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Are doctors' prescriptions influenced by gifts? In a series examining how medicines are marketed (available on the World Wide Web at (www.nytimes.com/drugs), Stolberg and Gerth1 look at pharmaceutical companies' use of computers to target doctors who may be receptive to prescribing their products.
Of $13.9 billion spent last year promoting drugs, 87% (about $12 billion) was aimed at doctors, as well as nurse practitioners (FNPs) and physicians' assistants (PAs), who can prescribe some drugs. "The pharmaceutical industry has the best market research system...in the world," says Mickey C. Smith, professor of pharmaceutical marketing at the University of Mississippi. This system includes a river of gifts, from prescription pads and pens to fancy dinners and free weekends (called "seminars"?) at resorts, complete with "honoraria" for attendees.
The limited decision-makers pool—about one million doctors, FNPs, and PA—makes things easy for marketers. And they share the wealth: while the American Medical Association (AMA) says it wants to discourage doctors from accepting pharmaceutical firms' gifts, it brings in $20 million annually selling its master file of doctors. While only about 40% of U.S. doctors are AMA members, the organization has detailed information, including an identification number issued by the Drug Enforcement Administration (DEA), on every doctor in the country, and itself assigns a "medical education number" to all new medical students in order to track their careers. The DEA sells its numbers, with corresponding identification, for fees up to $10,200 monthly, depending on how widely the list will be distributed. Paired with pharmacies' records of prescription drug sales (sold routinely to drug makers), which include the prescriber's DEA number, the medical education number allows marketers to rank highest-to-lowest prescribers of any drug by location.
Agreeable doctors are given red carpet treatment by sales representatives. One market research firm hosted 10,400 "peer-to-peer" dinner meetings in 1997 alone. With new drugs coming onto the market almost every day, marketers say that physicians are "hungry" for information—but the free steaks don't hurt! A meta-analysis of 29 studies on the effects of gifts on doctors, conducted by Dr. Ashley Wazana, psychiatry resident at Montreal's McGill University, published in January 2000 in the Journal of the American Medical Association, found an association between meetings with salesmen and "awareness, preference and rapid prescribing of new drugs and decreased prescribing of generics."
The AMA's Council on Ethical and Judicial Affairs published guidelines in 1990 limiting the gifts doctors may accept. The guidelines, also adopted by the Pharmaceutical Research and Manufacturers' Association, the drug industry trade group, prohibit token consulting arrangements, but allow "modest meals" that have "genuine educational function." But compliance is voluntary, and the definition of "modest" is vague. One restaurant manager whose facility is used regularly for pharmaceutical "info-dinners" said ?, "Doctors will only go to an expensive restaurant."?
JAMA devoted its November 1, 2000 issue to medical conflicts of interest, including an article questioning the effects of pharmaceutical companies' gifts to doctors, but prominent doctors see this as hypocritical, given the Association's sale of information to drug manufacturers. This, according to Dr. David Blumenthal, professor of health policy at Harvard Medical School, "hands the weapon to the drug company that the AMA is saying is... illicit..."
Dr. Thomas B. Reardon, past president of the AMA, dismisses the connection, stating that doctors are responsible for their own actions. If the Association did not sell the information, it could be obtained from other sources, including the federal government. Lawrence O. Gostin, an expert on health privacy at Georgetown University Law Center and JAMA's health law and ethics editor, disagrees. The availability of information from other sources "doesn't mean it's all right for people to assemble it, make it easy and sell it."
Doctors who do not want their biographies given out can request the AMA to remove them from the master file, but many are unaware that their prescribing resumes are being sold, or that they have a medical education number assigned by the Association.
Some hospitals and clinics ban free drug samples and visits from drug salesmen, and discourage doctors from taking consulting fees. Everett Clinic, a group practice of 180 doctors in Washington State, has done so, and officials say that its drug costs have declined since the decision.
The American Botanical Council (ABC) is the world's leading non-profit education and research organization disseminating science-based information promoting the safe and effective use of medicinal plants and phytomedicines. This review was originally distributed as part of the HerbClip Educational Mailing Service, one of the benefits of membership in ABC. To join ABC, logon to their website, www.herbalgram.org, or contact Debbie Jones at (800) 373-7105 ext. 106, or e-mail firstname.lastname@example.org.
Sidebar: How Nine States Are Regulating Medical Marijuana
Law-makers and patients in three states are awaiting the U.S. Supreme Court's decision on medical marijuana (Cannabis spp.) distribution in California before formulating regulations for distribution in their own states.
Nine states currently permit medical marijuana use. Most require doctor approval, impose limitations on the illnesses for which marijuana may be used, and set maximum amounts that may be possessed or grown. None of the states provides a source of medical marijuana except through personal cultivation.
New Mexico is expected to become the tenth state legalizing medical marijuana, pending Gov. Gary Johnson's signature. The New Mexico bill calls upon state health authorities to create a means of cultivating and distributing marijuana consistent with federal law. Maine and Nevada are also considering bills which would set up state-sponsored distribution centers.
Maine, along with California, Arizona, and Washington, currently permits patients to possess and cultivate small amounts of marijuana. Legislation introduced there by Sen. Anne Rand (D-Cumberland) would set up a Pilot Medical Marijuana Distribution Program, in which the state would cultivate and distribute the herb to qualified persons.
Nevada, along with Alaska, Oregon, Colorado, and Hawaii, has a state registry of qualified patients and their caregivers. Registrants may possess and, except in Nevada, cultivate small amounts of marijuana. One provision of the Nevada ballot initiative was the requirement for the state to create a legal method of supplying cannabis for medicinal use.
The California case now before the Supreme Court stems froma brief filed by Attorney General Bill Lockyer, who argued before the California Supreme Court that the state has the right to enforce its medical marijuana law, despite the objections of the federal government.*
* Editor's note from ABC: The U.S. Supreme Court handed down a decision in May 2001, overturning a lower court decision that allowed a California Cannabis Buying Club to distribute marijuana to members whose physicians had prescribed the use of marijuana for medicinal purposes. The Court found that this practice was in violation of federal laws prohibiting distribution of marijuana and that, officially, marijuana had no recognized medical value. The Court did leave open, however, the possibility that individual states could still regulate medical marijuana.