want. A survey of family physicians found that 71 percent felt DTC ads pressure doctors into prescribing drugs that they would not normally prescribe. And, according to a study by the Henry K. Kaiser Foundation, when patients request a specific drug, doctors prescribe it 44 percent of the time. 

Yet patients are often in the dark about the nature of DTC ads and about the risks of the drugs promoted. According to one study, one-half of respondents erroneously believed that DTC ads received government approval prior to release and 43 percent believed (also erroneously) that only “completely safe” drugs could be advertised. 

In addition to adding cost and risk, the drugs promoted by DTC ads are often for unnecessary or “lifestyle” drugs that fuel the belief that there is a “pill for every ill.” Drugs for thinning hair, toenail fungus, and other problems are heavily promoted while important, inexpensive treatments, like water pills for high blood pressure, are ignored. 

For emergency doctors, patient demand for drugs of marginal value can create particularly daunting challenges. Dr. Robert Solomon, vice chair of the Department of Emergency Medicine at Ohio Valley Medical Center in Wheeling, West Virginia, feels he has no choice but to spend time undoing the bad information his patients receive. This isn’t easy when the emergency department is overflowing with patients having heart attacks and other serious emergencies. 

Solomon relates a recent incident: “Roche has been waging an aggressive marketing campaign for Tamiflu. The ad tells people some symptoms and urges them to call their doctor immediately if they have any of the symptoms. But, for all the patients who can’t reach their doctor right away, or their doctor isn’t willing to see them right away, where do they go? They come to me.” Solomon explains that most patients with cold symptoms don’t have the flu and even of those with a true influenza-like illness, only half will actually be infected with influenza virus. Of those, only 70 percent or so will benefit from an antiviral drug—and then only marginally, since the medication shortens symptoms by one day, at best. 

Doctors Feel The Squeeze 

Robert Roth, MD, a family practitioner in Kingston, New York, thinks DTC ads tend to interfere with proper treatment because some patients are hell-bent on obtaining prescriptions for a particular drug. He has seen patients who come in wanting a drug they’ve seen advertised. “If they come in and say, ‘Doctor, is this drug right for me?’ I can work with them and their condition. But some patients insist that a drug they’ve seen advertised is what they need.” In these situations, doctors with simple, low-cost, and effective treatments in mind find themselves fighting impressions formed by corporate ad campaigns calculated to seduce the public into demanding products. 

Recent surveys have shown that patients are disappointed if they don’t receive the requested drug. Forty-six percent of patients said they would try to persuade their physician; 24 percent said they would try to get the drug from another doctor; 15 percent said they might change doctors if they didn’t get the drug they requested. Some doctors admit that between time pressure and possible patient dissatisfaction, they are tempted to give patients what they want. 

But this can backfire too.According to a review of DTC ads in Health Affairs, in one scenario, a patient sees an ad for an antidepressant and she recognizes her symptoms as those of a major depression. She tells her symptoms to her doctor, who performs a careful history and physical exam, orders some tests, and concludes that the patient is hypothyroid. She is then successfully treated with thyroid hormone. 

A second patient presents with the same symptoms and shows the ad for the antidepressant to his doctor and requests a prescription for the medication. The doctor does a brief exam, confirms depressive symptoms, and prescribes the requested medication. Six months later the patient is hospitalized with severe hypothy- roidism. 

What Can Consumers Do? 

First of all, remember, Madison Avenue’s stock in trade is manipulating people into believing they need things they don’t. 

It isn’t unreasonable, say doctors, to ask about a drug. But focusing on the symptoms causing concern—rather than on advertised drugs is crucial. Turning to a trusted medical practitioner with a clear explanation of symptoms, rather than a mind made up about manufactured remedies is a more direct route to resolution of medical difficulties. 

In addition, consumers should look to non-commercial resources for health care information. Such sources are limited but options include Consumer Reports health newsletter, the National Library of Medicine’s MedlinePlus: medline- plus.gov/ and Harvard Medical School’s InteliHealth website: www.intelihealth.com.            Z 

Jeanne Lenzer has written for Harvard Medical School’s InteliHealth (which receives no drug company funding).