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Trade deals are bad medicine: Patents, profits and payola physicians

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In the last four articles on the TPP and Big Pharma, the discussion looked at a variety of topics ranging from how trade deals are largely driven by the interests of the pharma lobby, create a policy chill and could preclude universal pharmacare, only serve to cement high drug costs in Canada, are in the interests of drug companies' patents over patients, have nothing to do with more R&D, and so on and so on....

Trade and health isn't a simply subject. The downstream results are not always as apparent as they should be, and are often obfuscated by corporate interests. This is perhaps nowhere more disturbing than with the results we see at the end of the line, with doctors and patients.

On the ground in Canada, the same big pharma lobby that is (in too many cases) producing flawed data while pushing for less transparency and more patent "rights" in the TPP is also influencing what doctors prescribe. A recent Star investigation found, that

drug companies routinely host and bankroll dinners at upscale restaurants as training for family doctors. Speakers, paid by the drug company, give presentations and field questions from doctors, who get professional credits for attending the event. At more than one dinner, the Star found the speaker recommended a medication for certain treatments — the medication made by the same company that organized the event, paid for the wine and food, and paid the doctor giving the talk.

In Ontario alone there were more than 500 such industry sponsored events. In an investigation it was revealed roughly 70 per cent of the events listed on The College of Family Physicians of Canada's website were put on by drug companies, sometimes indirectly through hired communication firms. In the past the Canadian Medical Association took $780,000 from Pfizer Canada to fund continuing medical education" (Two Pfizer staff members also sat on an administrative board during this time). It is not surprising, then, that a correlation can also be drawn between the epidemic of over-prescribing and polypharmacy.

Earlier this year, it was reported that the College of Family Physicians of Canada has maintained "that it would keep taking drug-industry money to pay for its education programs despite commissioning a report on Big Pharma’s influence, which it then kept under wraps for two years," and the college still "refuses to divulge an analysis of exactly how much corporate funding its educational programs receive." Expert researchers in the field have pointed out that "the College should simply have said No to industry funding, and required doctors to pay the whole cost of their conferences and seminars. That’s what other professions -- from accounting to law -- already do."

By influencing how doctors prescribe medication through sponsorship of education and professional development of doctors, Big Pharma has a perfect avenue to influence their sales. In particular, this influence leads to a narrower range of topics at educational events (i.e. topics where drug companies can make money are discussed not what doctors most need education on). For example, industry-sponsored educational programs tend to emphasize medications and ignore other treatments, such as diet, exercise and physiotherapy. Additionally, the programs favour the pharmaceutical sponsor's products. This bias, in turn, has a harmful effect on physician prescribing. Studies show that physicians who interact more frequently with the pharmaceutical industry have poorer prescribing habits: they are less likely to follow independent guidelines and more likely to prescribe expensive medications.

The "gift relationship" between physicians and industry is well researched. As the Star defines it:

a drug company representative visits a physician's office with a high-end lunch, tickets to a sporting event, or some other gift, the goal is not simply to promote a product. Rather, the goal is to build trust -- sometimes, even friendship -- so that physicians are more likely to accept what they're told about the safety and effectiveness of not just one drug, but the next one too. 

It has been documented that, "medical students and physicians are unlikely to believe that their views are biased by their interactions with the pharmaceutical industry, but there is evidence that educational interventions are effective at changing this view." A study that compared prescribing habits of primary care physicians in Montreal, Vancouver, Sacramento and Toulouse who were visited by pharmaceutical sales reps (PSRs) found,

PSRs rarely provided information defined a priori, based on a physician survey and regulatory standards, to be 'minimally adequate safety information' (1.7 % of promotions). Information on health benefits was provided twice as often as information on harm, with not a single harmful effect mentioned in over half of promotions in the three North American sites. It might be expected that if physicians were unfamiliar with a medication, PSRs would provide safety information to help ensure appropriate use. Information on serious harm was no more frequent for drugs not previously prescribed. Similarly, serious harm was rarely mentioned for drugs with boxed warnings or subject to recent safety advisories...Nevertheless, physicians judged the quality of scientific information to be good or excellent in 901 (54 %) of promotions, and indicated readiness to prescribe 64 % of the time...

The study also noted that the most common reason for Canadian physicians in surveys to see PSRs is to obtain information on a drug, and in many cases PSRs are the first information source on new drugs.  Of the four cities compared, it was found that "minimally adequate safety information is provided more often in Toulouse, with stricter information standards, than in Vancouver, Montreal or Sacramento, and that harm is mentioned more often in Sacramento than Canadian sites, reflecting US 'fair balance' provisions."

There is an urgent need for federal legislation requiring all pharmaceutical companies to reveal the payments or transfers of value that they give of any kind they give individual doctors and hospitals. In the U.S. this type of disclosure is required under the 2010 Physician Payments Sunshine Act. Under the U.S. law, "drug companies reported $6.45 billion (U.S.) in payments to physicians and hospitals in 2014, including money for research. More than 600,000 doctors – about two-thirds of the total – received sums ranging from a few dollars to millions of dollars. A recent analysis of Sunshine Act data by the Propublica investigative-journalism group found that doctors who receive industry cash are more likely to prescribe pricier brand-name drugs than generics." In Canada there is no such system for disclosure and people are literally dying as a result (for example the resent opioid epidemic sweeping the country).

Always aware of the effects that bad PR have on their bottom line -- and with a high profile court case in the US around Purdue Pharma’s behaviour -- big pharma in Canada recently announced a "voluntary sunshine" initiative (it should be noted on 10 firms have signed up so far). Not surprisingly, what they are proposing is more of a PR stunt than anything to do with good public health policy. Critics have stated, "what they’ve proposed is disingenuous and deceptive. Under the initiative, participating companies will report only aggregate amounts given to medical education, rather than how much money made its way to which doctors and why. It gives the illusion of transparency, while cloaking the money pocketed by individual physicians. This initiative will not illuminate ties between drug companies and doctors, and it will not make doctors rethink their treatment decisions or relationships with Big Pharma. Nor will it allow patients to question what might be influencing their doctors’ prescribing. Pharma's voluntary initiative is a thinly veiled attempt to clean up its image." The Canadian plan is "a PR gesture at best, and it will produce a largely meaningless set of figures," charged Sergio Sismondo, a Queen's University professor who studies links between drug companies and doctors and further noted that, "I think this is very likely an effort to forestall real accountability or real transparency on this issue."

What we seriously need is an amendment to Canada’s Food and Drugs Act to legally require individual drug companies to disclose their financial ties to individual doctors and for that record to be public. Or further, ban the practice all together. While the president of Innovative Medicines Canada (the pharmaceutical industry group formerly known as Rx&D) feels, to no one's surprise, that a law like this would violate Canadian privacy law, other like Ontario's former privacy commissioner, Ann Cavoukian, are not so sure. As Cavoukian said, "My gut reaction is no, it shouldn't violate privacy per se because the use of physicians' names, in the context of the performance of their duties, would not be treated as personal information.”

To this day, there remains an alarming lack of oversight into the actions of pharmaceutical companies and their influence on doctors. We need more sunshine and fewer myopic PR gestures by big pharma. This also means that doctors need to start taking an evidence-based look at their own practices and recognize their actions are not infallible. At the end of the day, it is patients who suffer when we allow patents, profits and payola physicians to control our public health.

Michael Butler's blog

 

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