Below the Fold: Pitching Prescriptions and Patient Empowerment

Michael Blim

An elderly couple is at the piano, the wife playing and the husband standing next to her turning the pages of the music. They have been to see their doctor. The husband has Alzheimer’s disease, and he has been prescribed Aricept. The result: he can follow a piano score and turn pages on cue.

Remarkable. For the 5 million suffering from Alzheimer’s and for the several million people who care for them, this television ad offers hope. The message is that high cognitive functioning – reading music, responding to the pianist’s behavioral cues, and turning the pages in time – is within their grasp if Alzheimer’s patients take Aricept. Lulled by a reassuring female voice, the figure of a helpful and informative doctor in a white coat seated with the patient and his spouse, a beautiful house replete with piano, and the figure of a loving couple, they forget (as I admit I do) that the people in the ad are actors. They forget that this ad is no less an act of persuasion than the Mazda “Zoom-zoom.” They forget, or are not told, that the scene is a fake and interaction is scripted. Nor are they told that the results of taking Aricept are modest, and the drug is costly.

Aricept, according to the Alzheimer’s Association, has been approved by the Food and Drug Administration to treat symptoms of mild to severe Alzheimer’s disease. “Its benefit in treating Alzheimer’s,” they write, “is also modest, often described as postponing progression for an average of six months for some, but not all, individuals.” A recent study reported in the New England Journal of Medicine (June 9, 2005) showed that Aricept delayed the onset of Alzheimer’s disease for 12 months among persons already diagnosed as having mild cognitive impairment. As compared with control groups taking a placebo or vitamin E, the small advantage noted for Aricept-takers disappeared by the 3-year end of the study. The investigation was funded by the National Institute on Aging, Eisai, Aricept’s maker, and Pfizer, its promoter.

Aricept is expensive. According to Pillbot.com, a site that gathers current retail prices for drugs sold by major outlets like CVS, Rite Aid, and COSTCO, a 30-day prescription for 10 milligrams of Aricept, the usual dose, costs an average of $134, or $1608 a year. If a patient buys the same dose with a 90-day script, the cost is an average of $368, or $1272 a year.

Aricept, Nexium, Lipitor, Prevacid, Zocor, Viagra, Plavix, Pravachol, Paxil, Ambien, Celexa, Caduet. These brands are among a score or more of the drugs that are advertised during the nightly national news. Sometimes you can switch channels and find the same drug being advertised at the same time.

The pharmaceutical industry in the United States and worldwide is a big business. That’s why its critics (and now some Wall Street analysts too) call it “Big Pharma.” In the United States last year, the pharmaceutical industry grossed $275 billion. To put this figure into perspective, consider that the American people spent more on pharmaceutical drugs than they did on new cars last year.

Product “promotion” is key. No doubt you have noticed pharmaceutical representatives in your doctor’s waiting rooms. Young, clean-cut, always smiling, they are the detailers hoping to get a word in with the doctor before she sees you. Blandishments include those free samples, “starter kits,” of drugs your doctor passes on to you. Big Pharma spent $6.7 billion in 2006 on detailing, and another half a billion dollars a year advertising in professional journals. They spent $4.8 billion on consumer advertising. In all, Big Pharma spent $12 billion to push its products.

Like the old senator used to say: “A billion here, a billion there, and pretty soon it adds up to real money.” It is consoling perhaps to know that there are other industries –11 in fact – that spent more last year on consumer advertising than Big Pharma. They include auto producers and retailers with $20 billion each, and telecom and financial services industries between $8 and $10 billion a piece. Personal care, airlines and hotels, films, media, and restaurant industries spent around $5 billion each last year, as did advertising for non-prescription health remedies.

Against these industries, Big Pharma’s $4.8 billion spent on advertising seems positive prudent – a mere 1.8% of their American revenues, while the auto industry spent the equivalent of 10% of sales on ads.

Getting well, however, is not like buying a Chevrolet. You can’t kick the tires and road-test a drug, even if from time to time you are offered money like a cash back rebate for getting your doctor to prescribe it. Big Pharma knows that its product is unique, and that because few in the audience can understand what the drugs do and how the drugs do it, the companies must sell trust and well-being. They invite us into a world where nothing is fatal – at least not yet – and most illnesses have cures. To build trust and to offer well being, they put actors in white coats, surround actors pretending to be sick with other actors who pretend to be their spouses, children, or grandchildren. The drug world, once the actors pretending to be patients leave the doctor’s office, is a sunny, green, outdoor world. It could be Walden Pond, a corral in Kentucky blue grass country, or a suburban playground filled with beautiful children, one among them the actor portraying someone’s child or grandchild. In the drug world, there is love all around, including a helping hand extended by Big Pharma.

“Ask your doctor about….” Fill in the blank. It is almost always the cut line. And with good reason, because people do. A survey of 784 physicians reported in the 2004 Archives of Internal Medicine conducted by a team headed by Dr. Andrew Robinson found that 80% of the doctors indicated that patients had asked them for prescriptions for specific drugs by name, even though a companion study of 500 Colorado households showed that only 29% of those surveyed thought drug advertising was a good thing. Do as I say, not as I do, those households seem to be saying.

Advertising and a patient’s suggestion seem to work on doctors too. Another study reported in the April 2005 issue of the Journal of the American Medical Association an experiment in which actors pretending to be fatigued were sent to 152 doctors. When they mentioned that they had heard of the antidepressant Paxil, they were five times more likely to be prescribed the drug than if they had made no mention of the drug during the office visit. As a supplemental finding, the study found that 50% of the actors were diagnosed with depression!

Pharmaceutical companies were prohibited from advertising directly to consumers until the Food and Drug Administration in 1997, during the Clinton Administration, gave them the green light. Since then, the FDA with few exceptions has given Big Pharma carte blanche. Its FDA Magazine in the July-August 2004 issue featured a glowing article on the impact of direct consumer advertising. Of the 736 doctors reported surveyed by the FDA, 53% believed that they had better discussions with their patients; 42% felt that their patients had better awareness of treatment options. The article quotes Peter Pitts, then the FDA associate commissioner for external relations: "The goal here is getting truthful, non-misleading information to consumers about safe and effective therapeutic products so they can be partners in their own health care. Better-informed consumers are empowered to choose and use the products we regulate to improve their health." (emphasis mine)

What is the value of empowerment when one is provided a few highly selective facts in a gauzy, feel good frame? One remembers the emotion and the drug name, and probably little else. As far as those better discussions doctors say they are having, one might take this response with a grain of salt, given Dr. Jerome Groopman’s report in his new book, How Doctors Think, that physicians begin making their diagnosis within seconds of seeing their patients.

Doctors no less than their patients are being led along by Big Pharma. Research is sponsored by Big Pharma, and only now are these funding sources mentioned in scientific journals alongside findings. Conferences, seminars, calendars, pads, pens, clipboards, anatomical diagrams, plastic replicas of organs – and even the Friday afternoon staff pizza – are being paid for by Big Pharma. And doctors watch TV too.

Could we ban drug advertising to consumers once again? It would take a revolution at the FDA, an act of Congress, or both. And then, our runaway Supreme Court could outdo itself in ignoring institutional prerogatives and legislative history and proclaim drug advertising an exercise in freedom of speech.

As a practical matter, though, young people don’t even know that cigarette television advertising was banned and the rest of us probably don’t remember much about it either – save that hunky Marlboro man.

It could be done. Knowledge about our health and remedies could acquire a professional filter once again. Rather than the motivation of an emotion and a name, a higher standard of judgment could be applied as to what drugs work, and what drugs are worth the expense. Perhaps it would be a good thing as well to eliminate those junkets for doctors, the detailers’ blandishments, and all of the other inducements carefully placed in our physicians’ paths.

Evening up the odds with Big Pharma -- now that could be empowerment.