How Drug Companies Control Doctors

March 21, 2024 by Doctor Vernon Coleman

The following essay is taken from `Betrayal of Trust’ by Vernon Coleman, which was first published in 1994.

Any remaining doubts about the effectiveness of the drug industry in controlling doctors’ prescribing habits can be removed when one studies what happens to new drugs which are put onto the market. If drug company promotional efforts were of little significance it would be reasonable to suspect that new drugs would only acquire a noticeable market share after a fairly lengthy time period. After all new drugs are competing with existing products which are, by definition, well tried. Theoretically, it should be quite difficult for a new product to break into the market place and acquire prescriber loyalty.

In practice, however, new products become ‘fashionable’ very quickly – far more speedily than one would imagine they might. In a report entitled ‘Market penetration of new drugs in one United Kingdom region: implications for general practitioners and administrators’ authors from the Drug Utilization Research Unit at the Department of Therapeutics and Pharmacology of Queens University in Belfast, the Department of Bacteriology at the Royal Victoria Hospital in Belfast and the Department of Therapeutics and Pharmacology at Queen’s University of Belfast concluded that: ‘The increase in prescribing of these (new) drugs seems to be greater than can be accounted for by an increase in patients with specific indications for these drugs. This suggests that the profession has not instituted effective checks to ensure that the legitimate promotion of new products does not lead to inappropriate and wasteful use.’

If there are any final doubts let them be removed by this comment from a study commissioned by a group of five pharmaceutical companies. The study concluded that: ‘pharmaceutical manufacturers can have confidence that...when sales messages are communicated through journal advertising market shares of new prescriptions will increase.’

Now, this would be of only limited significance if the drug companies – whose exhortations must have been responsible for this over enthusiastic prescribing – were honest and honourable when it came to promoting their new products. After all if the drug industry was scrupulously accurate in its advertising and promotion it wouldn’t really matter whether doctors got their prescribing information from an official body or the industry. But the industry’s advertising isn’t honest.

According to a survey recently published in the Annals of Internal Medicine 62% nearly two thirds of the pharmaceutical advertisements in medical journals were either grossly misleading or downright inaccurate. A total of 109 advertisements from 10 leading medical journals were each reviewed by two doctors and an academic clinical pharmacist. The reviewers used guidelines from the Food and Drug Administration to assess the advertisements. In 30% of cases the independent reviewers disagreed with the advertiser’s claim that the drug was the drug of choice. In 44% of cases the reviewers thought that the advertisement would lead to improper prescribing if a doctor had no information about the drug other than that provided in the advertisement.

In Britain the Association of the British Pharmaceutical Industry tries to regulate itself through a voluntary code of practice but a study published in 1990 by Andrew Herxheimer and Joe Collier, past and present editors of the Drug and Therapeutics Bulletin, concluded that: ‘the code has failed to deter promotional excesses’. The authors of the study estimated that between 1983 and 1988 no less than 100 breaches of the code were detected a year. (You will remember, however, that in a decade the International Federation of Pharmaceutical Manufacturers Association had received just 72 complaints).

The secretary of the Association of the British Pharmaceutical Industry was reported in the British Medical Journal as commenting: ‘We are currently updating the code, but we think it’s already working adequately.’

The power of the drug industry to control its working environment and, to a large extent, its own destiny was vividly illustrated in 1993 when an attempt was made in the British Parliament to introduce a new piece of legislation (the UK Medicines Information Bill) which was, modestly and apparently sensibly, intended to overcome the secrecy behind the decisions about drug licensing applications.

Astonishingly, the law in Britain prevents the government from releasing any information about drug companies and their products. Neither the medical profession nor the public have any right of access to information about prescription drugs. Even victims of side effects of licensed medicines are unable to find out anything about the drugs they have taken (inevitably, this helps to make it difficult for a patient who has been injured by a drug to sue the manufacturing company).

The proposed bill failed to pass onto the statute book because of 77 amendments that were tabled and which meant that the time available for the bill ran out. Most of the amendments were tabled by a number of Conservative Members of Parliament who receive payments to represent the pharmaceutical industry. The government explained their apprehension about the proposed change in the law by warning that disclosing formerly confidential information about drugs (including details of how they had been tested prior to being put on the market) would ‘cause unjustified alarm’ and ‘would increase the danger to the public’.

Some critics have claimed that the government’s reluctance to allow information about pre-marketing drug tests to be made public (despite its clear promise under the Patient’s Charter to make available to patients a clear explanation of any proposed treatment) was not so much a sign of their determination to keep information secret as a sign of their embarrassment at the possibility of the public finding out just how little information they have when licensing new drugs. The government frequently claims that the Committee on Safety of Medicines is an effective way of monitoring drug problems but only a tiny minority of doctors ever bother to report side effects to the CSM which is, as I have often complained, more of a toothless poodle than an effective watch-dog.

Just as frightening is the way that the pharmaceutical industry manages to influence so many of the world’s apparently independent medical journals. In my early book ‘Paper Doctors’ (published by Temple Smith in 1977) I reported how some journals were charging drug companies a fee – said to be around £500 – to publish an article of average length. The Journal of International Medical Research, for example, was in September 1975 charging £85 per printed page for scientific papers published in it. According to the publishers, `In addition to publishing medical and scientific papers the Journal of International Medical Research also undertakes the recording, transcription and publication of symposia, under its imprint; with, where necessary, the translation of the proceedings into languages other than English.’

Volume 3 Supplement 3 of the Journal included the proceedings of an international Vivalan Symposium held at the Cunard International Hotel, London. This symposium was attended by 28 foreign employees of Imperial Chemical Industries Ltd, the manufacturers of Vivalan,(an anti-depressant drug), 78 doctors from Argentina, Australia, Belgium, Brazil, Denmark, Eire, Finland, France, Germany, Holland, Italy, Japan, Mexico, Norway, Poland, Portugal, Sweden, Switzerland and Yugoslavia, and 110 doctors from different parts of the United Kingdom. There were 125 pages in the Journal Supplement referring to Vivalan.

When I wrote to ICI for prescribing information about Vivalan I was sent a colourful and well produced brochure describing in the usual glowing terms the work done, proving how effective and unique Vivalan is. The prose was based largely on twelve references listed in the back of the brochure in proper scientific fashion. The majority of these references dealt with information published in the Journal of International Medical Research. Did ICI pay for the publication?

I commented in ‘Paper Doctors’ that few GPs would see the Journal regularly and even fewer would know that companies bought space in it to publish their papers. Many doctors probably see nothing wrong in companies paying for the publication of articles. But it worries me.

During the decade and a half since the publication of ‘Paper Doctors’ drug companies have become even cleverer and these days many drug companies ‘use’ apparently independent doctors to get their papers published in medical journals. One drug company employee I spoke to complained bitterly that his research work was regularly being published under the names of doctors who had done little or none of the work. The doctors are, of course, happy to have their names on these papers (publishing scientific papers is essential for the doctor who wishes to make his way up the career ladder in academic medicine).

In 1992 The Lancet reported on a new publication entitled ‘Medical Publishing’, the third in a series of practical guides by Pharmaceutical Marketing. This publication, giving advice to company employees trying to get articles published, explained: ‘The editor should be unaware that you are behind (the offer of a review article) so don’t offer it free of charge if the journal normally expects to pay contributors, nor use your company address’.

Around the world even apparently reputable journals now frequently publish supplements dealing with specific drugs which are supported wholly or partly by the companies making those drugs. The company concerned can then quote the references from the journal supplement in its advertisements and its sales representatives can quote the supplement when talking to potential prescribers. There is no doubt in my mind that many otherwise sceptical doctors are influenced by the apparently independent nature of these supplements and similar publications. Dr George Dunea, attending physician at Cook County Hospital in Chicago, put it straightforwardly enough when he wrote, in 1992, ‘considering the pharmaceutical industry’s enormous influence on doctors’ prescribing habits, there remains the point of view that neither doctors nor institutions should have to depend on the money of drug companies, nor for that matter the medical journals that carry their advertisements – surely a different prescription to follow in the real world.’

The simple truth is that the drug industry has ‘bought’ the medical profession and that it now controls the education of graduate doctors and the way in which patients receiving drug therapy are treated.’

Note

This essay is taken from the book `Betrayal of Trust’ by Vernon Coleman. `Betrayal of Trust’ can be purchased via the shop on www.vernoncoleman.com