Key words: advertising, drug industry.
(Aust Prescr 2010;33:98-9)
Pharmaceutical companies can contribute to the quality use of medicines, when it is in their interests to do so. However, there are barriers against companies doing anything contrary to their interests. These include the Corporations Act, which requires officers to act in the interests of their company.1 Consequently, the extent to which pharmaceutical companies can make a beneficial contribution depends on what they are rewarded for doing. This is determined largely by government policies.
Current government policies include granting patent monopoly protection and subsidies which enable companies to charge prices way above production costs, in the hope of providing an incentive for research and development. Unfortunately, this leads to companies being rewarded even if they distort research to maximise revenue rather than provide the reliable evidence base that is the essential foundation for the quality use of medicines. One example of this distortion is the use of multiple analyses of clinical trial data with selective reporting of favourable results.2 Often such bias can only be detected if internal company documents are made available, for example by litigation.2
Paying high prices for new drugs is a less efficient way for taxpayers to fund research than direct grants to researchers. This is because most of the money from sales is diverted to other functions, especially promotion. Promotion involves synergistic combinations of many activities including persuasion disguised as education. Despite claims that some pharmaceutical sponsorship is 'unconditional', under the Corporations Act company officers 'may not be generous with company resources when there is no prospect of commercial advantage to the company'.1 Sponsorship can influence medicines use indirectly by eliciting reciprocal obligations that can work in many ways, including making it seem rude to refuse to see the company's representatives or to criticise the company or its products.
Promotion can improve the use of medicines when the promoted drug is superior to the alternatives and the information provided is complete and accurate. However, according to Australian Prescriber's French equivalent (Prescribe International), between 2000 and 2009 only 2.0% of new drugs and new indications were a real advance.3
The current system provides frequent large rewards for misleading promotion, but only rare small punishments. During the past 25 years, I have not found a single drug advertisement that does not include misleading persuasion techniques. There is even less accountability for what sales representatives do behind closed doors. Sometimes entire sales teams are misled by their own companies.2 Consequently, I believe the voluntary code of conduct for promotion is failing.
Health professionals are part of the problem because we often reward companies for producing misleading promotion by increasing use of the promoted drug. Many health professionals believe they can sort biased from unbiased information4 but there is no proven method for preventing, diagnosing or treating bias. Just as 19th century obstetricians, who did not understand the germ theory of disease, denied that they were asymptomatic carriers of the bacteria causing puerperal fever, many of today's health professionals deny their vulnerability to bias, because they do not know about the psychology of persuasion. Persuasion often works below the radar of conscious awareness. Overconfidence is a major risk factor for being misled.4,5
Another of the causes of problems in the pharmaceutical industry is that companies are currently allowed to perform, fund or influence multiple functions including manufacturing, research, promotion, education, regulation and policy development. Companies are rewarded for each function, not according to how it contributes to improving medicines use, but according to how effectively they use each function to increase sales revenue. There are therefore incentives for bias in the performance of each function.
I believe that the pharmaceutical industry's capacity to contribute to the quality use of medicines could be dramatically improved by reforms.6 Splitting 'Big Pharma' into separate companies with one function each and abolishing patents and subsidies to allow free market competition between manufacturing companies would probably lead to prices for most worthwhile drugs plummeting below current co-payment prices.7The savings could be used to fund research and improvements in the use of medicines.6 Such reforms could create an environment where pharmaceutical industry staff would be more consistently rewarded for contributing to the quality use of medicines. They would be empowered to use their considerable skills more consistently for the benefit of all.
References
- Australian Government Corporations and Markets Advisory Committee. The social responsibility of corporations. Canberra: The Committee; 2006.www.camac.gov.au/camac/camac.nsf/byHeadline/PDFFinal+Reports+2006/$file/CSR_Report.pdf [cited 2010 Jul 7]
- Jureidini JN, McHenry LB, Mansfield PR. Clinical trials and drug promotion: selective reporting of study 329. Int J Risk Saf Med 2008;20:73-81.
- A look back at 2009: one step forward, two steps back. Prescribe Int 2010;19:89-94.
- Fischer MA, Keough ME, Baril JL, Saccoccio L, Mazor KM, Ladd E, et al. Prescribers and pharmaceutical representatives: why are we still meeting? J Gen Intern Med 2009;24:795-801.
- Sagarin BJ, Cialdini RB, Rice WE, Serna SB. Dispelling the illusion of invulnerability: the motivations and mechanisms of resistance to persuasion. J Pers Soc Psychol 2002;83:526-41.
- Mansfield P. Industry-sponsored research: a more comprehensive alternative. PLoS Med 2006;3:e463. http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0030463 [cited 2010 Jul 2]
- Baker D. Financing drug research: what are the issues? Washington DC: Center for Economic and Policy Research; 2004 Sep 21. www.cepr.net/index.php/publications/reports/financing-drug-research-what-are-the-issues/ [cited 2010 Jul 7]
Note: The views expressed in this editorial are the author's and do not necessarily reflect the views of others in any of the organisations he is associated with.
Dr Mansfield holds a National Heath and Medical Research Council National Institute of Clinical Studies – Therapeutic Guidelines Ltd Fellowship.
