Pushing Rx

You’ve seen them on television commercials: middle-aged men skip down the street like deliriously happy lottery winners. Women pass on a secret cure as if it were the key to everlasting life. Senior citizens perform their best Plácido Domingo imitations in the shower.

Like the woman eating next to Meg Ryan in When Harry Met Sally, you find yourself thinking, “I want what they’re having!”

That, of course, is the point.

In the medical industry promotional messages designed to speak directly to the fears and aspirations of patients are known as direct-to-consumer advertising, or DTCA. They seek to tap into, or feed, any emotional vulnerability we might have about our physical and mental
well-being. These classic examples of the power of lifestyle advertising operate by implying that we, too, can live happier, healthier, more comfortable and satisfying lives with the click of our physician’s pen.

They’re phenomenally successful.

Ads Drive Up Profits

A study conducted by researchers at Harvard and MIT found that for every dollar spent on DTCA, companies reaped $4.20 in increased drug sales. Between 2004 and 2005, for example, sleeping pill prescriptions in the United States increased by an astonishing 60 percent. The reason? Between them, two sleeping pill manufacturers had spent US$345 million promoting their prescription sleep aids.

Are you thinking, “Bravo for free enterprise!” and “Come to think of it, I could use a good night’s sleep myself”? Or does the thought of prescription pharmaceuticals being sold with the same tactics as perfume and beer give you pause?

Critics of DTCA offer a number of reasons why it should. They point out that drugs are not like other consumer products: even when used as directed, they’re capable of causing serious harm or even death.

In response, pharmaceutical companies and the media organizations reliant on ad revenues argue that consumers benefit from having access to information about new treatment options. They say that because patients have to go through their doctors to obtain prescriptions, consumers are protected from potential harm.

The story of Vioxx suggests otherwise.

A Cautionary Tale

Merck Frosst launched Vioxx in 1999, spending $550 million over a five-year period advertising its new treatment for arthritis. (Just for context, that’s more than Pepsi-Co spent promoting Pepsi.) Although there was no evidence that Vioxx was any more effective than already established (not to mention cheaper) alternatives, many arthritis patients appear to have responded to the advertising campaign by asking their physicians for Vioxx prescriptions.

Unfortunately, whether the new medication relieved arthritis pain became of secondary concern: it had a tragic tendency to increase the risk of heart attack. By the time it was pulled off the market in 2004, US Food and Drug Administration officials estimated that close to 30,000 Americans had died from heart attacks caused by their use of the drug. (In November 2007 Merck agreed to pay US$4.85 billion to settle most of the claims against Vioxx.)

This particular cautionary tale underlines one of the dangers presented by DTCA–pharmaceutical companies tend to promote only their brand new drugs. That means often little is known about long-term or rare side effects.

At the same time, doctors who are pressured by patients for a prescription for a new drug may be more inclined to comply, even if they’re ambivalent about the treatment. In a recent US study actors who went into doctors’ offices requesting a particular drug were likely to receive it, even without demonstrable symptoms of the indicated disease.

When confronted by ad-driven requests, doctors may not bother discussing the drug’s effectiveness relative to a placebo, older, more established and cheaper alternatives, or the nonpharmaceutical options available. As a result, many public health advocates also charge that DTCA campaigns are contributing to the medicalization of normal life by encouraging people to seek pharmaceutical treatments for common and non-life-threatening conditions such as baldness, PMS, and shyness.

Just Ask Your Doctor…

Considering the mounting body of evidence against DTCA, a growing question in many quarters is why anybody allows it. The short answer? Most don’t.

Only two jurisdictions in the world permit DTCA: the US and New Zealand. In the US ads for a prescription product are supposed to include accurate information about the risks associated with using the drug. Given the manufacturers’ inclination to promote their newest treatments, this doesn’t always happen, as Vioxx disastrously proved.

Moreover, research by the US Food and Drug Administration has found that DTCA campaigns regularly exaggerate the benefits and minimize the risks of the drugs being promoted. Not surprisingly, many American medical professionals and public health advocates also condemn the policy.

In New Zealand, as well, they’re having second thoughts. In 2003 professors at four of the country’s medical schools called for a ban on drug ads targeting consumers.

Everywhere else, the jury has come down soundly on the side of restricting promotional drug messages to channels targeting medical professionals trained to assess pharmaceutical risks and benefits. Yet here in Canada, although our Food and Drugs Act also prohibits DTCA, regulators currently turn a blind eye to two kinds of consumer-directed drug ads.

“Reminder” advertisements featuring brand names are permitted if they make no overt health claims about the product, or hints about its use. The ubiquitous Viagra spots described above fall into this category. “Help-seeking” ads are also ignored by authorities; these discuss a particular disease or condition but don’t mention a specific brand, encouraging consumers to ask their doctor for available treatments.

At this time, media conglomerate CanWest Global is in court making the case for why Canada should expand its DTCA allowances, not restrict them. CanWest’s newspapers and TV stations stand to potentially reap enormous financial benefits if they were able to run the kind of ads that are currently permitted south of the border.

But if the court rules in favour of CanWest Global, we’ll all pay for the fallout. When the US loosened up its own restrictions a decade ago, pharmaceutical advertising to consumers exploded, and prescription drug costs soared.

In our publicly funded health care system, drug costs are already the fastest growing expense. If we follow the US lead and permit more DTCA, research suggests that Canadian taxpayers will end up footing the bill for at least $1.1 billion in extra drug sales in the first year alone.

Prescription for Risk

Who wins out of that scenario? Certainly not patients.

In the past decade a number of independent studies have clearly shown that DTCA doesn’t help consumers make informed choices; it doesn’t facilitate diagnosis, improve the quality of prescription drug use, or reduce hospitalization. Instead, it drives up health care costs, exposes some patients to unnecessary and potentially serious health risks, and medicalizes normal life conditions.

None of this adds up to the kind of prescription that any ethically minded doctor would write.

The DTCA Debate

The case for:

• Consumers have a right to information about new medications.
• Prescribing doctors act as gatekeepers, ensuring patient protection.
• Since Canadians are exposed to DTCA coming from US manufacturers and media, it’s unfair to prevent Canadian companies from using DTCA.

The case against:

• DTCA campaigns regularly minimize drug risks and exaggerate their benefits.
• They encourage the rapid adoption of new, more expensive drugs before their long-term risks are fully realized.
• Doctors may be pressured by patients into prescribing drugs against their better judgment.
• Safer and/or alternative therapies may not even be considered.
• DTCA drives up health care costs by increasing doctor visits, medicalizing conditions that could be treated in other ways, and increasing Pharmacare expenses.