in Drugs and drugs policy

Drugs – no free lunch debate

Psychiatric drug critic Joanna Moncrieff and biomedical model champion Dr Trevor Turner were talking on the Today programme this morning.  The bone of contention is Moncrieff’s assertion, that we should not consider psychiatric drugs to be correcting an inherent ‘chemical imbalance’  and thus correcting a physiological abnormality, but rather to be drugs that alter brain states sometimes in a useful way.  I quite like this approach, it seems more humble and moves away from a ‘disease and correction’ model toward a more pragmatic symptom based model, which may be more compatible with non-pharmaceutical intervention.

Today discussion – 15 July 2009

Moncrieff’s paper – How do psychiatric drugs work?

Co-incidentally, I’ve volunteered to oppose the motion ‘this house believes that our lunch should continue to be funded by the pharmaceutical industry’ at a meeting today.  The ‘no free lunch’ debate is an ongoing one arising from concerns that pharma’s influence on doctors leads to a medical model biased towards ever increasing prescribing, a situation which is better for the pharmaceutical companies than for our patients or wider society.

Here is it, as ever I’d like to know what you think, unfortunately unless you comment in the next 30 minutes I’ll be unable to change the text!

I wish to oppose the motion “this house believes that our lunch should continue to be funded by the pharmaceutical industry”.  This is important for both our independence as doctors and is in the interests of our patients.  I will outline here why we should be wary of the pharmaceutical industry and why we should not accept their hospitality;

First a bit of history.  Before the 1930s doctors were pretty useless.  We had insulin, morphine and had worked out the benefits of conducting operations in sterile conditions, but that was about it.  Then miraculously an era of advancement between 1930-1970 produced an impressive array of medical cures such as antibiotics, transplants, ITUs, dialysis and during this time pharmaceutical companies grew big by producing and promoting innovative medicines for major diseases.

However of recent years it has become ever more difficult and expensive for these companies to repeat such successes and the number of genuinely innovative new products being released by them has significantly reduced.  I would argue that the continuing benefits of prior triumphs have led us to view pharmaceutical companies in the positive light of their past achievements, and we do not sufficiently scrutinize their current practice.

Today’s situation is that faced with maintaining their profits without the support of truly innovative products, pharmaceutical companies have engaged in refashioning and repackaging old products as ‘innovations’ and, worse, identifying and promoting new diseases for their medicines.  Many of the truly innovative treatments that have emerged in recent years have come from the funding of public bodies, whilst pharmaceutical firms have concentrated on ‘me-too’ drugs which aim simply to gain footholds in established and lucrative markets.

Psychiatry is particularly vulnerable to drug company tactics.  Our sketchily defined diseases provide opportunities for increasing product sales as they allow scope for expanding definitions of sickness, for instance depression, social phobia, female sexual dysfunction, to include more and more areas of social and personal difficulty not previously within the medical realm and thereby sell more medication.  Overall this has been  a very successful tactic and antidepressant prescribing increased 173% from 1991 to 2001.  The UK’s overall drug spending has increased from 3.9% GDP in 1960 to 7.7% GDP in 2002.

There are other concerns too.  The industry’s heavy involvement in the organisation of research into psychiatric drugs and the dissemination of research findings raises questions about the scientific objectivity of this research and the extent to which the industry is able to shape the research agenda. They also seek to gain advantage by political lobbying and funding drug-friendly patient support groups.  There has been disquiet about the burying of negative trials and over the exaggeration of drug benefits as newer expensive treatments such as SSRIs and atypical antipsychotics have not proved more effective than older and cheaper alternatives.

Pharmaceutical companies have thus sold us a reductionist biomedical model of the world.  They haven’t done this on their own of course, as it suits the purposes of many to live in a world where there are simple problems requiring simple solutions, but they have done their best to make sure that their voice is heard above any of those that might provide an alternate, non pharmaceutical vision.  For human beings can survive without endless drugs to cure every possible ill, but the companies that prescribe them cannot.  Pharmaceutical companies are primarily commercial concerns, and their major motivation is maximizing their profits.
But does this knowledge necessarily stop us accepting a free lunch from the dark side?  After all it saves us from buying our own thus allowing us to conserve funds in these uncertain times.  Can we not use our contact with pharmaceutical company representatives to evaluate what they tell us and learn about their products?

I argue no and for one simple reason: because we are weak.

Ask yourself this question: why would a commercial company, to whom profits are key, spend money on buying us lunch if they felt it would make no difference to our behaviour?  The answer is that they wouldn’t.  They know that by their engagement with us they can persuade us to use their products despite any other reservations we might previously have had.  They know that they can influence us to choose the treatment that is best for them, and not necessarily best for the patients we seek to treat.

You don’t need to believe me on this one.  Believe the authors of an article in the JAMA, who found that meetings with pharmaceutical representatives were associated with changes in prescribing practice.  And the next time you use your sponsored pen, consider an article in the Am J Bioethics, which concluded that ‘considerable evidence from the social sciences suggests that gifts of negligible value can influence the behavior of the recipient in ways the recipient does not always realize’.

The true situation is that pharmaceutical companies realize that in order for their products to find a market, they must first influence doctors to prescribe them and they spend a lot of money ensuring this takes place.  From early in our careers they win our favour by providing small gifts, and by taking part in medical education seek to inculcate us with their world view.

We should realise our vulnerabilities and not tempt ourselves so.  I’m not saying that drugs have no place in modern medical health care.  What I am saying is that as doctors we have but one duty, and that is toward improving the health of our patients; any action we may take to place ourselves at the risk of being influenced by another competing agenda is unwise and should be avoided.

For these reasons I commend you to join with me and oppose this motion.  Thank you.

Further reading:

Jackie Law Big Pharma – a comprehensive guide to this subject

Extract from Richard Bentall’s book Doctoring the Mind

Ben Goldacre on Medicalisation from his book Bad Science

The myth of the chemical cure Joanna Moncrieff BBC Health 15 July 2009
The myth of the chemical cure book on Amazon

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  1. Where I work (CAMHS) we have the ADHD drug reps round here every bloody week. They’re always offering to buy us lunch, sponsor a conference, give us all the stationary we can eat, invite us to a “webinar” (not sure what that is, because I decided I didn’t care)…and if we say we’re going down the route of parenting classes, CBT etc, they’ll offer to supply us all the worksheets and teaching materials for that too.

    In the end I got rather sick of them, and there’s no doubt it does skew the likelihood of a child being prescribed methylphenidate or atomoxetine. After all, if on one side there’s a pair of pushy parents loudly insisting that all that parenting classes stuff is bollocks and demanding you sort out their little monster, and on the other side there’s a set of smooth-talking drug reps telling you their wonders over a tasty sandwich…and in the middle is a stressed-out child psychiatrist…then it’s clearly going to increase the likelihood of that psychiatrist thinking, “Sod it, let’s give the meds a try.”

  2. I recently read this very good paper:

    on the PLoS, that gives details of how reps manipulate doctors emotionally so that they feel guilty and feel obliged to prescribe the rep’s drugs.

    It sounds as if the deliberate manipulations of sales reps are designed to “trigger” guilt in doctors (who are probably going to be very conscientious and perhaps are a bit more susceptible to that kind of thing than other groups would be). If the sales rep intimates that they feel disappointed in the doctor because the doctor said they would prescribe and then did not, the doctor could end up berating themselves. “I’m not good enough, I have disappointed him, he feels let down, I might harm patients if I don’t prescribe this drug, the nice friendly sales rep will be disappointed in me, I’ll have let everyone down”.

    I wondered whether such guilty ruminations might then combine to make the doctor look for and focus on the symptoms of patients that might fit the drug, and then simply be less aware of symptoms that did not fit, because he is more actively looking for justifications to prescribe the drug, in order to relieve himself of the pain of the guilt of letting the drug rep down, in having said he would consider prescribing it, and having done this when he was invited to lunch, so feeling under a sense of obligation, and the rep perhaps suggesting that he might be letting his patients down if he did not. Does this mean a doctor would feel less likely to “hear” evidence from the patient that did not support the case to prescribe it? It is just human nature – not deliberate deception or malpractice. The doctor might be more “primed” – because of guilt – to notice evidence that suggested he should prescribe it. The “rule” would be: “In order to please the sales rep, I need to find cases where I can safely prescribe this drug.”

  3. Hi,

    I’ve been lurking but haven’t said anything til now.

    How did your opposition go over?

    It looks to me like you struck just the right tone; balanced, not too preachy and did not demonize Pharma. I admire you.

    I wish I knew exactly where my pdoc stood on this issue. The pens/clocks/pads etc. are obvious and I know he’s given one drug talk. I don’t know why, but I feel funny bringing the subject up with him.

    I didn’t realize Pharma marketing is a big deal over there as well.

  4. Interacting with the pharma reps was by far the most interesting part of the time I spent working in a psychiatrist’s office. Unfortunately I did not at the time think to note and do not now have access to records that would indicate how the doctor’s relationships with any given rep correlated with his prescribing practices; certainly, he spent a fair bit of time trying to decide whether he wanted to maintain distance from them more or less than he wanted a sandwich on any given day.

    Personally I feel like the issue is tangential; yes, accepting lunch and clocks and pens and all that from people who are working very hard to be your friend is likely to have unfortunate effects on your practice, but declining lunch doesn’t go nearly far enough to correct the situation while offering a dangerous feeling of self-rightousness entirely out of proportion to the action. What’s needed here is better research practices and a more scientifically literate public; refusing a sandwich isn’t even a drop in the ocean.

  5. Hi, thanks for your interest. The turn out for the debate was disappointing. the vote was something like initially 7 for and 3 against (including me) with one abstention. (note to self: in future avoid posting on this blog what I am planning to say before it is presented and forgetting that my opponent reads what I write here…) After the debate it was 8 for and 3 against – the abstenter had made up his mind.

    I think if I was to give the talk again, I’d focus on the notion that doctors are free to keep the company of whomever they may choose in their own time, but in allowing them to be part of educational functions, we allow them into a space that is communal and, in a way, sacred. It is asking a lot from a doctor who may feel uneasy about receiving drug company hospitality to refuse a sandwich as this will aslo mean that they miss out on time spent with their peers, which can be very valuable. So drug company hospitality would best be restricted to meetings that are opt-in, rather than our current set-up, which is opt-out.

  6. Two studies suggest that incentives may change our behaviour:

    The first study looked at what drugs doctors prescribed when they were offered all-expenses-paid trips by drug companies to conferences sponsored by the drug company. (Orlowski and Wateska. 1992)

    This was done by checking the doctors’ prescribing patterns with the hospital pharmacy inventory. The prescribing of two drugs was looked at.

    The prescribing patterns were tracked for 22 months before each conference and 17 months after each conference.

    Ten doctors invited to each conference were interviewed about how likely they thought that such an incentive might affect their prescribing patterns.

    There was a significant increase in doctors prescribing both drugs after the all-expenses trips to the conferences.

    This alteration took place even though the majority of physicians who attended the symposia were sure that such incentives would not alter what they prescribed.

    The second study was the first large-scale study of its kind (Halperin et al. 2004).

    It demonstrated that:

    1. gift-giving in radiation oncology was endemic;

    2. each physician was likely to consider himself or herself immune from being influenced by gift-giving;

    3. he/she was suspicious that the “next person” might be influenced.

    There was a correlation between the willingness of individual physician to accept gifts of high value and their sympathy toward this practice.

    From these two studies, it sounds as if medical decision-makers worry that others are too easily persuaded and are very confident that they themselves can’t be – even though their own behaviour suggests that something quite different may be happening, and that the more it happens to them, the more they accept it as normal.

    Orlowski and Wateska.
    Chest. (1992; 102:270-273.
    “The effects of pharmaceutical firm enticements on physician prescribing patterns”

    Halperin et al.
    International Journal of Radiation Oncology, Biology and Physics:
    2004 Aug 1;59(5):1477-83
    “A population-based study of the prevalence and influence of gifts to radiation oncologists”

  7. Stumbled upon your blog. I’ve been trying to convince pharmacy students in the U.S. about why they too should refuse free lunch from reps as well. It’s confusing for them since the school allows large chain drugstores (ex. Walmart) to provide steak dinners at school. Keep fighting the good fight.