Many nurse practitioners have mixed views about the marketing strategies used by the pharmaceutical industry. While NPs recognize that pharmaceutical promotional activities can be beneficial, the industry's increasingly aggressive marketing, particularly in direct-to-consumer (DTC) advertising, is worrisome to them. Gift giving and promotional activities have been curtailed as a result of voluntary guidelines developed by the Pharmaceutical Research and Manufacturers of America (PhRMA). Under these guidelines, noneducational programs and lavish gifts unrelated to health care are not permitted.^1,2 However, intense marketing is still common.

When does pharmaceutical marketing go overboard? When is the intensity of drug promotion detrimental to rational prescribing practices? Using a point-counterpoint format, this article presents a two-sided discussion of the ethical acceptability of pharmaceutical sales tactics.

Statement of Nancy J. Crigger, NP:

A significant conflict of interest exists between rational prescribing and the best interests of patients, on the one hand, and irrational prescribing promoted by the sales efforts of the pharmaceutical industry, on the other. This conflict is well documented in the health care literature.^3,4 A conflict of interest is any influence, loyalty or other concern that can result in a compromised ability to act for the benefit of a patient.⁵

Health care providers who have prescriptive authority are increasingly challenged by conflicts of interest because they, along with the public, are the target of the pharmaceutical industry's promotional activities.⁶

Are the current PhRMA guidelines to reduce conflict of interest and unethical strategies sufficient? If cost of medication is an indicator, the answer is no. Prescription drugs continue to account for the fastest growing fraction of health care costs.^7,8 As one nurse practitioner wrote, "Pharmaceutical companies would not continue to use their current marketing strategies if they did not work."⁹ In many ways, health care providers and the pharmaceutical industry are on two sides of a deep philosophical divide. Drug companies' primary focus is sales and gaining more market share, while the primary focus of providers is to deliver the most appropriate care for the patient.^10-12

Statement of Larry W. Bennison, Pharmaceutical Representative:

The pharmaceutical industry is under intense scrutiny, and relationships with health care providers are strained. When I began my pharmaceutical sales career 34 years ago, fewer sales representatives were in circulation, and our relationships with providers were much less formal: We could leave journal articles with prescribers and insert underlining, no signatures were required for sampling, and restrictions on promotional activity were few. I had more room to be creative in order to be customer focused. The most significant difference, however, was that pharmaceutical representatives were considered part of the health care team.

Contrary to what is reported in the media, pharmaceutical products represent only a small fraction of health care spending.¹³ Drug prices have been increasing at a rate of about 5% each year, which is similar to other consumer goods.¹⁴ The free enterprise system allows financial rewards for developing new and innovative medicines. This potential to prosper turns investment from revenues into research for new drug discoveries. As a result, the United States has the most advanced health care in the world.

Although the health care environment has changed, the primary focus of pharmaceutical companies is not much different from what it was 30 years ago: It remains in the business of searching for solutions that allow people to live longer, healthier, happier lives through innovation in pharmaceutical products.

To achieve this purpose and mission, we focus on the values of integrity and respect for people, customers, community, innovation, teamwork, performance, leadership and quality.

Problem: The cost of prescription drugs and medical care in general are increasing beyond society's ability to pay. Pharmaceutical companies are behaving unethically by using intense and expensive marketing strategies and by attempting to delay the availability of generic drugs.

Crigger Comment:

Pharmaceutical companies claim that drug development drives high drug costs, yet the majority of medication costs stem from marketing rather than drug development.² According to the literature, 70% to 84% of the costs associated with new drugs are cost accounted under research and development (R&D).^2,10,11 The "D" is not research, but marketing.^2,10,11 The pharmaceutical industry's primary goal is to increase sales and profits, not patient interests.

The pharmaceutical industry makes money unethically whenever its actions negatively affect the health of the people who depend on their products. Pharmaceutical advertisements often claim that the public is the industry's primary concern. I would be more likely to believe it if their strategies didn't contradict this claim.

"Me-too" drugs are a good example. These are drugs that are only trivially different from what is already available (such as the statins and triptans).¹⁵ Drug companies are replicating drugs rather than developing drugs that will make a difference. By bringing me-too drugs to market, the fiduciary role of the pharmaceutical industry is eclipsed by the desire to make money.

Pharmaceutical companies also show their true intentions by extending patents for intellectual innovations - newly developed drugs. Manufacturers pay hefty amounts to lawyers to keep patent drugs from becoming generic, which would make the drug available at a lower price. One of the strategies is to change a minor element in the drug, thus extending the patent and the manufacturer's exclusive rights to sell it.¹² The patent extension then causes a delay in generic availability and maintains the higher costs of the brand name drug. The pharmaceutical company sells more of its drugs at a higher price, thus making more profit. As one author suggests, it is time for drug companies to consider the good of society and focus their resources on the laboratory rather than on the legal fees required to prolong patents.³ Practices that limit the flow, potency and affordability of medications should be considered unethical.

Marketing enhancement drugs and inventing or expanding the so-called diseases they treat are other ways of increasing pharmaceutical sales. Enhancement drugs appear to b developed to treat a disease state but are soon afterward marketed to improve normal function. Examples are drugs used in healthy people as performance boosters (sexual enhancement) or as mood enhancers (antidepressants).^4,16

The intense promotion of drugs is an unjust allocation of resources. The patient and society bear the excessive expense of the promotional activities directed at producing more sales. In 2000, the pharmaceutical industry spent between $8,000 and $13,000 on each U.S. physician to promote drugs.¹⁷ A substantial portion of the promotional money goes to prescribers and to DTC advertising.¹⁸ With expensive drug promotion, NPs and physicians are receiving the benefits of drug sales - educational programs, dinners and clocks - but rather than spend the profits from drug sales on gift giving to providers, shouldn't drug costs be reduced?

To get face time with prescribers, it is standard practice for sales representatives to bring lunch for entire office staffs. When asked, one representative stated that although she was appalled at having to pay $700 for lunch for the office staff, the physicians in the practice would not see her without this "courtesy." Why should the elderly, the retired, the pensioned and the poor buy the lunch? That is what it amounts to because the cost of this courtesy is passed on to the drug's final cost.