How Drug Companies Deceive Doctors

Dr Vernon Coleman





The following essay is taken from a chapter in Vernon Coleman’s book `Paper Doctors’, which was first published in 1977 but which is now available again as a paperback.

How Drug Companies Deceive Doctors

During the past two decades a good deal of the money spent on medical research has been spent by the pharmaceutical companies. The value of the work done by commercial laboratories is difficult to assess objectively. For various political reasons, research done by the drug industry tends to be either over valued or under-valued, the variation in emphasis depending upon the political inclinations of the commentator concerned or indeed upon his commercial involvement. Observers within the medical profession have been widely divided in their attitudes towards the work done in this way. For example, Lord Platt in his 1967 address to the Royal College of Physicians said that 'The phenomenal success of medical treatment seems to have depended almost wholly on non-clinical and often nonmedical scientists frequently working in, or in close collaboration with, the pharmaceutical industry.' Other doctors (myself included) have accused the drug industry of spending too much money on advertising and developing profitable but medically unnecessary drugs and not enough on doing really useful research. According to a report from the National Economic Development Office 'Focus on Pharmaceuticals', a good proportion of the new drugs put on the market have no advantage over existing ones, they serve only to confuse patients and doctors.

One fact which cannot be disputed is that there have been no real breakthroughs in pharmaceutical research since the 1950s. In a booklet published in 1975 by the Association of the British Pharmaceutical Industry entitled 'Pharmaceutical Research and Public Ownership', the writer, John Maddox, argues that `the past 15 years have seen the introduction of increasingly more specific drugs for the treatment of heart disease, asthma, steroids for the treatment of metabolic diseases as well as for the regulation of fertility.' It is by no means an impressive list when one considers the effort allegedly employed.

As John Maddox in this ABPI publication admits, 'Research programmes costing several million pounds and consuming the energies of dozens of skilled scientists for several years on end are frequently written off as worthless.' He does not admit – but could not deny – that many of the equally expensive research programmes not written off merely produce variations on existing themes. The production of new antacids, tranquillisers and sleeping tablets is seemingly endless.

Most of the money spent on research is spent on searches for products which the companies believe will have a ready sale among doctors. There are a small number of groups of diseases and symptoms which make up a very large proportion of all the work general practitioners do. (Since it is general practitioners who do most of the prescribing in Britain the drug companies aim their efforts largely at them.)

The drug companies seem to me anxious to bring out products which will satisfy two criteria: first that they will be prescribed to a large number of patients, and second that they will be prescribed for long periods of time. Obviously a magical drug which provided a complete cure in one day would not sell in such quantities. So the industry is particularly interested in such conditions as peptic ulceration, iron deficiency anaemia, eczema and psoriasis, obesity, insomnia, and chronic pain such as the pains of arthritis. These are conditions which often need treating for a long period of time and they are also very common.

In the summer of 1975 doctors in the United Kingdom could choose from 57 different brands and varieties of antacid when faced with a patient suffering from gastritis or peptic ulceration. They could prescribe either medicines or tablets and the different compounds all contained slightly different quantities of antacid. But, by and large, the only differences were the names of the products, the names of the manufacturers and the prices.

There is no quick and logical way for the doctor to know which product to prescribe for his patients. He cannot easily compare prices for though these are available, the manufacturers, using all the tricks of the food trade, give prices for different quantities. For example, how do you compare a price of 22 pence for 30 tablets with a price of 87 pence for 300 millilitres? How, indeed, do you compare 22 pence for 30 tablets and 40 pence for 50 tablets? Doctors would need pocket calculators on their desks to be able to ensure that they always prescribed the `best buy'. And they have no incentive to care.

The companies making those 57 different antacids all promote their products fiercely, they all claim that their version is the best one, and to make matters even more complicated, there is no permanency in the products available. As one product falls out of favour or fails to attract new prescribers, so a new one will be launched by a company anxious to keep its part of the valuable antacid market. The production of these new varieties involves a research project but it is hardly research likely to add usefully to the doctors' armoury of drugs. It will, on the contrary, merely add to their confusion.

The duplication of products continues in all profitable fields. In the summer of 1975 there were 75 different types of iron which could be prescribed by the doctor treating the patient with iron deficiency. These different types of iron were available in different forms, it is true – some as tablets, some as capsules and some for injection. But they were all designed to do exactly the same job. Similarly, there were 15 different types of spermicidal contraceptive waiting to be prescribed, 33 different types of oral contraceptive, 23 different preparations for patients with acne, 103 preparations for patients needing a topical steroid (these drugs are used for patients with long-lasting conditions such as eczema and psoriasis which need semi-continuous therapy and are therefore potentially very profitable), 17 drugs for patients trying to lose weight, 33 drugs for patients unable to sleep, 34 for patients complaining of nausea and sickness and 100 for patients with pain.

In most of these areas one or two branded products would have been quite enough. The amount of research involved in producing all these different products must have been enormous. The companies will have had to try out a new formulation which they can claim will do something no other formulation does; they will then have had to make sure that the combination is not obviously lethal, and that it does indeed sometimes do the job it is supposed to do. When drug companies talk with pride about the amount of money they are spending on research, this is what they are talking about.

The number of products of real value produced in recent years is insignificant compared to the number of products marketed. In fact, it is difficult to think of products introduced in the last two decades which would be missed. Any experienced doctor asked to pick the eight drugs he would choose to take with him on a desert island would choose drugs which have been around for many decades, not because these are the drugs which have been well tried but simply because these are the drugs which work best. Apart from the discovery of sulphonamide, penicillin, steroids, chlorpromazine and insulin in the first half of this century, there have been relatively few discoveries of real note. The drug companies produce hundreds of different products for heart conditions these days but still by far the most important and widely prescribed is digitalis, which has been in use for two centuries. The two most important pain-relieving drugs are aspirin for mild pain, and morphine for more severe pain. These two drugs have been in existence in different forms for centuries although the aspirin tablet as we know it now was not marketed until the end of the nineteenth century. The drug industry has spent much money on producing variations on these two themes but the improvements and additions could hardly be described as revolutionary. Effective antibiotics, analgesics, sedatives and hypnotics were available in the early 1950s. The drug companies are, however, naturally unwilling to admit that the pharmacological revolution is over and that instead of more spectacular discoveries there will merely be the proliferation of products offering marginal advantages to small numbers of patients.

Much drug company money is being spent on research for new drugs which will help relieve anxiety and depression. The drugs so far discovered have been of equivocal value. Nothing has made the same impact as chlorpromazine in the 1950s. There are many different new drugs which have little more value than placebos. They are manufactured and prescribed, however, because this is a fashionable area and one in which there is a great potential for money making. The drug companies which produced the first effective drugs for use against infectious diseases started a gold rush which is still in full flow. Any company that can produce a drug which has a real effect on one or other of the common mental conditions knows that it will make a fortune. Doctors and the industry are both happy to ignore the ethical problems which the discovery of such a drug would produce.

Vast amounts of money have also been spent on the search for a drug with which to attack cancer. So far the drugs which have been produced have only been used on small numbers of patients, though there have been occasional claims that an effective anti-cancer drug is likely to become available. What will probably happen in the next few years will be the promotion of anti-cancer drugs to general practitioners. There is much evidence to show that drug companies have no compunction whatsoever about promoting drugs which may be dangerous, if they think they can make money. There is undoubting big market for these drugs and it will be easy to argue that the drugs will have to be prescribed for long periods of time. Anti-cancer drugs, therefore, fit well into the pattern of drugs suitable for heavy promotion to general practitioners.

In their attempts to produce revolutionary compounds which will match the impact made by the first antibiotics and the first steroids, the drug companies have developed and sold a number of very dangerous substances which they have encouraged doctors to prescribe widely on the basis of limited trials.

There is plenty of evidence to show that drug companies are much more concerned with doing research that will help to sell products than in doing research to ensure that products are safe and effective. I described the evidence in greater detail in my book The Medicine Men (published in 1975).

Hospital and general practice trials are often done by doctors working for the company which has made the drug under trial. Even if the doctors concerned are contractually employed outside the company there is a very good chance that they will be paid a fee for their work. In America hospitals charge drug companies for each case record supplied. The charge of about 2,000 dollars for each record can mount up to a quarter of a million dollars for enough records to make a complete trial. In European hospitals outside Britain the charges are rather lower than this – and in Britain they are much lower, with the doctors accepting a free dinner, a piece of equipment or a ticket to a conference abroad as a reward. The size of the reward is unimportant: the fact is that when inducements are offered to doctors, the doctors become, effectively, employees of the companies concerned and their reports must inevitably be considered bearing that fact in mind.

Another worrying aspect of the testing of drug company products is the fact that patients are rarely told that they are taking part in a trial when they are given drugs by their general practitioner or hospital consultant. They may be told that the doctor has something new for them to try and the doctor himself may be under the impression that he is handing out a well-tried product which merely needs proving in clinical practice. In fact he may well be giving a potentially lethal drug to patients who will be out of his sight for a week at a time.

There is another result of the drug companies' need to publicise their products and ensure that the information they think relevant reaches the maximum number of doctors. As a writer in General Practitioner, one of the free circulation medical magazines, put it, 'For the drug companies the need to publish information overrides considerations like the circulation of the journal or its editorial standards.' The reason for this is that the drug companies know that few prescribers actually read any of the articles in the medical journals. What the drug companies want are references to quote on their attractive give-away literature and for their representatives to quote when visiting general practitioners.

Again in the words of General Practitioner, `The medical reference is the most trusty weapon in the drug company representative's armoury. Quoting chapter and verse on a published clinical trial gives an air of respectability to his claims, which are then harder for the doctor to question…’

This would be all very well if the drug companies only published in journals such as British Medical Journal, The Lancet and so on. The drug companies do not, however, publish their findings only in these established journals. They also publish in journals which actually charge the companies a fee – said to be about £500 for an article of average length.

The Journal of International Medical Research, for example, was in September 1975 charging £85 per printed page for scientific papers published in it. According to the publishers, In addition to publishing medical and scientific papers the Journal of International Medical Research also undertakes the recording, transcription and publication of symposia, under its imprint; with, where necessary, the translation of the proceedings into languages other than English.

Researchers are so delighted to have their work published that they will happily agree to let drug companies pay for the work to appear in journals of lesser standing. And even members of the medical profession appear to give their approval to the whole business by allowing their names to be used as members of the editorial boards of these journals. The Journal of International Medical Research, for example, includes on its United Kingdom editorial board Professor J.P. Payne, Professor W. Linford Rees and Professor Andrew Semple.

The research into new drugs is also beset with many ethical problems. Difficulties may arise, for example, if a new drug is discovered which, though excellent in itself, has no marketing advantage over competitors' products. And it is not unknown for a company to develop a product which has advantages over existing drugs but to refrain from marketing it because they already have a market leader and see no point in competing with themselves.

There is no doubt that the commercial drug companies have in the last three-quarters of a century put onto the market a number of extremely important drugs. Much of the most important medical research done this century has been financed by drug companies. However, the evidence now suggests convincingly that the drug companies are unlikely to continue producing useful drugs at a similar rate in the future. Most of the drugs being put onto the market today are merely variations on existing themes and the drug companies are doing themselves irreparable harm in their attempts to promote these products. There is no medical justification for the continued expenditure of vast amounts of money on traditional research by the drug companies.

NOTE
The essay above is taken from a chapter in `Paper Doctors’ which was first published in 1977. `Paper Doctors’ is available as a paperback and can be purchased via the bookshop on www.vernoncoleman.com

Copyright Vernon Coleman March 2024





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