Bennison Comment:
Pharmaceutical educational programs cannot be promotional in nature. Some of the more common channels for promotion of prescription medications include journal advertisements, direct mailings, product sampling, educational programs, product giveaways, DTC advertising and pharmaceutical representative detailing. The PhRMA code provides rules and regulations for all of these promotional activities.

One type of educational program supported by pharmaceutical companies is continuing medical education (CME). CME programs cannot be promotional in nature and are planned and implemented by providers accredited by the Accreditation Council on Graduate Medical Education rather than by the pharmaceutical companies who fund them through unrestricted educational grants. The programs are conducted independently of pharmaceutical company input and are provided to further scientific exchange related to the practice of medicine. Pfizer is the largest pharmaceutical sponsor of unrestricted educational grants. During 2004, Pfizer gave more than $155 million in educational grants to fund independent educational activities.³⁴

Speaker programs are educational presentations given on behalf of pharmaceutical companies and are promotional in nature. Even these programs must follow specific guidelines. The content of the presentation must be consistent with product labeling and properly balanced. If not, the integrity and credibility of the speaker could be in jeopardy. Pharmaceutical companies provide valuable and often needed educational support and resources for the providers, not conflicts of interest.

Modest giveaways or reminder items with a product logo are also addressed by the PhRMA Guidelines. These materials may not be worth more than $100 and must be medically related. A recent study found that inexpensive gifts are more likely to be considered appropriate than expensive ones.³⁵ Educational items were rated more appropriate than noneducational ones. Educational value-added items for patient education can be one of the best promotional tools for pharmaceutical companies. As stated earlier, physicians report using pharmaceutical patient education materials more than any other source.

The most established form of product promotion by pharmaceutical companies is face-to-face detailing with prescribers. In general, favorable attitudes toward representatives have been documented among physicians.³⁶ Physician views of pharmaceutical representatives are mixed, but most believe that benefits outweigh the concerns. (Nurse practitioner views have not been studied.) The benefits include providing product information, clinical studies, product samples and patient education materials. Most prescribers can sort out the important information and factor out personalities.³⁷ I asked several of my physician friends about this subject. They all told me that medical knowledge and clinical experience would not allow them to be negatively influenced by sales representatives when it comes to making decisions about what's best for their patients.

Over the years, I have built rapport and strong relationships with many physicians. I can remember several instances in which product knowledge and knowledge of the medical literature has helped make a positive impact on patient outcomes. I believe that my success requires being customer focused, providing valuable service, being a product expert and knowing the disease states treated by the products I represent.

It would be great to see the pharmaceutical industry considered part of the health care team again. To help reestablish this, the companies' primary focus during representative training should be on medical knowledge about the product and the disease state. In many circumstances, effective and efficient strategies involving pharmaceutical products are underutilized, whereas marketing by drug companies plays an important role in improving outcomes for patients.³⁸

Problem: Direct-to-consumer advertising is biased and influences patients and their families to pressure providers to prescribe more liberally. As a result, irrational prescribing occurs.

Crigger Comment:
Pharmaceutical companies spent $2.5 billion on DTC advertising in 2000.² Major sporting events and consumer magazines are replete with advertisements for prescription drugs. Studies of DTC ads indicate that the majority of the public and health care professionals have negative views of them. In one study, 67% of physicians who responded claimed that their prescribing practices were changed and that a higher incidence of irrational prescription writing was based on patient demands.39 Each advertisement ultimately raises the price of the drug.

Some reactions to DTC advertising focus on its inappropriateness. Pharmaceutical advertisements promote the use of drugs for symptoms that are not disease specific and encourage use for enhancement of normal functions rather than disease treatment. For example, advertisements for the three FDA-approved erectile dysfunction drugs equate human sexuality and satisfaction with male performance. Performance and satisfaction are emphasized, rather than appropriate use as it relates to disease processes.

DTC ads appeal not to people with diseases who have symptoms, but rather to any person with the symptoms. DTC ads exaggerate the benefits of drug use and minimize the risks of use.⁴

One of Pfizer's main advertisements for Viagra features a photograph of a man standing in front of a sign that says "Viagra." He wears a smug facial expression and has his arms crossed. He is standing in front of the first letter so that the "V" makes little horns on his head, suggesting a devil or satyr. This type of advertising is obviously not geared toward men with legitimate organic erectile dysfunction, but toward enhancement of performance. It promotes inappropriate, irrational prescribing. Society should be outraged at the pharmaceutical industry's marketing of ED to a much larger pool of buyers who use the drugs for enhancement and recreation. It may be that society and the government pay for enhancement therapies rather than other pressing health care needs. Selling this drug to patients with legitimate organic disease differs greatly from the sale of this drug for recreation.