Money talks in Washington, D.C., and no sector of the economy speaks more loudly than the pharmaceutical and biotech industry. Its flow of cash has fostered an epidemic of medication overload.
Over the past five years, pharma has spent about $1.2 billion lobbying federal lawmakers, far more than any other industry. The industry has massive influence over public policy, much of it devoted in recent months to hindering legislative efforts to lower drug prices.
In addition to keeping prices high, the industry has protected its freedom to market its products. A series of Supreme Court rulings from the 1970s through the 1990s opened the floodgates to direct-to-consumer drug ads in print and broadcast media.
Those ads, together with marketing to clinicians — in the form of visits from drug reps, free samples, free lunches, continuing education, and more — has created a pervasive culture of prescribing in which patients and clinicians expect a pill to cure every ill. Thanks in part to this cultural norm, nearly half of Americans over the age of 65 take at least five medications a day, and almost 20% take more than 10.
This is no minor problem. In “Medication Overload: America’s Other Drug Problem,” a report issued last year by the Lown Institute, we estimated that 1 in 5 older Americans — that’s 10 million people — experienced an adverse drug event in 2018. More than one-quarter million were hospitalized because of a medication reaction. Over the next decade, adverse drug events can be expected to cause 4.6 million hospitalizations of older Americans, 74 million outpatient visits, and nearly 150,000 premature deaths.
To address the epidemic of medication overload, we worked with a group of experts on medication use to develop a national action plan, which we released today. In it, the powerful influence exerted by pharmaceutical marketing came up time and again as a key driver of overprescribing.
The pharmaceutical industry spends $26 billion a year marketing to clinicians and patients because it works. Physicians are more likely to prescribe drugs they receive as free samples; free lunches double the likelihood physicians will prescribe a brand-name drug over a generic; visits from sales reps increase prescribing of a company’s drug; and when patients “ask their doctor” about a medication — something that many ads recommend doing — doctors are more likely to prescribe it.
The path toward regulating that marketing is strewn with obstacles. Despite support from many clinicians and the American Medical Association, recent efforts by members of Congress to ban or limit direct-to-consumer drug ads have been stymied by industry lobbying. Two bills introduced in 2019, one to ban ads for three years after the approval of a new drug and another to remove the tax deduction for drug ads, have not advanced. Even on a local level, a 2019 Philadelphia city council proposal to regulate drug company sales reps was quashed amid strong industry pressure.
The immense political power of the pharmaceutical industry is a barrier to change, but that doesn’t mean that change is impossible. Federal and local legislators should continue to propose legislation to ban direct-to-consumer pharmaceutical marketing, or at least regulate it so the information presented is more balanced. In the meantime, clinicians, patients, and policymakers can pursue other avenues to reduce pharmaceutical industry influence. Here are five possible strategies:
Refuse to see drug reps. Clinicians can adopt pharma-free policies for their own practices and refuse to accept food, gifts, visits with drug reps, or free samples. These clinicians should display their pharma-free status proudly, and invite conversations with other clinicians and patients about why they made this decision.
Advocate for pharma-free facilities. Health care institutions can also become pharma free and ban or limit access by sales reps within the hospital or clinic. Many academic medical centers have limited such access, which has led to fewer prescriptions of marketed drugs and more appropriate prescribing. Academic medical centers instituted these policies partly in response to pressure from the American Medical Student Association. Clinicians at other hospitals or clinics should similarly band together and demand pharma-free work environments for the sake of their patients.
Choose pharma-free clinicians. Patients should be able to choose to see pharma-free doctors. Those who want to exercise this option should take into account whether the doctor accepts gifts from pharma, and how much. Patients can find useful information about that at the Open Payments database, which is run by the Centers for Medicare and Medicaid Services, though it does not include information on whether doctors accept free samples. The acceptance of samples should be incorporated into Open Payments and similar databases, such as ProPublica’s “Dollars For Docs,” to make it easier for patients to find pharma-free clinicians.
Regulate drug samples. Current regulations make it easy for prescribers to accept drug samples because the requirements for storing and dispensing samples are lax. Clinical practices are allowed to keep drug samples in a “sample closet,” which often becomes a disorganized heap of pill bottles that stay in the closet far past their expiration dates. If clinicians had to comply with safe drug storage practices for drug samples and knew the rules would be enforced, they might reconsider whether accepting free samples was worth it for their practices and their patients.
Popularize the Drug Facts box. Patients need a clear answer to the question: “How many patients like me will be helped by this drug, and how many will be harmed?” Fortunately, there’s an effective tool that conveys this information. The Drug Facts box, developed by Dartmouth Institute researchers Lisa Schwartz and Steve Woloshin, is a standardized, single-page format for conveying drug effectiveness and risk of harm. Like the Nutrition Facts box that by law must appear on packaged foods and beverages, the Drug Facts box gives patients clear information on the proportion of people who benefit from a drug compared to people who take a placebo.
While viewers of an ad for sleep aid Lunesta may be seduced by calming images of a good night’s sleep, readers of the Drug Facts box will know that Lunesta improves time to sleep by just 15 minutes compared to a placebo. Drug Facts boxes created by independent researchers should be required to be printed alongside print and online ads, and added to television ads whenever possible.
Big Pharma’s political power is formidable, but there are plenty of ways in which patients, clinicians, and health care institutions can take matters into their own hands and reduce medication overload.
Shannon Brownlee is senior vice president of the Lown Institute and author of “Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer” (Bloomsbury, 2007). Judith Garber is a health care policy and communications fellow at the Lown Institute and writer of “Eliminating Medication Overload: A National Action Plan.“