Questions swirl around drug ads for patients

Many doctors at the AMA Annual Meeting said they still hated them, but others are learning to live with them and even see benefits.

By Victoria Stagg Elliott, amednews staff. July 9/16, 2001.

Chicago -- When Arthur Silk, MD, writes a prescription for atorvastatin calcium -- sold under the trade name of Lipitor -- he knows that there's a chance that his patient will leave his office without it. Or that they'll take the prescription, but not fill it. Or that even if they do, they might not take it as instructed.

The drug, manufactured by Pfizer Inc., however, is heavily advertised directly to consumers, and Dr. Silk believes this makes his patients more likely to follow doctor's orders.

"When I recommend it, they don't always take the prescription," the Garden Grove, Calif., internist said during a debate about direct-to-consumer prescription drug advertising at last month's AMA Annual Meeting in Chicago. "[But] when they see the ad in the paper, they call me up and say they'd like it."

Dr. Silk is part of a growing number of physicians who have learned to like direct-to-consumer ads, or at least to live with them.

"It's too late to ban direct-to-consumer advertising," said Sandra Adamson Fryhofer, MD, immediate past president of the American College of Physicians--American Society of Internal Medicine. "The cat's out of the bag."

Some doctors say it improves patient compliance because the ads act as regular reminders to take medication. The ads also bring people into the office to talk about conditions that they rarely asked doctors about before.

The AMA advocates that consumer-targeted ads include the phrase, "Your physician may recommend other appropriate treatments."

"I like DTC advertising," said Stuart Gitlow, MD, an addiction psychiatrist from Providence, R.I., and a delegate from the American Society of Addiction Medicine. "Individuals now come to me to stop smoking. Individuals never came to me prior to Zyban [bupropion hydrochloride] advertising specifically to stop smoking. Not once. The Zyban ads began and all of sudden people came to me and said: 'Help me stop smoking.' "

DTC advertising supporters also say patients are more educated and empowered to seek solutions for sometimes stigmatized conditions.

"When I watch these ads on TV, I have to wonder if these ads are doing real good," said Saul Levin, MD, a psychiatrist from Washington, D.C. "The anti-depressants are publicized this way. Mental illness is a discriminated illness with a lot of stigma. Sometimes you do get general publicity to the general society through these ads."

What docs really want: oversight

DTC advertising is clearly here to stay, despite long-standing, vociferous opposition from many physicians since the ads first started appearing in the 1980s. There are still many physicians who hate them, but attempts to ban the ads or at least express loud distaste for the practice are fading in favor of attempts to control what's out there and what's going to be published next.

For example, an effort to press the AMA to petition the Food and Drug Administration and the Federal Trade Commission to ban DTC advertising failed at the June meeting, despite being presented twice.

"We're not blinded by our passion," said otolaryngologist Angelo Agro, MD, a New Jersey delegate from Voorhees who proposed a policy to ban DTC ads. "We recognize that a ban is just not going to happen for all sorts of reasons. What we really want is some oversight with some real teeth."

Many felt that seeking an outright prohibition would have violated the First Amendment. Instead, the organization is advocating that consumer-targeted ads include the phrase, "Your physician may recommend other appropriate treatments."

But the AMA will collaborate with the National Council for Patient Education and Information to create and distribute materials that will educate consumers and physicians about the risks, benefits and potentially misleading information in drug ads.

"We want patients to receive the best products for them, not just the most heavily advertised," Dr. Fryhofer said.

Reining in the ads now tops the agenda because even the staunchest supporters are still concerned about DTC advertising's darker side. The most expensive drugs are frequently the ones most heavily advertised -- leading patients to request those medications when lower-cost ones are available. Doctors also complain that the ads can get in the way of a doctor-patient relationship already strained by the demands of managed care.

"Not only do we have to explain to our patients the nature of the medical problems that they have, but we also have to discuss why they don't need the drug that was advertised and what is the best option," Dr. Fryhofer said.

And although the ads clearly have a role in patient education, the information presented is far from perfect or complete. A study published last year in The Journal of Family Practice found that although some advertisements were informative, the educational value of most was minimal.

"The public is not being given the whole truth," Dr. Agro said. "By its very nature advertising is biased, and it's compressed. We are not against information being brought to the patient, but we have a problem when it's biased, limited and brought about by multimillion-dollar organizations that have a profit motive only."

Expiration dates and refill barriers

In other prescription-drug-related moves, the AMA recommended that expiration dates on the containers of prescription drugs be determined by scientific testing and urged the pharmaceutical industry to determine whether lengthening of expiration dates would provide clinical or economic benefits or risks for patients. The Association also recommended that there be fewer barriers to patients wanting to refill their prescriptions, including establishing pharmacy hours and locations for refills that are the same as for those filling new prescriptions. Some currently limit the times and locations at which refills may be obtained.

Those on medications for chronic conditions also should not be limited to a 90-day supply or less and should be able to get all their prescriptions filled at one time.