According to the Canadian Medical Association Journal, our government should continue to prohibit research-based drug makers from communicating with patients through direct-to-consumer advertising (DTCA). A survey reported in the latest issue of the journal that shows that patients who request advertised drugs from their doctors are much more likely to receive prescriptions than patients who do not.
The journal’s contributors suggest that DTCA increases the price and cost of prescription drugs, encourages people to buy “lifestyle” drugs for baldness or sexual dysfunction, and lures patients into taking medicines without understanding the risks.
According to the survey, patients who requested advertised drugs receive them in 86 percent of cases, whereas patients who did not request drugs only receive prescriptions in 26 percent of cases. However, the survey also showed that patients who request non-advertised drugs receive prescriptions in 74 percent of cases. So, while DTCA explains some increase in patients’ requests for prescriptions, it is quite minor relative to other, unexplained, reasons why patients request prescriptions. If the journal’s authors really think that patients’ taking up their physicians’ valuable time by asking them questions about medicines is a problem, banning DTCA is a pretty trivial step. They should propose a law that forbids patients from talking about medicines to their doctors at all!
The survey asked doctors to indicate whether the prescriptions written were “very likely”, “possibly”, or “unlikely” to be the right choices. For prescriptions written without patients’ requests, only 12 percent were considered “possibly” or “unlikely” to be appropriate. For prescriptions for requested, advertised drugs, the rate of ambivalence was 50 percent. However, the rate of ambivalence for prescriptions for requested, non-advertised drugs was 39 percent, so we have the same problem as above. Although advertising increased ambiguity somewhat, the big jump occurred when a prescription was requested for other reasons.
Of course, the real question arising from these results is: Why did the doctors cave in to their patients’ requests without exercising their professional duty of care? Happily, the reported numbers do not indicate that the increase in prescriptions had a net negative effect.
This is because we do not know how many “possibly” or “unlikely” prescriptions would have caused negative outcomes.
The real number is unlikely to be that high. The US Food and Drug Administration recently completed a survey of 500 American physicians on the fifth anniversary of the liberalization of DTCA there. In 91 percent of cases, patients did not try to influence the treatment in a way that would have been harmful.
Furthermore, although many thousands of prescription medicines are sold in the US, only 50 accounted for 95 percent of all DTCA spending in 2000, and the top ten accounted for 41 percent of spending. Viagra®, was the only one of the top ten that could be described as a lifestyle drug. The other nine treated cholesterol, obesity, stomach ulcers, depression, arthritis, or allergies. Propecia®, for baldness, ranked 41st with less than one percent of total DTCA spending.
If we compare spending on DTCA in the US in 2001 with overall spending on prescription drugs down there, the numbers imply that a $49 prescription would “contain” advertising costs of one dollar – hardly a big deal. However, even this analysis is overly simplistic. Advertising enhances competition by increasing awareness of different products. It is expensive for patients to learn about different products, and advertising reduces these costs. The better-informed patients are about alternative therapies, the more leverage they have over individual suppliers. Furthermore, many drugs that are advertised are for conditions that are under diagnosed and under treated, as even the journal’s editor admits.
As well, governments pay almost half of all prescription costs in Canada. Therefore, there is a conflict of interest in government regulation of DTCA. If regulations preventing DTCA keep patients ignorant of alternatives, they won’t know if government drug benefit plans are giving them good coverage.
Canadian patients have a right to diverse sources of information about therapeutic alternatives, not just what their governments or physicians want them to know. Direct-to-consumer pharmaceutical advertising should be one of those sources.