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Drug Samples Sway Doctors

Posted on: Friday, 29 July 2005, 00:00 CDT

Jul. 28--If doctors give their patients free samples of expensive medications, they probably will continue prescribing those medications, even when cheaper options are available, according to a study conducted at a Twin Cities clinic.

The study, released today, offers some of the first hard evidence that free drug samples have a persuasive influence on physicians. The link long has been assumed, but only a few studies and surveys, nationally, have tried to prove it.

In this case, the research focused on the prescribing practices of residents (doctors in training from the University of Minnesota) who see patients at an Allina clinic in South Minneapolis. But even veteran physicians have worried that free samples negatively affect their prescribing practices. Some have banned samples in their clinics.

The Minneapolis clinic serves many uninsured patients, who have to pay for prescriptions on their own.

Initially, free samples are great for those patients. But when the free samples run out, those uninsured patients have to pay the full cost to remain on the more expensive drugs. Often, patients at the clinic simply weren't filling their prescriptions, said Dr. Richard Adair, lead physician at the South Minneapolis clinic and co-author of the study, which was published in the American Journal of Medicine.

In a typical scenario, a doctor will give out a sample of a newer and more expensive prescription drug. The patient then will ask for a refill of the same drug if it worked, and the doctor is unlikely to suggest a change at that point.

"From the marketing standpoint, that's the reflex (the drug companies) want to trigger," Adair said. "They want to develop brand loyalty."

Adair's study showed modest, but statistically significant, differences in prescribing habits between two groups of residents: one that was allowed to give out samples and one that was not.

Over six months, the residents without access to samples were more likely to prescribe cheaper brand-name drugs or even cheaper generic drugs. They were much more likely to encourage the use of over-the-counter remedies instead of prescription medications as well.

This can affect costs for people with health insurance. Many health plans now have layered prescription benefits that charge higher co-pays for newer or brand-name medications.

"They're not really free," said Ila Harris, a pharmacist who works with physician residents at the Bethesda Clinic in St. Paul. "The patients get started on (samples) and eventually they have to pay out-of-pocket or pay their co-pay."

Her clinic eliminated samples three years ago, and others have followed with similar bans or restrictions.

HealthPartners created restrictions on free samples last year for its Twin Cities clinics, and the number of prescriptions involving samples decreased by 95 percent.

The cost of brand-name drugs, once the samples ran out, was only one reason for the change, said Dr. Michael McGrail, associate medical director for primary care. The other is that samples often compel doctors to give out the free drugs, even when other prescriptions might be safer or more effective, he said.

Samples were part of the marketing blitz that created huge public demand for the Cox-2 drugs, such as Celebrex, even though less expensive painkillers provided equivalent relief in some cases.

"The value of convenience and maybe a patient's desire for a popular advertised brand really doesn't outweigh our commitment to provide objective information and treatment to our patients," McGrail said.

A spokesman for the pharmaceutical industry said that samples still are useful for lower-income patients and for doctors who want to test new drugs. Jeff Trewhitt of Pharmaceutical Researchers and Manufacturers of America said physicians have the power to continue their patients on those medications or suggest changes.

Doctors are deciding they don't want to deal with the dilemma. Many HealthEast clinics in the Twin Cities are phasing out samples or already have eliminated them.

Park Nicollet restricts samples as well but gives individual clinics discretion based on the types of patients they see and the illnesses they commonly treat.

Adair said his clinic only accepts samples of 30 drugs it has determined are the most cost-effective.

Samples can be especially problematic for new doctors, said Harris, the Bethesda Clinic pharmacist. "Having a sample closet may teach the residents bad habits," he said.

PRESCRIPTION COMPARISON: A study compared prescribing habits of residents (doctors in training) who had access to free samples and those who did not. Doctors with samples were more likely to prescribe expensive drugs.

PRESCRIPTIONS AMONG DOCTORS WITH SAMPLES:

--57 percent inexpensive

--43 percent expensive

PRESCRIPTIONS AMONG DOCTORS WITHOUT SAMPLES:

--64 percent inexpensive

--36 percent expensive

COMPARISON OF AVERAGE MONTHLY DRUG COSTS

Painkillers:

--Celebrex (brand name): $132-$214

--Naproxen (generic): $44-$50

--Aleve (over the counter): $20-$40

Heartburn/acid reflux treatments:

--Nexium (brand name): $165-$171

--Prilosec (brand name): $119-$245

--Omeprazole (generic): $119-$120

--Prilosec OTC (over the counter): $24

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PFE,

Source: Saint Paul Pioneer Press (St. Paul, Minn.)

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