The Bay Area Reporter - June 2, 2000
Matt Sharp, Survive AIDS Writers Pool

These are the new marketing forces of the pharmaceutical industry: drug sales representatives, and they are seeking the ear of the care providers in order to get the word out about their products. The reps are inundating doctors' offices because this kind of marketing has become necessary due to increased competition in the field. There are 68,000 salespeople in the pharmaceutical industry today where in 1994 there were 36,000. Sales representatives are simply an additional part of the overall marketing strategy to sell drugs. And today, it is clear that drugs have become big business, unfortunately increasing the overall cost of health care.

The issue has raised concerns by many physicians and patients before, but is just now reaching widespread attention through the mainstream media. In the May issue of New York magazine, the cover article concerns Celexia, a "me too" antidepressant drug that missed the U.S. market because of poor toxicity data that prevented its approval. Now, because of aggressive marketing by its maker, Forest Laboratories, the drug has cornered the antidepressant market. Clearly, AIDS is not the only area where pharmaceutical marketing is booming. Television and print media are full of slick advertisements designed to make drugs look good.

There are 15 anti-HIV drugs available, each with different side effect profiles, dosing schedules and effectiveness. So, the doctor and patient have several choices to make. The decisions are complex and are individual, based on patient history and diagnosis. But, sales representatives have been unleashed to help influence doctors' decisions and sell their company's drugs, sometimes taking advantage of the complexity of HIV treatment and uneducated, unethical health care providers. The situation has serious implications for prescribing inferior or inappropriate treatments, risking the patient's health.

There is ample evidence to show how promotion of drugs influences treatment decisions made by physicians. One study in the Journal of the American Medical Association, in 1994, showed that physicians were shown to change their decision of drug formularies when they were influenced by drug companies. Doctors also were rewarded with expensive gifts and lavish trips in exchange for a speaking engagement for a specific drug. The AIDS activist community has even become bombarded with compromising honorariums, gifts and trips to attend "dog and pony shows" staged by companies. One company recently held a community meeting over a weekend at a first-class beach front hotel in Santa Monica, California. Even more disturbing is the companies will present biased or "curbed" data at these meetings in order to make their drugs look better than they actually are.

Regardless of the pharmaceutical sales pitches, gifts, and honoraria, ethical doctors who know the research can still make sound treatment decisions. Dr. Virginia Cafaro, a Bay Area infectious disease physician, said, "The sales pitches are endless, but how much does anyone listen is the question." She said sales representatives do serve a purpose by providing education on new medicines. Even though she doesn't spend much time with the reps she will allow the companies to buy lunch for her staff, in essence buying time to hear what they have to say. Cafaro stated, "Free drug samples also help us get patients started and sometimes treated with meds that may not be covered by their insurance or MediCal."

Dr. Robert Goodman, an internist who works for Columbia-Presbyterian in New York, is trying to educate physicians on the marketing effort. He has started a Web site, www.nofreelunch.org, that is a wealth of information on the pharmaceutical marketing influence on physicians. He said that physicians are too arrogant and na ve and that you will never hear them admit a sales pitch is influencing them.

Drug companies counter their aggressive marketing strategies by claiming that research and development costs are the reason for the high prices of drugs, and say that increased competition forces aggressive marketing. When you look at the data, however, it is clear that the companies spent over $10 billion on promotion, which is much more than research and development costs, more than the raw materials, and more than is spent on medical school and residency training. Most would agree that drug companies are a business and have to sell their products in order to continue research, but the trade off is how far should marketing go if it negatively influencing treatment decisions.

Are people with AIDS getting responsible treatment and care in this era of aggressive sales pitches? Could there be a bias with treatment decisions because of the pharmaceutical sales influence? Is marketing winning out over sound scientific data? Perhaps what is needed are more knowledgeable patients working with their doctors and other health care providers to make the best, most appropriate treatment decisions regardless of the sales pitch. Either way, the problem may only intensify as the Food and Drug Administration loosens restrictions on commercial advertising, the sales representative forces grow larger, and more AIDS drugs become competition for each other.

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