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How Does Pharmaceutical Company Promotion Affect Prescribing?

January 02, 2008 | 9,458 views

Dr. Mercola's Comment:

A newsletter subscriber forwarded this URL to me. This is an incredible window into the how and why of what is wrong with traditional medicine.

This was taken from the text of a poster presented at The First International Conference on Improving Use of Medicines (ICIUM), held in Chiang Mai, Thailand, from April 1-4, 1997. This conference was sponsored in part by the World Health Organization (WHO). The WHO is a very liberal organization that is no friend of natural medicine, and, I believe, part of the problem.


By Peter Mansfield

Problem Statement:

Pharmaceutical companies often use effective methods of influence in combination with misleading "logic." This may have adverse impacts on prescribing. Study of the techniques used in promotion may enable the development of interventions for reducing the adverse impact. Furthermore, it may be possible for the effective methods of influence used in promotion to be adapted for improving the use of medicines.

Objectives:

An overview of the main methods of influence and misleading "logic" used in promotion.

Design:

Opinion statement based on action research from 1981-97 and a non-systematic literature review.

Results:

More frequent and/or intense exposure to promotion correlates with increased prescribing volumes and more expensive and less appropriate prescribing.

Promotion may mislead by use of false statements, omission, fine print, poor quality evidence, and "red herring" surrogate endpoints, statements of relative risk, ambiguity or widened indications. The methods of influence used by "drug reps" include gifts, appeals to authority, social validation, commitment consistency and liking. Advertisements link drugs with images that appeal to desires, and then repetition takes those links to the top of the mental agenda. Conclusions: Further study of how promotion affects prescribing is required. However, enough is known now to enable work on the next steps. The next steps are:

Design and testing of interventions for reducing the adverse impact of promotion and Adaptation and testing of effective methods of influence used in promotion for improving the use of medicines. Promotion can influence prescribers more than you thought possible! Frequent exposure to promotion correlates with more expensive, less appropriate prescribing.

Pharmaceutical companies have gained secret knowledge about techniques which influence prescribing by "selection of the fittest" over hundreds of years. The "advertisement for advertising" targeting drug marketing staff displayed here is based on "The ARF/ABP Pharmaceutical Study." Limited information is available about this study, which appears to be flawed. However, the study suggests that printed promotion is very effective especially if it is repeated frequently. This is in contrast to printed educational materials produced by health professionals and used once only.

How do they do it?

Pharmaceutical promotion often uses:

Misleading "logic" and Methods of influence. The types of misleading "logic"(iii) used include:

A1. False statements

A2. Omission

A3. Fine print

A4. Evidence of poor quality

A5. "Red herring" surrogate endpoints

A6. Statements of relative risk

A7. Ambiguity

A8. Widening the indications

The methods of influence (iv) used include:

B1. Gifts (reciprocal obligations)

B2. Appeals to authority

B3. Social validation (Appeals to conformity)

B4. Liking / friendship

B5. Commitment consistency

B6. Scarcity

B7. Appeals to sympathy

B8. Magic words

B9. Images that appeal to desires (v)

B10. Repetition for agenda setting (vi)

Misleading "logic"

Of 109 US medical journal advertisements published in 1990 only 4% were rated as acceptable. Reviewers felt that 44% of the advertisement would lead to improper prescribing if a doctor had no other information.

A1. False statements

The product information was contradicted once or more during:

11 of 16 "drug rep" visits to Australian GPs. 7 of 12 presentations at a US Hospital.

A2. Omission.

Only 16% of 111 advertisements in the Ceylon Medical Journal provided basic prescribing information. Only 29% of 141 advertisements in Francophone Africa provided basic prescribing information. During 16 "drug rep" visits to Australian GPs, 64 drugs were detailed. Warnings were mentioned rarely: Type of warning Percentage of details where any warning information was provided (including false or misleading information). Special warnings 5% Precautions 15% Special groups (e.g. pregnancy) 3% adverse effects 27%

A3. Fine print

For example: The promotion of Toradol (ketorolac) for postoperative pain. The promotion emphasized the adverse drug reactions of narcotics but the adverse drug reactions of ketorolac appeared in user-unfriendly fine print only.

A4. Evidence of poor quality

International pharmaceutical companies justifications for claims of efficacy include the following types of "evidence" Endorsed by the companies own staff. Other companies do the same. Government approved (not banned yet) Longstanding use Endorsed by anonymous "experts" Animal or in vitro studies Clinical trials with major methodological flaws Mentioned in text books References cited in medical journal advertisements are often of very poor quality and may not support the claim that they appear to support.

A5. "Red herring" surrogate endpoints

For example: "3 months treatment of obesity with Adifax reduces high risk visceral fat by 31%" sounds impressive and obscures the lack of evidence of impact on clinically important morbidity or mortality.

A6. Statements of relative risk

For example: A relative risk reduction of 20% sounds impressive but if the initial level of risk is only 1% then the absolute risk reduction is only 0.2%. The number needed to treat for 1 to benefit is 500. The way probabilities are communicated affects conclusions.

A7. Ambiguity

For example: Ponstan: "unsurpassed efficacy compared to acetaminophen" superficially appears to mean "superior" but really means, "equal".

A8. Widening the indications

In France "drug reps" promote unapproved indications in around of all visits. People tend to use "mental shortcuts" to make quick decisions without the time and effort required to study the pros and cons of all the options. Use of "mental shortcuts" is often an unconscious automatic process and involves relying on others. If others are trustworthy then "mental shortcuts" will usually lead to the best answer. Prescribers often use "mental shortcuts" because they lack the time and skills required to determine the optimum therapy. Promotion often takes advantage of "mental shortcuts" in a way similar to a Cuckoo taking advantage of the feeding instincts of other birds.

Methods B1 to B6 below have been discovered during research on personal selling of any type of product and are used by "drug reps". Methods B5 and B6 are used in advertising.

"Drug reps" are the most powerful component of promotion. They can individualize their methods according to their assessment of the motivations of the prescribers they visit. One categorization for doctors is as follows: Species Concerned about: Sheep conservatives maintaining conformity Wolves entrepreneurs making money Bunnies progressives caring for patients Dodos burned out survival

B1. Gifts (reciprocal obligations)

For example: Ten doctors denied that going to all-expenses-paid seminars at popular vacation sites would influence them. However, their prescribing of the promoted drugs did increase significantly. Less expensive gifts such as brand name reminder pens may be a more cost-effective way to influence prescribing. "Wolves" are more influenced by gifts than other types of doctors.

B2. Appeals to authority - and - B3 Social validation (Appeals to conformity)

"Drug reps" often mention that their drug is endorsed by local "experts" and/or is popular with the prescriber's peers. "Sheep" are particularly vulnerable because of their concern about "keeping up" with "experts" and peers.

B4. Liking / friendship

This is one of the main reasons doctors give for being willing to see "drug reps". Attractive, caring people are more influential.

B5. Commitment consistency

People tend to prefer to appear consistent with any commitments they have made. Consequently, "drug reps" often invite doctors to agree with a series of statements starting with something most would agree with then moving in stages towards a commitment to prescribe.

B6. Scarcity

People often perceive things that are rare or are "available for a limited time only" as more valuable than otherwise.

B7. Appeals to sympathy

Dramatization or exaggeration of the suffering from the indication or the benefit from the drug can elicit a caring emotional response and thus bypass critical appraisal defenses. "Bunnies" are more vulnerable to this method.

B8. Magic words

There are a number of words that have powerful effects on behavior. The word "new" gets attention. "Free offers" are hard to resist but create reciprocal obligations. Compliance with requests is more likely if the word "because" is used because it implies that there is a good reason of the request and people may not take the time to think about whether the reason is really good enough.

B7. Images that appeal to desires

People often desire security, creativity, power, worth, love, sex, purpose, or to be special or superior. It is well known that "sex sells." Prescribers often desire competence, self-esteem, certainty, gratitude, simplicity or intellectual stimulation. Advertising uses images and/or words that appeal to those desires. It creates "mental links" between the drug, the indication and the image and associated positive attributes or benefits. This method of influence may work without arousing attention e.g. when a prescriber glances at an advertisement but does not read it. The limited awareness may enable the "mental link" to be established without arousing the prescriber's critical appraisal defenses. More powerful images will arouse more attention and create stronger "mental links."

B8. Repetition for agenda setting

The impact of the "mental links" (described above) on prescribing from glancing at an advertisement once is usually small. However, repeated exposure can build small effects up to take the "mental links" to the top of the "mental agenda." Consequently, when exposed to the promoted indication the first thing that the prescriber thinks of is the most powerfully promoted drug. It is easier to prescribe that drug than to take the time to think of alternatives. Frequent repetition can drown out, or overcome with time, any competition e.g. from independent information. Agenda setting will have the greatest impact on prescribing behavior when prescribers feel they have little time to consider alternatives.

World Health Organization

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