How The Big Players Sell Drugs and Influence People
This very disconcerting story was taken from The Age in February 2007. I believe it is a MUST READ not only for all patients of the practice, but for the many millions of Australians who continue to take a “pill for every ill”.
It is rather long but well worth the read.
If you are on drug medications it is your right to question whether you really need it.
I am not saying that you should arbitrarily throw away your blood pressure medication.
BUT you should explore all possible natural and lifestyle solutions to your problems and discuss with your practitioners ways you can reduce your dependency on drugs.
Professor Martin Tattersall has a big job – the committee he heads decides which medical drugs are allowed into Australia. For that, he needs experts to help him evaluate the dozens of medications submitted each year.
Professor Tattersall, a cancer specialist, also has a big problem. He says that finding experts to sit on the committee is now all but impossible because so many doctors have ‘huge conflicts of interest’ with drug companies.
For years, drug companies have targeted the cream of Australia’s medical profession – the so-called ‘key opinion leaders’ – to work as paid consultants or to sit on company advisory boards. But people in senior positions, such as Professor Tattersall and Professor Lloyd Sansom, chairman of the Pharmaceutical Benefits Advisory Committee, which recommends to governments which drugs to subsidise, say the problem is not endemic.
Doctors with financial ties to drug companies are now in every corner of medicine. They write guidelines that dictate how thousands of patients are treated. They speak to the media and teach other doctors with power-point presentations finessed by drug companies.
They are the well-respected heads of patient groups, foundation and professional bodies. They are gatekeepers for hospital pharmacy lists, where decisions to favour one drug over another could mean thousands of extra taxpayer dollars.
A few spend weeks, sometimes months, away on drug company business, even though they are employed by the public purse in universities and hospitals.
Early last month, Professor Tattersall was complaining about the issue at a Canberra meeting with 11 other heads of crucial committees advising the Government on drugs and medical devices.
“I think I would be right in saying that almost every chairperson raised it as a common issue,” says Professor Tattersall, chairman of the Autralian Drug Evaluation Committee for the past decade. “The issue of buying the key opinion leaders is so overt these days.”
For the medical elite, the result is a spreading ambiguity and erosion of professional independence. For the public, the issue is whether the advice given in media interviews – or even by their doctors – is tainted by drug company influence.
An ophthalmologist, who spoke to The Age on conditon of anonymity, said the drug companies were teaching key opinion leaders how to “push poll” other doctors. “The opinion leaders become product champions,” he says. “This is what will slowly kill the profession and its standing in the community. It has gone way beyond a couple of endorsed pens and umbrellas.”
The issue has recently become so hot within the profession that new voluntary Royal Australasian College of Physicians guidelines have called on institutions to track and, when necessary, act to reduce the doctors’ conflicts of interest.
The Age can reveal that several major Melbourne hospitals, including the Peter MacCallum Cancer Institute and Southern Health, are reviewing their policies. Some institutions ask doctors to reveal conflicts, but they are moslty guided by voluntary professional codes.
Doctors are forced to list conflicts only in medical journal articles. In some ways, it is the real gravy train. On senior pharmacist at a major hospital says that there is now a “clinical drug trial circuit”. Doctors who criticise a company are unlikely to get free stocks of a new drug, be asked on an advisory board or participate in a clinical drug trial, so there is pressure to maintain “reasonable working relationships”.
A study published last year in the Archives of Internal Medicine estimated that 23 percent of specialists were now on an advisory board – groups of doctors who are paid up to $10,000 a year for their advice on a drug or a disease – and 5 percent were paid consultants.
The study’s lead author, Professor David Henry, a University of Newcastle pharmacologist, estimates that 60 percent of key opinion leaders sit on advisory boards or are paid consultants to industry.
Professor Henry says advisory boards and consultant positions are “open-ended” – largely unsupervised by institutions, which left the specialist feeling an unconscious committment to the company. Doctors, he says, do not necessarily sit on advisory boards for the money, but to be with their esteemed colleagues in a social setting. “It’s not the spectacular entertaining of doctors that worries me,” he says. “It’s more the subtle stuff – where people essentialy become part of a company.”
A group of specialists, led by Paul Komesaroff, a physician, medical researcher and philosopher at Monash University, believe drug company influence is a serious concern. But this group faces stiff opposition. The battle intensified when Professor Komesaroff led the recent rewrite of the phyicians’ voluntary guidelines. A vocal minority disputed the evidence that even small, trivial things come with strings attached – the proposed guidelines recommended doctors not even accept pens and pads. Earlier versions spelt out a more forceful statement on travel to conferences that were funded by drug companies. But this was overruled by popular statement. Instead, doctors were told such offers “should be considered carefully before being accepted”.
There is evidence that the links between drug companies and doctors do influence how they prescribe. Professor Komesaroff points to research published in some of the world’s most prestigious medical journals that shows the more interactions a doctor has, the more he or she is likely to prescribe that company’s pills, even if a better, more cost-effective drug is available. A review of the academic literature in 2000, published in the Journal of American Medical Association, found that meetings with drug representatives were linked to doctors requesting that company’s drugs be put on the hospital pharmacy list. Attending presentations by pharmaceutical representative speakers was also associated with “non-rational” prescribing.
Most medical professionals refuse to talk about their relationship with the drug industry. Many specialists declined to speak to The Age for this article or did not return calls.
The Victorian Department of Human Services refused to recommend to hospitals that they release their conflict-of-interest registers. Drug companies say privacy law prevents them from revealing the doctors on their advisory boards, while the Federal Government cites the same legislation for keeping secret the conflicts of interests of those sitting on key drug evaluation committees. Of the eight heads of cancer departments in Melbourne’s major hospitals, only one would talk on the record about how the industry tries to influence them.
When The Age asked gastroenterologist Terry Bolin, the Gut Foundation president, what advisory boards he sat on, he replied: “I don’t think that’s any of your business.”
Many specialists are insulted at the suggestion that they have lost independence and insist that advisory boards are purely scientific. But there are clues that hint at another agenda. On www.pmlive.com, a website of marketing tips for the pharmaceutical industry, it is all spelt out. One article provides the tip that companies ditch key opinion leaders (KOLs) if they are “over-exposed, over-paid and over-the-hill” and replace them with “up-and-coming rising stars” who will inject a fresh “enthusiasm and support for your brand”. “Although you might be talking to a world expert, they still need to be clearly briefed and understand the data and what is required of them,” the website says.
Flattery is key. A Melbourne specialist told The Age he was recently visited by two drug representatives. As they sat in his office, one of them told him that he was not only an opinion leader, he was a key opinion leader. There is an expectation, says a cancer specialist – who sits on several advisory boards – of speaking to the media about new developments and trials.
“But I am unwilling to do that,” the doctor says. “It is hard to talk to the press without giving the impression of hype.”
But he says advisory boards gave doctors the opportunity to exert some influence on companies, especially lobbying against ridiculously high prices.
Last year, British pharmaceutical giant AstraZeneca was fined $25,000 when it was caught using advisory boards to promote an unapproved use of Symbicort, an asthma inhaler drug. The code of conduct committee of Medicines Australia, the pharmaceutical industry body, found that the meetings appeared to be for priming key opinion leaders about a possible new use for Symbicort.
“This was a disturbing marketing concept,” the committee concluded.
The Age believes that some doctors send their invoices for service on advisory boards not directly to the drug company but via other organisations, some of which have “marketing” in their names. Elsewhere, Melbourne Pathology infectious diseases physician Rob Baird told The Age that British pharmaceutical company GlaxoSmithKline has deliberately enlisted Australia’s most prominent herpes experts to an advisory board with the aim of promoting long-term suppressive antiviral therapy for sufferers, the efficacy of which is not proved.
GlaxoSmithKline, which makes the genital herpes drug Valtrex, admitted enlisting key opinion leaders but stands by the safety of long-term drug therapy for herpes. Medicines Australia denies that advisory boards are about marketing and says its new code of conduct edition asks companeis to justify the boards if a complaint is lodged.
A Medicines Australia spokesman denies the use of KOLs has become too widespread, saying they provide advice on new medicines that ultimately benefit patients. For some doctors, advisory boards are a natural correlation: as leading experts they are most likely to be sought after by drug companies.
For example, Professor Philip Sambrook, medical director for Osteoporosis Australia, is on an advisory board for Fosamax, a drug that helps increase bone mass.
Associate Professor Matthew Naughton is president of the Australasian Sleep Association, the main body of sleep physicians, but also sits on the advisory board for ResMed, a large manufacturer of devices for sleep apnoea sufferers.
Doctors also like the kudos and intellectual stimulation. Some say they lose money serving on boards as it takes time away from seeing patients in private practice.
Professor David Barnes, the chair of professional standards for the Thoracic Society of Australia and New Zealand, has been on advisory boards in the past, and defends them as a way to advise on the Australian context for an important drug, device or disease.
“It’s purely a scientific discussion on the pros and cons of their products, particularly medication, and where it fits in to patient management.”
Oncologist Grant McArtur, at the Peter MacCallum Cancer Institute, agrees. In the modern era of new biological cancer therapies, he says, the doctors must work in collaboration with industry for the sake of patients.
Clinical guidelines can potentially expand or decrease a drug’s market depending on where the line is drawn between what is considered healthy and what is not. Of the 12 specialists who wrote the Heart Foundation’s guidelines on lowering cholesterol only five had no conflicts of interests to declare.
Professor Andrew Tonkin, the Heart Foundation’s outgoing chief medical officer, says guideline authors often have industry connections because they were leading research involved in drug company-funded trials.
But Professor Tonkin said transparency was important. He resigned from advisory boards when he joined the foundation, but still does some drug-company clinical research and gets speaker fees, although they may be directed to the foundation.
The independence of clinical guidelines is a matter of great controversy in the US and a “fundamental concern” in Australia, Paul Komesaroff says.
“I am not saying that everyone’s opinions are contaminated, but I think many people’s opinions are potentially contaminated.” He also believes that heads of foundations should be “at arms length” from industry.
Professor Tattersall says greater transparency is required and suggests doctors have their conflicts of interests listed in waiting rooms or on letterheads. It should be no different from the requirement on financial planners to disclose their interests, he says.
HOW IT WORKS
Works in a large institution, respected by peers. Could be head of disease foundation or professional society.
As a ‘key opinion leader’, the doctor is asked to sit on an advisory board or be a drug company consultant. He is flown to meetings twice a year and is paid up to $10,000 annually. Sometimes, the money goes to his public institution. He advises the company on disease developments and the Australian context of a drug.
The doctor is approached to run clinicial trials for a drug company. Funds may go to his department and his patients get access to new drugs they might otherwise not have had.
The doctor flies business class to conferences overseas and locally. Sometimes he is asked to give talks on the company’s drugs.
Conferences and Dinners
The doctor presents information to his colleagues at dinners and conferences. He may educate GPs about a company’s drugs.
He is called on to speak to media about a disease or a drug, and sometimes does not disclose connections to the drug company.
Studies that have shown drug company influence over doctors – prescribing habits.
- Bowman, Journal of Continuing Education in the Health Professions, 1988. Prescriptions for sponsors’ drugs increase in the six months after an event paid for by drug companies.
- Lexchin, Canadian Medical Association Journal, 1993. Advertising of drugs to doctors results in acceptance of commercial rather than scientific views.
- Chren, Journal of American Medical Association, 1994. Strong association between drug company interactions and doctors requesting a company’s medication to be added to a hospital drug list.
- Stryer, Journal of General Internal Mdicine, 1996. Material distributed by pharmaceutical companies is often biased, incomplete or unsupported by evidence.
- Loke, Medical Journal of Australia, 2002. Only 57 percent of drug advertising material distributed in Australia can be supported quantitatively.