Rx for Change — Help Your Doctor Break the Sample Habit

By Adriane Fugh-Berman
May June 2008

Does your doctor give you drug samples? It’s always nice to get something for free. But, medication samples aren’t like the free samples you get at the supermarket. If you accept a cube of cheese offered to you at a grocery store, you can decide to purchase more if you like it, and walk away if you don’t.

Evaluating which drug is safe and effective for you isn’t as easy a call, which is why a physician is supposed to mediate the process. Physicians (and other prescribers) control access to prescription drugs because they are supposed to know enough to evaluate the choices and make the best decision on behalf of their patients. Drug samples, however, are meant to muddle a doctor’s decision-making process in favor of the most aggressively promoted drugs.

Physicians would probably be more cautious about prescribing brand-new, relatively untested drugs if it weren’t for samples, which are the most effective marketing tool the pharmaceutical companies have. Many physicians only see pharmaceutical sales representatives (drug reps) in order to obtain drug samples, so providing samples is the key to getting into physicians’ offices. Drug reps only drop off limited amounts of samples in order to have a reason to come back regularly. Even doctors who try to avoid industry influence by rejecting drug company dinners, presents, and speaking engagements, will accept drug samples as a service to their patients.

These doctors mean well. They may not realize that samples are only available for the most expensive, most profitable drugs, and that the samples are very effective marketing tool to increase sales. Samples can tip a prescribing decision towards a specific drug, because a physician who gives a patient a sample almost always writes a prescription for the same drug as well. One study shows that if a sample is available, physicians will prescribe a drug that was not their first choice.(1)

Although physicians say that they give samples to their low-income patients, a recent study found that more samples are given to middle and upper-income patients than to poor people.(2) (See “Snapshots”.) This makes sense if you recognize that part of samples’ purpose is to create goodwill. Samples are gifts from the company both to the doctor and to the patient. Patients are grateful for free samples, so physicians get positive feedback for giving their patients a gift. And, patients who receive a free sample are more likely to refill prescriptions for that drug. Samples are the gift that keeps on giving – for drug manufacturers.

Samples increase the familiarity of both prescribers and patients with that drug. As a pharmaceutical marketing magazine puts it, “You can look at sampling as the start of a joint compliance program between the doctor and patient–where both work together to monitor results. …You want patients to tell others, ‘Hey, I’m using this drug. It’s great. You should go to your doctor and see if it would work for you.’ And you want doctors to tell their peers, ‘My patients have been very successful on this medication.’”(3)

Samples are primarily available for new drugs that are taken every day for a long time. A patient who receives a sampled drug, fills the prescription for that drug, and doesn’t seem to be having problems, is very likely to stay on that drug. The problem, however, is that symptoms are not a reliable marker for risk, so the fact that a patient is “tolerating” a drug well doesn’t necessarily mean the drug is safe.

Sampled drugs may be less safe because they are usually new — and newer drugs, as a group, are less safe than older drugs. Most risks are only identified after a drug has been on the market for several years. Newer drugs carry more risks because they have been tested in only a limited number of people, for a limited amount of time.(4) Problems associated with longer-term use, or use in special populations (like children, the elderly, people with multiple medical problems, or those taking multiple medications) show up only after a drug is in widespread use. Half of withdrawals or black box warnings (the FDA’s most severe warning) occur within two years of drug approval.(5) We know more about the true benefits and risks of older drugs simply because they’ve been around long enough for unforeseen risks to show up.

I know that asking consumers to refuse drug samples is a hard sell. But, if you have a medical condition that requires a prescription drug, you deserve a considered choice about which drug to take that’s based on science, not on marketing. Here’s another reason to refuse samples. Patients cannot affect most of the tactics used by pharmaceutical companies to market drugs to physicians (which include advertising, drug reps, dinners, meetings, and publications). But, samples are the most effective marketing tool, so refusing samples is a direct action that we can take to combat inappropriate pharmaceutical promotion. If some of us refuse the lure of free samples and said to our physicians, “Thanks, but I’d prefer a prescription for an older, time-tested drug,” it might cause physicians to reconsider accepting samples at all.

References
1. Chew LD, O’Young TS, Hazlet TK et al., “A physician survey of the effect of drug sample availability on physicians’ behavior,” J Gen Intern Med 2000; 15(7):478-83.
2. Cutrona SL, Woolhandler S, Lasser KE et al., “Characteristics of recipients of free prescription drug samples: a nationally representative analysis,” Am J Public Health 2008; 98(2):284-9.
3. No author, “Lifecycle Management — Three marketing experts, one burning question: how can pharma’s communications help ensure customers adopt a brand–and stick with it?” Pharmaceutical Executive 2005; 25(2):S22.
4. Olson MK, “Are novel drugs more risky for patients than less novel drugs?” J Health Econ 2004; 23(6):1135-58.
5. Lasser KE, Allen PD, Woolhandler SJ et al., “Timing of new black box warnings and withdrawals for prescription medications,” JAMA 2002; 287(17):2215-20.

Adriane Fugh-Berman, M.D., is an associate professor in the Georgetown University School of Medicine, Department of Physiology, and a former chair of the NWHN. Starting with the July 2008 issue, Adriane will be writing for the WHA every other month, in order to pursue other projects.