pharma promotion
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Educao e Informao aos
Profissionais Prescritores e
Usurios como Instrumento para
o Uso Racional
Promoting Quality Use of
Medicines via Education andInformation for Health
Professionals and Consumers
Dr Peter R [email protected]
Healthy Skepticism
www.healthyskepticism.org
Brasilia
6 April 2005
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Topics
1. The current situation in Australia:Information provision
2. How to increase resistance to misleadingpromotion: Overcoming overconfidence
3. AdWatch website
4. Teaching healthy skepticism5. Policy recommendations for education
about drug promotion
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1.The current situation in Australia
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National Medicines Policy
Quality, Safety and Efficacy
Therapeutic Goods Administration (TGA)
Access
Pharmaceutical Benefits Scheme (PBS)
Viable pharmaceutical industry
Dept of Industry ?PBS Quality Use of Medicines (no govt dept)
Missing: Health Professionals, Consumers,Health
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Quality Use of Medicines
National Prescribing Service
Australian Prescriber
Drug and Therapeutics Information Service
Educational visiting
Therapeutic Guidelines
Australian Medicines Handbook
Healthy Skepticism
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Providinginformation
works when
people knowthat they
dont know.
(doctorsoften dont)
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Information for consumers
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Adverse Medicines
Events Line Consumer product
information
NPS TelephoneInformation Service
Health Insite (www)
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2. How to increase resistance to
misleading promotion
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And if, indeed, candor, accuracy,scientific completeness, and a
permanent ban on cartoons came to be
essential for the successful promotionof [prescription] drugs, advertising
would have no choice but to comply.
Garai PR. Advertising and Promotion of Drugs. in: Talalay P. Editor. Drugs inOur Society. Baltimore: John Hopkins Press; 1964.
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The best defense doctors can muster against this
kind of advertising is a healthy skepticism and a
willingness, not always apparent in the past, to do
homework. Doctors must cultivate a flair for
spotting the logical loophole, the invalid clinical
trial, the unreliable or meaningless testimonial, the
unneeded improvement and the unlikely claim.Above all, doctors must develop greater resistance
to the lure of the fashionable and the new.Garai PR. Advertising and Promotion of Drugs. in: Talalay P. Editor. Drugs in
Our Society. Baltimore: John Hopkins Press; 1964.
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Improving health care decision
making
Hypothesis 1. Promotion might improve to
match Hypothesis 2. Promotion might become
more subtle but stay harmful.
Even if hypothesis 1 is correct, there is alimit to how much humans with limitedresources can be expected to improve.
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Educated
Mr Brindell [corporate affairs manager,
Pfizer Australasia] said doctors, who wereobviously highly educated, could sort the
chaff from the wheat.
Riggert E. Doctors seduced by drug giants: Drug companies tactics spark
rethink by doctors. The Courier Mail. Brisbane 1999;July 26:1-2
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Intelligence
Doctors have the intelligence to evaluate
information from a clearly biased source.
- Dr Rob Walters, ADGP chair
Richards D. Guess whos coming to dinner. Aust Dr. 2004;23 Jan:19-21
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I believe I may have the ability to think for
myself. I know there is a large percentage of
people (esp. in this class) who would easily be
sucked in as you put it but I am confident
this doesnt apply to me.
- 2nd year medical student 2004
The illusion of unique invulnerability
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The illusion of unique invulnerability Many people believe that others may be
vulnerable but not themselves.
Some doctors believe no doctor is vulnerable.
Consequently education about misleading
promotional techniques is not applied to the self
and thus not effective.
Thus the key is to dispel the illusion of unique
invulnerability.
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Dispel the illusion of invulnerabilityAttempts to confer resistance to appealswill likely be successful to the extent that
they install 2 conceptual features: perceivedundue manipulative intent of the source ofthe appeal and perceived personalvulnerability to such manipulation.
Sagarin, B. J.; Cialdini, R. B.; Rice, W. E., and Serna, S. B. Dispelling the
illusion of invulnerability: the motivations and mechanisms of resistance to
persuasion. J Pers Soc Psychol. 2002 Sep; 83(3):526-41.
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Fascinating way to learn.
www.healthyskepticism.org/adwatch.php
Illuminates the logical, psychological and
pharmacological techniques in drug ads.
Evidence based recommendations.
Feedback for the AdWatch team, the company
and regulatory agencies.
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Feedback to AdWatch and to the
company
To AdWatch re Nexium: Unfortunately
had me sucked in for a period but no
longer.
To the company re Micardis Plus: You
have misled me into a false understanding
of the response to telmisartan + Hcl.
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perceived undue manipulative
intent of the source of the appeal
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Put yourself in their shoes You are responsible for promotion of a new
drug that is no better than the old ones but
will be sold at a higher price.
If you do not succeed you will lose your
job. Because you will not be able to get
such a well paid job elsewhere you and yourfamily will loose your house.
What promotional methods will you use?
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Did you plan to tell:
the truth?
(without ambiguity)
the whole truth?
and nothing but the truth?
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Drug companies know how to
manipulate our main motivations
Burnt out Dodo
Caring Bunny
Conservative Sheep
Entrepreneurial Wolf
Branthwaite A, Downing T.Marketing to doctors thehuman factor. Scrip Magazine1995 March;32-5
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perceived personal vulnerability to
such manipulation
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Educated
Mr Brindell[corporate affairs manager,
Pfizer Australasia]said doctors, who wereobviously highly educated, could sort the
chaff from the wheat.
Riggert E. Doctors seduced by drug giants: Drug companies tactics spark
rethink by doctors. The Courier Mail. Brisbane 1999;July 26:1-2
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Intelligence
Doctors have the intelligence to evaluate
information from a clearly biased source.
- Dr Rob Walters, ADGP chair
Richards D. Guess whos coming to dinner. Aust Dr. 2004;23 Jan:19-21
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Shuttle pilots
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Your ability to cope with potentially
misleading promotion depends on your
understanding of: Medicine
Pharmacology, Epidemiology, Public Health, Evidence BasedMedicine, Drug Evaluation, Pharmacovigilance
Social sciences Psychology, Semiotics, Economics, Sociology, Anthropology,
Management, History, Politics, Communication Studies,
Humanities
Logic, Rhetoric, Epistemology, Linguistics, Literature, Art Marketing
Product Management, Advertising Account Planning, PublicRelations
Statistics
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Studies of influence of promotion on
prescribing find more harm than good.Becker MH, Stolley PD, Lasagna L, McEvilla JD, Sloane LM. Differential education concerning therapeutics and
resultant physician prescribing patterns. J Med Educ 1972;47:118-27.
Linn LS, Davis MS. Physicians orientation toward the legitimacy of drug use and their preferred source of new drug
information. Soc Sci Med 1972;6:199-203.
Mapes R. Aspects of British general practitioners prescribing. Med Care 1977;15:371-81
Haayer F. Rational prescribing and sources of information. Soc Sci Med 1982;16:2017-23.
Ferry ME, Lamy PP, Becker LA. Physicians knowledge of prescribing for the elderly: a study of primary carephysicians in Pennsylvania. J Am Geriatr Soc 1985; 33:616-21.
Blondeel L, Cannoodt L, DeMeyeere M, Proesmans H. Prescription behaviour of 358 Flemish general practitioners.
Paper presented at the International Society of General Medicine meeting, Prague, Spring 1987.
Bower AD, Burkett GL. Family physicians and generic drugs: a study of recognition, information sources, prescribing
attitudes, and practices. J Fam Pract 1987;24:612-6.
Cormack MA, Howells E. Factors linked to the prescribing of benzodiazepines by general practice principals and
trainees. Family Practice 199
2;9
:466-7
1.Berings D, Blondeel L, Habraken H. The effect of industry-independent drug information on the prescribing of
benzodiazepines in general practice. Eur J Clin Pharmacol 1994;46:501-505.
Caudill TS, Johnson MS, Rich EC, McKinney WP. Physicians, pharmaceutical sales representatives, and the cost of
prescribing. Arch Fam Med 1996;5:201-6.
Powers R. Time with drug reps affects prescribing. Paper presented at the Society of General Internal Medicine meeting,
1998
Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000 Jan 19;283(3):373-80
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Benzodiazepine prescribing in
Flanders
Years since graduation + positive views
about commercial information + seeing
more reps accounted for 26% of thevariation in prescribing.Berings D, Blondeel L, Habraken H. The effect of industry-independent drug
information on the prescribing of benzodiazepines in general practice. Eur J
Clin Pharmacol 1994;46:501-505.
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Until we
can fix thesystem the
best we
can do is
avoid all
contactwith drug
companies
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Results
A 90 minute session with 19 General
Practice registrars on 25 February 2005.
5 questions asked before and after the
session about beliefs and plans
Answers on 1 to 7 Likert like scales
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1) Is it ethically acceptable for
doctors to receive gifts from drug
companies?
1 = Completely acceptable7 = Completely unacceptable
median mean range
Before 4 3.68 1-6
After 6 5.53 2-7
Wilcoxon signed-rank test p < 0.001
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2) Will you accept visits from drug
company representatives?
1=Never
7=At every opportunity
median mean range
Before 5 4.37 1-7
After 3 3.26 1-7
Wilcoxon signed-rank test p = 0.0119
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3) Will you accept gifts from drug
companies?
1= Never
7 = At every opportunity
median mean range
Before 5 5 2-7
After 4 3.74 1-7
Wilcoxon signed-rank test p = 0.0034
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4) How often is information
from drug companies reliable?
1 = Never reliable
7 = Always reliable
median mean range
Before 4 3.68 2-5
After 2 2.47 1-5
Wilcoxon signed-rank test p = 0.0006
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5) Will you be vulnerable to
being misled by drug companies?
1 = Completely vulnerable
7 = Completely invulnerable
median mean range
Before 4 3.79 2-6
After 3 3.42 1-7
Wilcoxon signed-rank test p = 0.2377
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The role of drug promotion in the heavy deathtoll from COX2 selective drugs illustrates thereality that misleading drug promotion is amajor health threat.
The World Health Assembly resolution 52.19urges member states to:
"integrate the rational use of drugs andinformation on commercial marketing
strategies into training for health practitionersat all levels."
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Healthy Skepticism Inc and No Free Lunch
recommend the following 4 objectives for
education about pharmaceutical promotion forhealth professionals at all levels of training and
practice.
Pharmaceutical promotion includes any activity
that can increase pharmaceutical sales.
Education should use methods that are effective
for changing behavior, such as involvement of
influential peers. Education for health professionals should never be
funded by vested interests.
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1. Health Professionals should avoid
pharmaceutical promotion
Exposure to pharmaceutical promotion correlates with
harmful and wasteful use of pharmaceuticals.
There are no proven methods for enabling health
professionals to gain more benefit than harm fromexposure to drug promotion.
Consequently, education for health professionals
should increase the understanding that all health
professionals have a professional fiduciaryresponsibility to patients to take all practical steps to
avoid pharmaceutical promotion.
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This responsibility includes refusing to accept gifts
and one to one visits from drug company
representatives both at the personal and
organisational levels.
Meetings of groups of doctors with drug companyrepresentatives may be less harmful than one to one
meetings but it is highly unlikely that this type of
activity will be found to do more good than harm
compared to no such meetings.
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2. Health Professionals should be educated
about decision makingEducation for health professionals should include
teaching the psychology and illogic of misleading
arguments and appeals with the aim of improving
the quality of medical decision making in responseto evidence.
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3. Health professionals should be warned thatthey are vulnerable to pharmaceuticalpromotion
Knowledge of misleading arguments and appealsdoes not reliably protect people from being misledby promotional techniques.
The key to reducing vulnerability to being misled
by promotion is helping people move fromoverconfidence in their abilities to understandingthat they are vulnerable.
Consequently, education for health professionalsshould explain that whilst knowledge of
misleading promotional techniques may increasetheir resistance to being mislead, it is unlikely toenable them to reach a level of resistance wherethey would gain more benefit than harm fromexposure to drug promotion.
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An effective way to reduce dangerousoverconfidence is to expose participants to
misleading promotion, allow them to expressincorrect beliefs and then debunk those beliefs andexplain the misleading techniques used so thatparticipants can understand that they are personally
vulnerable.
4. Health professionals should be educated aboutmore reliable sources of information
Health professionals should receive education aboutthe availability and strengths and weaknesses of theleast biased useful sources of information.
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1. Lomas J, Enkin M, Anderson GM, Hannah WJ, Vayda E, Singer J. Opinion leaders vs audit andfeedback to implement practice guidelines. Delivery after previous cesarean section. JAMA.1991 May 1;265(17):2202-7.1
2. Rogers WA, Mansfield PR, Braunack-Mayer AJ, Jureidini JN. The ethics of pharmaceuticalindustry relationships with medical students. Med J Aust. 2004 Apr 19;180(8):411-4.
3. Steinbrook R. Commercial support and continuing medical education. N Engl J Med. 2005 Feb10;352(6):534-5. 4. Schafer A. Biomedical conflicts of interest: a defence of the sequestrationthesis-learning from the cases of Nancy Olivieri and David Healy. J Med Ethics. 2004Feb;30(1):8-24.
5. Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA2003; 290: 252-255.
6. Katz D, Caplan AL, Merz JF. All gifts large and small: toward an understanding of the ethics ofpharmaceutical industry gift giving. Am J Bioethics 2003; 3: 39-46.
7. Katz D, Mansfield P, Goodman R, Tiefer L, Merz J. Psychological aspects of gifts from drugcompanies. JAMA. 2003 Nov 12;290(18):2404-5
8. Becker MH, Stolley PD, Lasagna L, McEvilla JD, Sloane LM. Differential education concerningtherapeutics and resultant physician prescribing patterns. J Med Educ 1972;47:118-27.
9. Linn LS, Davis MS. Physicians' orientation toward the legitimacy of drug use and their preferredsource of new drug information. Soc Sci Med 1972;6:199-203.
10. Mapes R. Aspects of British general practitioners' prescribing. Med Care 1977;15:371-81
11. Haayer F. Rational prescribing and sources of information. Soc Sci Med 1982;16:2017-23.
12. Ferry ME, Lamy PP, Becker LA. Physicians' knowledge of prescribing for the elderly: a study ofprimary care physicians in Pennsylvania. J Am Geriatr Soc 1985; 33:616-21.
13. Bower AD, Burkett GL. Family physicians and generic drugs: a study of recognition, informationsources, prescribing attitudes, and practices. J Fam Pract 1987;24:612-6.
14. Cormack MA, Howells E. Factors linked to the prescribing of benzodiazepines by generalpractice principals and trainees. Family Practice 1992;9:466-71.
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15. Berings D, Blondeel L, Habraken H. The effect of industry-independent drug information on theprescribing of benzodiazepines in general practice. Eur J Clin Pharmacol 1994;46:501-505.
16. Caudill TS, Johnson MS, Rich EC, McKinney WP. Physicians, pharmaceutical salesrepresentatives, and the cost of prescribing. Arch Fam Med 1996;5:201-6.
17. Mansfield PR, Lexchin J. Scepticism and beliefs about new drugs. Healthy Skepticism
International News 2001;19:1-618. Caamano, F.; Figueiras, A., and Gestal-Otero, J. J. Influence of commercial information on
prescription quantity in primary care. Eur J Public Health. 2002 Sep; 12(3):187-91.
19. Watkins, C. Harvey, I. Carthy, P. Moore, L. Robinson, E. Brawn, R. Attitudes and behaviour ofgeneral practitioners and their prescribing costs a national cross sectional survey. Qual SafHealth Care. 2003 Feb; 12(1)29-34.
20. Mansfield PR, Henry D. Misleading drug promotion-no sign of improvements.Pharmacoepidemiol Drug Saf 2004 Nov;13(11):797-9.
21. Brody H. The company we keep: why physicians should refuse to see pharmaceuticalrepresentatives. Ann Fam Med. 2005 Jan-Feb;3(1):82-5.
22. Scott DK, Ferner RE. "The strategy of desire" and rational prescribing.Br J Clin Pharmacol1994;37: 217-9.
23. Shaughnessy AF, Slawson DC, Bennett JH. Separating the wheat from the chaff: identifyingfallacies in pharmaceutical promotion. J Gen Intern Med. 1994 Oct;9(10):563-8.
24. Mansfield PR. Healthy Skepticism's new AdWatch: understanding drug promotion. Med J Aust.
2003 Dec 1-15;179
(11-12):644-5.25. Sagarin BJ, Cialdini RB, Rice WE, Serna SB. Dispelling the illusion of invulnerability: themotivations and mechanisms of resistance to persuasion. J Pers Soc Psychol 2002;83: 526-41.
26. Mansfield P. Accepting what we can learn from advertising's mirror of desire. BMJ. 2004 Dec18;329(7480):1487-8.
27. Wilkes MS, Hoffman JR. An innovative approach to educating medical students aboutpharmaceutical promotion. Acad Med 2001; 76: 1271-1277.
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Healthy Skepticism
Countering misleading
drug promotion
www.healthyskepticism.org