Pharma Promotion

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Educao e Informao aos

Profissionais Prescritores e

Usurios como Instrumento para

o Uso Racional

Promoting Quality Use of

Medicines via Education andInformation for Health

Professionals and Consumers

Dr Peter R [email protected]

Healthy Skepticism

www.healthyskepticism.org

Brasilia

6 April 2005


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Topics

1. The current situation in Australia:Information provision

2. How to increase resistance to misleadingpromotion: Overcoming overconfidence

3. AdWatch website

4. Teaching healthy skepticism5. Policy recommendations for education

about drug promotion


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1.The current situation in Australia


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National Medicines Policy

Quality, Safety and Efficacy

Therapeutic Goods Administration (TGA)

Access

Pharmaceutical Benefits Scheme (PBS)

Viable pharmaceutical industry

Dept of Industry ?PBS Quality Use of Medicines (no govt dept)

Missing: Health Professionals, Consumers,Health


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Quality Use of Medicines

National Prescribing Service

Australian Prescriber

Drug and Therapeutics Information Service

Educational visiting

Therapeutic Guidelines

Australian Medicines Handbook

Healthy Skepticism


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Providinginformation

works when

people knowthat they

dont know.

(doctorsoften dont)


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Information for consumers


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Adverse Medicines

Events Line Consumer product

information

NPS TelephoneInformation Service

Health Insite (www)


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2. How to increase resistance to

misleading promotion


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And if, indeed, candor, accuracy,scientific completeness, and a

permanent ban on cartoons came to be

essential for the successful promotionof [prescription] drugs, advertising

would have no choice but to comply.

Garai PR. Advertising and Promotion of Drugs. in: Talalay P. Editor. Drugs inOur Society. Baltimore: John Hopkins Press; 1964.


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The best defense doctors can muster against this

kind of advertising is a healthy skepticism and a

willingness, not always apparent in the past, to do

homework. Doctors must cultivate a flair for

spotting the logical loophole, the invalid clinical

trial, the unreliable or meaningless testimonial, the

unneeded improvement and the unlikely claim.Above all, doctors must develop greater resistance

to the lure of the fashionable and the new.Garai PR. Advertising and Promotion of Drugs. in: Talalay P. Editor. Drugs in

Our Society. Baltimore: John Hopkins Press; 1964.


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Improving health care decision

making

Hypothesis 1. Promotion might improve to

match Hypothesis 2. Promotion might become

more subtle but stay harmful.

Even if hypothesis 1 is correct, there is alimit to how much humans with limitedresources can be expected to improve.


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Educated

Mr Brindell [corporate affairs manager,

Pfizer Australasia] said doctors, who wereobviously highly educated, could sort the

chaff from the wheat.

Riggert E. Doctors seduced by drug giants: Drug companies tactics spark

rethink by doctors. The Courier Mail. Brisbane 1999;July 26:1-2


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Intelligence

Doctors have the intelligence to evaluate

information from a clearly biased source.

- Dr Rob Walters, ADGP chair

Richards D. Guess whos coming to dinner. Aust Dr. 2004;23 Jan:19-21


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I believe I may have the ability to think for

myself. I know there is a large percentage of

people (esp. in this class) who would easily be

sucked in as you put it but I am confident

this doesnt apply to me.

- 2nd year medical student 2004

The illusion of unique invulnerability


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The illusion of unique invulnerability Many people believe that others may be

vulnerable but not themselves.

Some doctors believe no doctor is vulnerable.

Consequently education about misleading

promotional techniques is not applied to the self

and thus not effective.

Thus the key is to dispel the illusion of unique

invulnerability.


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Dispel the illusion of invulnerabilityAttempts to confer resistance to appealswill likely be successful to the extent that

they install 2 conceptual features: perceivedundue manipulative intent of the source ofthe appeal and perceived personalvulnerability to such manipulation.

Sagarin, B. J.; Cialdini, R. B.; Rice, W. E., and Serna, S. B. Dispelling the

illusion of invulnerability: the motivations and mechanisms of resistance to

persuasion. J Pers Soc Psychol. 2002 Sep; 83(3):526-41.


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Fascinating way to learn.

www.healthyskepticism.org/adwatch.php

Illuminates the logical, psychological and

pharmacological techniques in drug ads.

Evidence based recommendations.

Feedback for the AdWatch team, the company

and regulatory agencies.


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Feedback to AdWatch and to the

company

To AdWatch re Nexium: Unfortunately

had me sucked in for a period but no

longer.

To the company re Micardis Plus: You

have misled me into a false understanding

of the response to telmisartan + Hcl.


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perceived undue manipulative

intent of the source of the appeal


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Put yourself in their shoes You are responsible for promotion of a new

drug that is no better than the old ones but

will be sold at a higher price.

If you do not succeed you will lose your

job. Because you will not be able to get

such a well paid job elsewhere you and yourfamily will loose your house.

What promotional methods will you use?


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Did you plan to tell:

the truth?

(without ambiguity)

the whole truth?

and nothing but the truth?


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Drug companies know how to

manipulate our main motivations

Burnt out Dodo

Caring Bunny

Conservative Sheep

Entrepreneurial Wolf

Branthwaite A, Downing T.Marketing to doctors thehuman factor. Scrip Magazine1995 March;32-5


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perceived personal vulnerability to

such manipulation


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Educated

Mr Brindell[corporate affairs manager,

Pfizer Australasia]said doctors, who wereobviously highly educated, could sort the

chaff from the wheat.

Riggert E. Doctors seduced by drug giants: Drug companies tactics spark

rethink by doctors. The Courier Mail. Brisbane 1999;July 26:1-2


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Intelligence

Doctors have the intelligence to evaluate

information from a clearly biased source.

- Dr Rob Walters, ADGP chair

Richards D. Guess whos coming to dinner. Aust Dr. 2004;23 Jan:19-21


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Shuttle pilots


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Your ability to cope with potentially

misleading promotion depends on your

understanding of: Medicine

Pharmacology, Epidemiology, Public Health, Evidence BasedMedicine, Drug Evaluation, Pharmacovigilance

Social sciences Psychology, Semiotics, Economics, Sociology, Anthropology,

Management, History, Politics, Communication Studies,

Humanities

Logic, Rhetoric, Epistemology, Linguistics, Literature, Art Marketing

Product Management, Advertising Account Planning, PublicRelations

Statistics


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Studies of influence of promotion on

prescribing find more harm than good.Becker MH, Stolley PD, Lasagna L, McEvilla JD, Sloane LM. Differential education concerning therapeutics and

resultant physician prescribing patterns. J Med Educ 1972;47:118-27.

Linn LS, Davis MS. Physicians orientation toward the legitimacy of drug use and their preferred source of new drug

information. Soc Sci Med 1972;6:199-203.

Mapes R. Aspects of British general practitioners prescribing. Med Care 1977;15:371-81

Haayer F. Rational prescribing and sources of information. Soc Sci Med 1982;16:2017-23.

Ferry ME, Lamy PP, Becker LA. Physicians knowledge of prescribing for the elderly: a study of primary carephysicians in Pennsylvania. J Am Geriatr Soc 1985; 33:616-21.

Blondeel L, Cannoodt L, DeMeyeere M, Proesmans H. Prescription behaviour of 358 Flemish general practitioners.

Paper presented at the International Society of General Medicine meeting, Prague, Spring 1987.

Bower AD, Burkett GL. Family physicians and generic drugs: a study of recognition, information sources, prescribing

attitudes, and practices. J Fam Pract 1987;24:612-6.

Cormack MA, Howells E. Factors linked to the prescribing of benzodiazepines by general practice principals and

trainees. Family Practice 199

2;9

:466-7

1.Berings D, Blondeel L, Habraken H. The effect of industry-independent drug information on the prescribing of

benzodiazepines in general practice. Eur J Clin Pharmacol 1994;46:501-505.

Caudill TS, Johnson MS, Rich EC, McKinney WP. Physicians, pharmaceutical sales representatives, and the cost of

prescribing. Arch Fam Med 1996;5:201-6.

Powers R. Time with drug reps affects prescribing. Paper presented at the Society of General Internal Medicine meeting,

1998

Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000 Jan 19;283(3):373-80


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Benzodiazepine prescribing in

Flanders

Years since graduation + positive views

about commercial information + seeing

more reps accounted for 26% of thevariation in prescribing.Berings D, Blondeel L, Habraken H. The effect of industry-independent drug

information on the prescribing of benzodiazepines in general practice. Eur J

Clin Pharmacol 1994;46:501-505.


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Until we

can fix thesystem the

best we

can do is

avoid all

contactwith drug

companies


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Results

A 90 minute session with 19 General

Practice registrars on 25 February 2005.

5 questions asked before and after the

session about beliefs and plans

Answers on 1 to 7 Likert like scales


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1) Is it ethically acceptable for

doctors to receive gifts from drug

companies?

1 = Completely acceptable7 = Completely unacceptable

median mean range

Before 4 3.68 1-6

After 6 5.53 2-7

Wilcoxon signed-rank test p < 0.001


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2) Will you accept visits from drug

company representatives?

1=Never

7=At every opportunity

median mean range

Before 5 4.37 1-7

After 3 3.26 1-7

Wilcoxon signed-rank test p = 0.0119


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3) Will you accept gifts from drug

companies?

1= Never

7 = At every opportunity

median mean range

Before 5 5 2-7

After 4 3.74 1-7



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4) How often is information

from drug companies reliable?

1 = Never reliable

7 = Always reliable

median mean range

Before 4 3.68 2-5

After 2 2.47 1-5



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5) Will you be vulnerable to

being misled by drug companies?

1 = Completely vulnerable

7 = Completely invulnerable

median mean range

Before 4 3.79 2-6

After 3 3.42 1-7



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The role of drug promotion in the heavy deathtoll from COX2 selective drugs illustrates thereality that misleading drug promotion is amajor health threat.

The World Health Assembly resolution 52.19urges member states to:

"integrate the rational use of drugs andinformation on commercial marketing

strategies into training for health practitionersat all levels."


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Healthy Skepticism Inc and No Free Lunch

recommend the following 4 objectives for

education about pharmaceutical promotion forhealth professionals at all levels of training and

practice.

Pharmaceutical promotion includes any activity

that can increase pharmaceutical sales.

Education should use methods that are effective

for changing behavior, such as involvement of

influential peers. Education for health professionals should never be

funded by vested interests.


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1. Health Professionals should avoid

pharmaceutical promotion

Exposure to pharmaceutical promotion correlates with

harmful and wasteful use of pharmaceuticals.

There are no proven methods for enabling health

professionals to gain more benefit than harm fromexposure to drug promotion.

Consequently, education for health professionals

should increase the understanding that all health

professionals have a professional fiduciaryresponsibility to patients to take all practical steps to

avoid pharmaceutical promotion.


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This responsibility includes refusing to accept gifts

and one to one visits from drug company

representatives both at the personal and

organisational levels.

Meetings of groups of doctors with drug companyrepresentatives may be less harmful than one to one

meetings but it is highly unlikely that this type of

activity will be found to do more good than harm

compared to no such meetings.


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2. Health Professionals should be educated

about decision makingEducation for health professionals should include

teaching the psychology and illogic of misleading

arguments and appeals with the aim of improving

the quality of medical decision making in responseto evidence.


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3. Health professionals should be warned thatthey are vulnerable to pharmaceuticalpromotion

Knowledge of misleading arguments and appealsdoes not reliably protect people from being misledby promotional techniques.

The key to reducing vulnerability to being misled

by promotion is helping people move fromoverconfidence in their abilities to understandingthat they are vulnerable.

Consequently, education for health professionalsshould explain that whilst knowledge of

misleading promotional techniques may increasetheir resistance to being mislead, it is unlikely toenable them to reach a level of resistance wherethey would gain more benefit than harm fromexposure to drug promotion.


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An effective way to reduce dangerousoverconfidence is to expose participants to

misleading promotion, allow them to expressincorrect beliefs and then debunk those beliefs andexplain the misleading techniques used so thatparticipants can understand that they are personally

vulnerable.

4. Health professionals should be educated aboutmore reliable sources of information

Health professionals should receive education aboutthe availability and strengths and weaknesses of theleast biased useful sources of information.


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1. Lomas J, Enkin M, Anderson GM, Hannah WJ, Vayda E, Singer J. Opinion leaders vs audit andfeedback to implement practice guidelines. Delivery after previous cesarean section. JAMA.1991 May 1;265(17):2202-7.1

2. Rogers WA, Mansfield PR, Braunack-Mayer AJ, Jureidini JN. The ethics of pharmaceuticalindustry relationships with medical students. Med J Aust. 2004 Apr 19;180(8):411-4.

3. Steinbrook R. Commercial support and continuing medical education. N Engl J Med. 2005 Feb10;352(6):534-5. 4. Schafer A. Biomedical conflicts of interest: a defence of the sequestrationthesis-learning from the cases of Nancy Olivieri and David Healy. J Med Ethics. 2004Feb;30(1):8-24.

5. Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA2003; 290: 252-255.

6. Katz D, Caplan AL, Merz JF. All gifts large and small: toward an understanding of the ethics ofpharmaceutical industry gift giving. Am J Bioethics 2003; 3: 39-46.

7. Katz D, Mansfield P, Goodman R, Tiefer L, Merz J. Psychological aspects of gifts from drugcompanies. JAMA. 2003 Nov 12;290(18):2404-5

8. Becker MH, Stolley PD, Lasagna L, McEvilla JD, Sloane LM. Differential education concerningtherapeutics and resultant physician prescribing patterns. J Med Educ 1972;47:118-27.

9. Linn LS, Davis MS. Physicians' orientation toward the legitimacy of drug use and their preferredsource of new drug information. Soc Sci Med 1972;6:199-203.

10. Mapes R. Aspects of British general practitioners' prescribing. Med Care 1977;15:371-81

11. Haayer F. Rational prescribing and sources of information. Soc Sci Med 1982;16:2017-23.

12. Ferry ME, Lamy PP, Becker LA. Physicians' knowledge of prescribing for the elderly: a study ofprimary care physicians in Pennsylvania. J Am Geriatr Soc 1985; 33:616-21.

13. Bower AD, Burkett GL. Family physicians and generic drugs: a study of recognition, informationsources, prescribing attitudes, and practices. J Fam Pract 1987;24:612-6.

14. Cormack MA, Howells E. Factors linked to the prescribing of benzodiazepines by generalpractice principals and trainees. Family Practice 1992;9:466-71.


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15. Berings D, Blondeel L, Habraken H. The effect of industry-independent drug information on theprescribing of benzodiazepines in general practice. Eur J Clin Pharmacol 1994;46:501-505.

16. Caudill TS, Johnson MS, Rich EC, McKinney WP. Physicians, pharmaceutical salesrepresentatives, and the cost of prescribing. Arch Fam Med 1996;5:201-6.

17. Mansfield PR, Lexchin J. Scepticism and beliefs about new drugs. Healthy Skepticism

International News 2001;19:1-618. Caamano, F.; Figueiras, A., and Gestal-Otero, J. J. Influence of commercial information on

prescription quantity in primary care. Eur J Public Health. 2002 Sep; 12(3):187-91.

19. Watkins, C. Harvey, I. Carthy, P. Moore, L. Robinson, E. Brawn, R. Attitudes and behaviour ofgeneral practitioners and their prescribing costs a national cross sectional survey. Qual SafHealth Care. 2003 Feb; 12(1)29-34.

20. Mansfield PR, Henry D. Misleading drug promotion-no sign of improvements.Pharmacoepidemiol Drug Saf 2004 Nov;13(11):797-9.

21. Brody H. The company we keep: why physicians should refuse to see pharmaceuticalrepresentatives. Ann Fam Med. 2005 Jan-Feb;3(1):82-5.

22. Scott DK, Ferner RE. "The strategy of desire" and rational prescribing.Br J Clin Pharmacol1994;37: 217-9.

23. Shaughnessy AF, Slawson DC, Bennett JH. Separating the wheat from the chaff: identifyingfallacies in pharmaceutical promotion. J Gen Intern Med. 1994 Oct;9(10):563-8.

24. Mansfield PR. Healthy Skepticism's new AdWatch: understanding drug promotion. Med J Aust.

2003 Dec 1-15;179

(11-12):644-5.25. Sagarin BJ, Cialdini RB, Rice WE, Serna SB. Dispelling the illusion of invulnerability: themotivations and mechanisms of resistance to persuasion. J Pers Soc Psychol 2002;83: 526-41.

26. Mansfield P. Accepting what we can learn from advertising's mirror of desire. BMJ. 2004 Dec18;329(7480):1487-8.

27. Wilkes MS, Hoffman JR. An innovative approach to educating medical students aboutpharmaceutical promotion. Acad Med 2001; 76: 1271-1277.


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Healthy Skepticism

Countering misleading

drug promotion

www.healthyskepticism.org

Pharma Promotion

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