| I'm the first to admire the strengths and | | | | none.3. When they draw attention away from |
| virtues of the free-enterprise model as it | | | | non-medication treatments.Drug companies sell |
| applies to drug development and sales. This | | | | drugs. Therefore, when it comes to marketing |
| model encourages drug companies to employ | | | | their products, they have no interest in |
| talented people and to take risks in | | | | promoting -- or even mentioning -- non-drug |
| developing new drugs for serious medical | | | | treatments. There are no salespeople making |
| problems. But let's face it, current | | | | the rounds of doctors' offices to remind |
| practices also produce undesirable effects.1. | | | | physicians of the rigorously proved benefits |
| When their drug that was wonderful last month | | | | of stress management training for migraine |
| is suddenly no good.It's been entertaining to | | | | and tension-type headaches, or of |
| watch the drug companies suddenly come up | | | | cognitive-behavioral counseling for |
| with new, patentable variations of their | | | | depression.4. When they hook us on |
| drugs just when their old patents are | | | | samples.Doctors' offices receive samples of |
| expiring. For example, since the 1970s, the | | | | patented (high mark-up) drugs and not of |
| Abbott company has been doing a dance with | | | | unpatented (low mark-up) drugs. Therefore, |
| different formulations of valproic acid (used | | | | patients are steered toward the expensive |
| for seizures, migraines and bipolar | | | | drugs by means of these "loss-leaders."5. |
| disorder). At first, the brand name was | | | | When they shape medical practice.Drug |
| Depakene, but when that patent ran out, | | | | companies aggressively court the |
| Depakene was suddenly no good any more, and | | | | thought-leaders, like faculty members at |
| Depakote (just barely different enough to be | | | | medical schools, with financial perks such as |
| patentable) was the only drug one should | | | | impressive fees for speaking engagements. |
| think of. Then when Depakote's patent ran | | | | They also subsidize medical publications. The |
| out, suddenly it wasn't any good, either. Now | | | | effects of these marketing activities on |
| Depakote ER (extended release) is the only | | | | medical practice are not necessarily |
| way to fly.This approach of reworking the old | | | | beneficial to patients.For example, tissue |
| drug into longer-acting formats has worked | | | | plasminogen activator (tPA) is an expensive |
| for other drug companies, too. For example, | | | | clot-dissolving drug approved for use in |
| GlaxoSmithKline has gone through the same | | | | stroke patients. Its benefits are modest and |
| dance with their formulations of bupropion | | | | its risks are real (brain hemorrhage and |
| for depression, evolving from Wellbutrin to | | | | death). Thoughtful clinicians might |
| Wellbutrin SR (sustained release) to | | | | reasonably conclude that the benefits of |
| Wellbutrin XL (extended release). Wyeth, | | | | administering tPA do not outweigh the risks. |
| seeing a good thing, followed the same path | | | | But this is not the message that comes from |
| with venlafaxine antidepressant, going from | | | | many thought-leaders and publications. |
| Effexor to Effexor XR (extended release). | | | | Instead, the implication is that |
| It's just an amazing coincidence how these | | | | administering this drug is a standard of |
| new, suddenly-better drugs emerge just when | | | | care, and omitting it constitutes |
| the old drugs expire and face generic | | | | malpractice.6. When the sales reps push |
| competition.2. When they make us forget that | | | | unapproved uses.Recently, a Pfizer sales rep |
| the older drugs work just fine.Since 1954 | | | | told me that his company's drug, pregabalin, |
| we've had effective anti-psychotic drugs to | | | | is effective in preventing migraine. He |
| treat schizophrenia, but beginning in the | | | | shouldn't have said that. Pregabalin is |
| 1990s a series of new anti-psychotics | | | | FDA-approved for treatment of epilepsy and |
| emerged, now called the "atypical" or "novel" | | | | nerve-pain, but not migraine. Although |
| anti-psychotics. Suddenly, the older drugs -- | | | | physicians in the U.S. are allowed to |
| all generic and therefore reasonably priced | | | | prescribe drugs for "off-label" uses, drug |
| -- were no good. Only the new, patented | | | | companies are prohibited from advertising |
| anti-psychotics were any good and one might | | | | their drugs for non-approved uses. In fact, |
| even be guilty of malpractice if one | | | | Pfizer got in trouble for pushing another |
| prescribed an older drug (or continued | | | | drug, gabapentin, for unapproved uses.7. When |
| prescribing one to a patient who seemed to be | | | | doctors don't think critically about what |
| doing fine). Indeed, a generation of new | | | | they're doing.This, strictly speaking, isn't |
| psychiatrists cycled through training | | | | a deficiency of the drug companies. But |
| programs with this concept in mind, rarely | | | | because the only salespeople that doctors see |
| writing a prescription for an older drug.The | | | | are for expensive, branded drugs, the names |
| alleged superiority of the newer drugs was | | | | of less expensive (or more effective) |
| tested in the recently completed CATIE | | | | alternatives may not come to mind when |
| (Clinical Antipsychotic Trials in | | | | prescriptions are written.(C) 2006 by Gary |
| Intervention Effectiveness) study and found | | | | CordingleyGary Cordingley, MD, PhD, is a |
| to be absent. The study compared four newer | | | | clinical neurologist, teacher and researcher |
| drugs to an older drug, perphenazine, and the | | | | who works in Athens, Ohio. |
| differences in outcome were minimal to | | | | |