Samples

There’s a lot of controversy in the United States about the role of pharmaceutical representatives in medical practice. Pharmaceutical representatives hand out freebies ranging from luxury vacations to branded pens, with the expectation that doctors will return the favour and prescribe their brand-name medications. Some hospitals, practices, and medical schools have started cracking down on these practices, worrying that doctors may not be making the best choices with (good doctors make choices with, not for patients) their patients as a result of the intensive lobbying on the part of the pharmaceutical industry.

There are a lot of ethical problems with this which have been raised before, ranging from concerns that doctors will pick a medication on the basis of freebies received, rather than patient welfare, to worries about the obvious expense of brand name medications for patients paying out of pocket or dealing with restrictive insurance plans. There are also concerns that patients given a freebie sample of a medication might be drawn to request it by name in the future, which is of course the goal of the pharmaceutical representative, but may not be best for the patient.

But there’s one thing that doesn’t get brought up very often: the benefits of freebies for patients.

Image description: an unpacked Advair Discus package, showing the original packaging box, medication information pamphlet, purple foil packet, and inhaler. Inhaler is marked Sample--Not For Sale
Image description: an unpacked Advair Diskus 250/50 package, showing the original packaging box, medication information pamphlet, purple foil packet used to keep the inhaler fresh until ready to be opened, and inhaler. Inhaler is marked "Sample--Not For Sale"

Many patients with chronic conditions have received free samples of medication. Back in the days when I had health insurance and we were trying to work out an appropriate regimen to manage my asthma, I benefited from scores of freebies, some of which were very expensive medications. My doctor recognized that my insurance would fight on every prescription she wrote, so it made more sense to give me a free sample to see if the medication even worked than it did to write a prescription for one round, fight viciously with the insurance company to get it honored and filled, and then find out that the medication wouldn’t be suitable.

Now that I don’t have insurance, I benefit from freebies in a major way. Asthma medications are rather expensive. The Advair Diskus, pictured above, is not available generically, and a 250/50 inhaler costs between $100-$200 in the United States. The inhaler pictured above lasts for two weeks. Medications for other conditions I have are also extremely expensive, with out of pocket costs which can climb into the thousands every month.

I can’t afford these medications at this time. That means that even though I should be using them on a regular basis, I can’t if I have to pay for every drug I use. So, my doctor gives me freebies. Lots and lots of freebies. Those help bridge the gaps between when I can afford the medication, and when I can’t. I’m sure this isn’t how the drug rep meant for those freebies to be used, but a lot of medical practices which deal with low income patients and patients in weird financial situations like mine use their freebies in this way; not as promotional tools to get patients interested in medication, but as life-saving assistance for patients who need medications and can’t afford them.

Some pharmaceutical companies have plans which offer medication at little or no cost to people of low income. But these plans don’t cover all medications, and it takes time to apply and prove eligibility. This is time which many patients may not have. And some patients don’t qualify; my income is such that most would be unlikely to think I was a worthy beneficiary of such a program. Thus, renegade doctors and medical practices stretch their freebie privileges to get medications into the hands of patients who need them.

Do we need to have a larger discussion about the ethics of pharmaceutical representatives and the impact they have on medical practice? Yes, we do. It’s a problem. It’s not going to go away. But let’s not forget, at the same time, that there are some distinctive benefits happening under the existing system, like making sure that at least some patients who need them can get medications they can’t afford.

By 20 October, 2009.    medical practice  ,  



13 Comments

  1. Agreed, that’s always been part of my problem with the whole issue of freebie ethics; my psychiatrist kept me stable on freebies for four or five years before the drug became covered under my mother’s insurance plan and until generics came out. It’s not an easy black/white issue at all.

  2. Bene: I think it can be a simple issue if the other side of the coin isn’t “a fully private system where a bunch of people have no insurance, drugs are horribly expensive, and freebies aren’t available”, but “universal single-payer health insurance where those who need medications the most can always afford them, without having to strike it lucky with a doctor who’ll slip them something”.

    Unfortunately, sick people are still paying for the freebies and all the other marketing, in the form of massively increased retail drug prices. I just looked up the same drug in Australia, and it’s only $55 ($51) if the person is paying the full price. Most people pay around $5 (if the government recognises them as low-income or veterans; I believe this is around a third of the population or so), or $32 (for everyone else), with an annual Safety Net cap. There’s just no excuse for the same drug to be 100-200% more expensive in the USA, except that the ridiculous, baroque, evil system that has perpetuated such price gouging.

    If it always works out that people who are more able to pay are consistently subsidising people who aren’t, as you identify, that can be a useful way of mitigating some of the damage until the vile system is overturned. I don’t disagree with the basic premise of the post. I just abhor that this avoidable need exists in the first place, and that so many people (not the people here, I know!) just shrug and accept it as The Way Things Are.

  3. Oh, yes, I am by no means saying “hey, let’s keep the system the way it is, because I get freebies!” I actually think that’s a horrible way to get medicine (all the more so because I can’t get enough freebies to meet my needs, so I end up paying out of pocket about half the time for that I need, but other people might not be able to do that, so would be going on and off their medication all the time).

    I don’t really want to get into a diatribe here, but the American health care system is broken; things like this are an example of why. If they’re not going to fix the overall system, though, I would rather that loopholes like this continue to exist (even though drug costs are sky-high because of all the associated marketing costs, including handouts of samples and the abhorrent direct to consumer marketing campaigns). One of the things that has greatly concerned me about the current tone of “reform” is that it’s not reform at all, but they’re proposing closure of a lot of loopholes like this. Hence, in the not too distant future, I could end up still not having insurance/not being able to get insurance, but I wouldn’t be able to get free medicine from my doctor. That scares me.
    .-= meloukhia´s last blog ..meloukhia’s Quick and Dirty Voter’s Guide to the 3 November, 2009 Consolidated District Election (and an Observation) =-.

  4. Oh, I agree–as I went into today on my Dreamwidth, I sort of had a wakeup call to the utter brokenness of the system within the last 24 hours. It’s terrible, and one could argue that the loopholes add to it. But they also keep some people afloat.

    Basically, we need to wipe the slate clean.

    Incidentally, I’ve been finding that it’s not just prescription drugs that are overpriced in the US. The 10 count pack of brand name Lemsip that I bought for my cold cost £3.12 (at current exchange: $5 USD) at major pharmacy price, and contains more effective medicine. US equivalent brand name Theraflu costs $5.49 at the cheapest, and it’s only a 6 count pack.

  5. Yes, drug prices here are generally more expensive; in part because of all the reasons Lauredhel identified. DTC marketing is quite expensive, and people definitely pay for that in drug prices. They also charge high prices because, well, they can get away with it, since it’s structured into the system. Very few consumers question drug prices because they’re either insured and unaware of the actual sticker price, or they’re paying out of pocket and need the medication so they can’t fight the price.

    And I concur; the best fix for the system is to dismantle the system and start over. Alas, the same nice pharmaceutical company that sometimes gives out free medication is also in Washington, lining the pockets of members of Congress to ensure that they don’t pass the obvious solution: a nationalized single payer plan.

  6. I’ve been rescued by freebies. I suffer from breakthrough bleeding while on the pill. The first prescription I was ever on had a too-low dose, so in the middle of the month, I started bleeding and bleeding and after a week it wasn’t stopping. The doctor gave me a freebie pack of pills to boost my hormone levels so that I could recover quickly before switching to a different prescription. Freebies give doctors the freedom to make on-the-spot effective decisions. If only there were a way to make all medication free to the public…

  7. I still can’t quite get my head around the idea of paying for healthcare. I thank my lucky stars I’ve rarely had to do so (I am on Incapacity Benefit so I don’t pay), and when I have it’s been at a fixed price (here in the UK, no matter what your medication is it costs you £7.40 (I think) per prescription). The NHS isn’t perfect, but it works. I hope the US finds a way that works soon… nobody should be without vital medication simply because of cost.
    .-= Anji´s last blog ..Blogrollin’ =-.

  8. Yep. I have a medication that is very expensive, has no generic alternative, and that my insurance stopped covering awhile back – even with my doctor’s letter explaining why I really need it. So, when I see my doctor, I ask for samples. Sometimes I get them and sometimes not. It’s lucky for me this is a medication I only take “as needed” and don’t need all that frequently. It’s prescribed for me off-label, so even if the company that makes it has an assistance program, I don’t think I’d be eligible. [It’s lidoderm patches that help my severe back pain, but it’s only FDA approved for shingles, which is why my insurance company won’t let me have it anymore, either.]

    I’m grateful, obviously, for the samples. But it would be much much better if we could change how unnecessarily expensive medications are and how unnecessarily difficult it can be to get certain medications, than for me to get some free samples from my doctor every few months.
    .-= Rosemary´s last blog ..Blah-der-day. =-.

  9. If they’re not going to fix the overall system, though, I would rather that loopholes like this continue to exist

    Yeah. The problem is not the presence of freebies, the problem is that lack of genuine alternatives. Australia is slower to get new drugs than the US, but the government negotiates us a stable and lower price in the meantime. This can be really bad for people with rapidly progressing or rare diseases who can see people in the US getting new treatment that might benefit them – but they can’t access it, or only at high prices. But it’s not like people in the US are paying less for those new drugs, and we do get fairly distributed (except in very rural areas) and relatively affordable medications in return. I take a contraceptive pill for my PCOS, and because it’s a higher dose pill usually used for control of skin conditions, it’s not subsidised by the government. It’s still 70% cheaper than the same drug in the US, and I can buy it as often as I need it, allowing me to stack the pills and have only 4 periods a year.

  10. lilacsigil, something that a lot of people do not know about development of drugs in the US is that the federal government subsidizes and sometimes outright pays for a lot of the most complex and long term drug studies and development. The National Institute of Health is the single largest investor in new drug development, and it gets its funds from tax dollars. So, while some people assume that it is the profit driven system that speeds up development, in fact a lot of this development relies on federal funds. The largest expenditure of drug companies does not lie in development, it lies in lobbying.

  11. I googled advair diskus, and learned it has the same active ingredient as my inhaler. I pay $3 per inhaler. I don’t have insurance… I live in new zealand where we have government subsidies on prescriptions… But I also see the full cost on the receipt. These inhalers are approx us$60 each. So ye gads what a price hike they have in your area!

  12. I’m a medical student in Australia, and I just thought I’d mention that the reason drugs are so cheap here isn’t entirely because the pharmaceutical companies price-gouge in the USA; the government covers most of the cost. If you don’t match their requirements though, you have to pay the full price. And they’re often limited in amounts or repeats or brands, and in some cases the doctors have to ring up a special phone-line to get the authority to prescribe it EACH script.
    Our government is very wary of drug companies and their influence on doctors. For the past few years there have been limits placed on how much they can spend on ‘gifts’ and lunches for GPs. And from this year, I believe, they’re no longer allowed to give out pens and pads of paper and things that patients might walk away with. While we medical students mourn the fact that we now have to pay for our pens and notebooks, I’ll freely admit that it might be a good thing. The notebooks I’ve used have lodged the brand names of certain medications in my memory. We’re taught not to use brand names when studying, but I have to think harder to remember Pregabalin as opposed to Lyrica. And I actually have to look up Xanax to work out what kind of anxiolytic it is.
    And just as an amusing aside; I sat in with a GP for 8 weeks who used to save up samples of a certain medication for a patient. I don’t know if it was because she couldn’t afford it or didn’t qualify for the subsidised program. But every time that drug rep came in, the GP’d go straight to the sample cupboard with a bag and take all of them!

  13. Tarpy: it’s some of the reason, but not the only reason. If you compare private prices, with no subsidies in sight, many medications in America are still substantially more expensive (often 50-100% or more) than in Australia.