Disease-mongering is big business: It sells sickness and promotes drugs
15th Social Pharmacy Workshop held in Queenstown, New Zealand (8 to 11 July, 2008), 125 delegates — pharmacists, psychologists and sociologists from 28 countries — gathered to discuss pharmacy in a social context, with the emphasis on globalisation, marketing and transcultural practices.At the
Ray Moynihan, author and researcher from Australia, made a presentation on selling sickness. He used the fictitious condition of motivational deficiency disorder to highlight how drug companies were in the business of disease-mongering.
The boundaries of illness were constantly being widened in order to sell more drugs. Risk factors, which were being made into diseases, were one of the strategies being used.
Mr Moynihan cited attention deficit disorder, female sexual dysfunction, high cholesterol and high blood pressure as examples, leading to over-medicalisation and over-treatment.
Entanglement between the health professionals and the industry resulted. Many of the professionals who sat on the panels which had defined these new diseases had all been working with the drug companies. Mr Moynihan said that laws were needed to stop such entanglement. Professional bodies should also take a stand on this matter.
Healthy scepticism on drug promotion
Peter Mansfield, a GP in Australia and founder of website HealthySkepticism.org, gave delegates an insight into why intelligent, well educated, well intentioned, confident health professionals were particularly vulnerable to unintended bias towards drug promotion.
Professionals generally exhibited the “illusion of unique invulnerability”, that is, while they thought that others were influenced by advertising, they were immune to it. Insights from psychology, including dual process theories of social psychology, such as the systematic-heuristic model, the elaboration likelihood model and cognitive-experiential theory helped to explain such behaviour.
Dr Mansfield gave the results of studies that indicated that exposure to promotion correlates with lower quality prescribing. He cited the over prescribing of COX-2 inhibitors, hormone replacement therapy, glitazones, long-acting beta agonists, the newer antidepressants and antipsychotics as examples of some of the disasters linked to drug promotion.
Selective reporting of drug trials contributed to the problem. In a study of over a hundred trials, 65 per cent of harmful outcomes had been incompletely reported.
New Zealand, along with the US, allows direct to consumer advertising (DTCA) of prescription medicines. Delegates attending a workshop led by Barbara Mintzes, University of British Columbia, heard of the supposed benefits, for which there was little evidence:
- Educates, informs and empowers the public
- Improves compliance
- Stimulates the need for treatment
However she said there was more evidence for the risks:
- Misinforms and misleads on both drug and disease
- Increases drug costs
- Results in greater exposure to harmful drug effects
A systematic review of DTCA has shown increased demand without any documented health benefits.
In a case study of ezetimibe, with matched patients in the US and Canada, Ms Mintzes said that those from the US, where advertising was legal, were twice as likely to ask for the named drug when consulting a doctor. They, in turn, prescribed requested drugs three-quarters of the time and in 50 per cent of cases it was possibly an unlikely choice.
Advertising leading to harm was evidenced from Vioxx. Ms Mintzes said that in the Kaiser Permanante organisation, 20 per cent of prescriptions were attributed to DTCA and that these were four times as likely to contain an inappropriately prescribed product. Research suggested that around 18,000 extra heart attack deaths could be attributed to DTCA.
She said that even in countries where DTCA was not legal, there was an increase in disease awareness advertising campaigns. One such campaign for fungal nail infections had led to an increase in consultations, and an increase in the prescribing of terbinafine, with a decrease in the prescribing of itraconazole.
Such advertising by stealth was occurring in Australia, where cholesterol testing was being advertised, with the recommendation that viewers raise the issue with their doctor.
In New Zealand, this evidence was being used in an attempt to change policy. A call for a ban of DTCA in 2003 had received widespread support but had been unsuccessful so far. Almost all professional organisations had supported the ban, although the group representing retail pharmacies had not given their support.
It was suggested that this was because of their business interests. One suggestion was that DTCA should be banned and that it should be replaced by independent evidence-based information.
Therapeutic risk management
The iterative process of assessing a product’s benefit-risk balance is the concept of therapeutic risk management.
Bram Hartzema, pharmacoeconomics professor at the University of Florida College of Pharmacy, explained to delegates that benefits, as well as risks, are also patient-specific and influenced by such factors as:
- The severity of the disease being treated
- The outcome of the disease if untreated
- The probability and magnitude of any treatment effect
- Existing therapeutic options
- A person’s understanding of risks and benefits and the value they attach to them
He shared with delegates the five stages involved in therapeutic risk management:
- Risk assessment — estimation and evaluation of risk
- Risk confrontation — determination of acceptable levels of risk
- Risk intervention — actions to control risk
- Risk communication — interactive process of exchanging risk information
- Risk management evaluation — measurement of effectiveness of aforementioned activities
Citation: The Pharmaceutical Journal URI: 10026179
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