Drug dinners

[BobA]

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Sorry, two relatively independent opinions that I crammed together in one incoherent thought. 😀

*tangential*
I frequently used a Zyprexa clipboard and endless Zyprexa pens...good, though the medication itself (per CATIE, etc) is more problematic compared to other typicals/atypicals because of the more rapid weight gain.....bad. IMHO the BB warning for the class actually minimized Zyprexa's contribution since it bunched them together, even though the research showed a (relative and IIRC a statistically significant) greater gain in weight for Zyprexa patients.

I agree with you that Zyprexa is a very problematic drug and that CATIE says it should certainly not be first line. I also agree that Eli Lily did some nasty things suppressing the terrible metabolic side effects.

However, Zyprexa can still be a very effective anti-psychotic for some people. I've seen it have amazing results in seriously psychotic patients.

It shouldn't be first line, but it shouldn't be pulled either.

 

[Faebinder]

BobA is correct. 👍

 

[whopper]

CATIE says it should certainly not be first line

I think I understand you, but CATIE didn't give opinions such as don't use Zyprexa first line (unless I missed or forgot that part).

I am very open to using Zyprexa first line, so long as the metabolic factors are observed, and if they get worse, providing the option to get off of it to another psychotropic before the patient balloons with an added 100lbs or their cholesterol, HTN, etc get out of whack.

But I'm also in an atypical situation--a forensic unit with several violent patients. Zyprexa worked better than all the atypicals except Clozaril. When you have 4 patients at once who are attacking each other on a basis of every few days, things like weight gain are not as important as preventing patients & staff from getting hit in the head & suffering permanent hearing problems (which has happened to one of my staff).

Several of the patients I do have were switched from Zyprexa to metabolically neutral meds with great results--but when we got a chronically violent patient, I'm not going to care so much about metabolic issues so much. I'm going for the big guns, and if they stabilize, then I'm going to see if I can get them on something more metabolically neutral.

 

[Llenroc]

Well my medical school was big on the anti-drug rep dinner tub thumping. I remember one girl went around with a badge that said, "No Free Lunch". I asked her what that was about, and she said, "these drug rep pens and free lunches have been shown to influence prescribing behavior!" I thought to myself, "No ****, Sherlock, why else would they be doing it?"

Point is though, you make any new product whether it's a drug, a car, a drink, a service, or whatever, you need someway to promote it. Otherwise you could have this product, a warehouse full of inventory, 10,000 staff, but zero customers. How will people buy it if they don't know about it? And in medicine it's the doctors that prescribe the medications, so obviously much of the marketing tends to be oriented towards them. None of this is rocket science. You'd think smart people would be able to grasp these concepts.

If you asked the average person on the street what the greatest advances in medicine have been in the past 50 years, they'll probably tell you, "the artificial heart" or "the complete liver pancreas kidney transplant" or some such nonsense. In reality, most of the advances in medicine have had to do with pharmaceutical drugs. The anti-drug rep dinner tub thumpers live in a fantasy world where everyone goes home each night and reads JAMA and NEJM of medicine cover to cover so they know about all the latest pharmaceutical innovations, so they're not still prescribing Minoxidil for blood pressure. 'course, nobody actually does that. One guy that I worked with in Family Practice who was big on the anti-drug rep crusade was extremely ignorant about useful medications on the market. A guy with allergic rhinitis failed Flonase, he was about to send him to the ENT without trying Astelin. Another patient with bad asthma didn't like granules of Advair, so he was at his wits end until I suggested Symbicort. He also hadn't heard of Lyrica, a great drug for neuropathic pain.

Once you're out in practice and detached from academic medicine, going to the drug rep dinners at least keeps you aware of some of the new developments in medicine. And if there wasn't at least some food and perhaps some booze there, nobody would go. Nobody goes to these things and then says, "Yeah, I'm only prescribing Tekturna from now on 'cuz they took me to the Hibachi grill!!!", but they might consider the drug for a young guy with HTN and bronchitis who comes in, instead of Lisinopril. It's actually harder to break old prescribing patterns than it is to introduce new ones, IMO. They also refresh some of the old med 1 med 2 basic science at the drug rep dinners which is nice to have, regardless of how "biased" their studies may be. But everyone who goes knows of these biases, and it's only the anti-drug rep tub thumpers that seem to think anyone who goes is automatically brainwashed by what transpires.

 

[notdeadyet]

Pay 100 people $200 vs $200,000, you will most definitely get more people bribed & having biased opinions on $200,000.

Agreed. You get a lot more bribed and biased from $200K. You'll be less bribed and biased from $200.

IMHO, and I do think there are people who in good faith would disagree with me, there are actually some merits to attending a pharm lecture with a dinner or lunch.

I wouldn't disagree that some of the pharm lectures are useful, I just disagree that you have to give free pharm food. If you are going to be an active and engaged listener, you can just as easily do so over a cafeteria tray as pharm-catered meal.

I disagree with the notion that the sort of practitioner that will attend if it's nice catered food but won't attend if it's brown-bag is the sort of audience member that is going to carefully listen to the lecture to pick out relevant tidbits while carefully disregarding the marketing fluff.

$10-15 (and let's be fair--x12--if its done once a month) cannot compare to being given $45K a year in gifts.

Agreed. It's much less. And $45K/year is less than $200K. Is a $100 lunch okay? How about $50? $200? It's all on a spectrum.

What I find interesting is that if a pharm rep comes in and brings lunch to a small office of 5 once/month, it comes out to about $600/year. Many of the folks who consider this okay, but I have a hunch most of these people would have a problem with this same office just accepting a $600 check each year from the Pharm company.

I do though think that if pharm reps can give new data or bring in good lecturers (which they do from time to time) and do it during a lunch--it greatly saves time for clinicians. Want to ban that? Fine with me-if you create an alternate source that would report this in a quick & timely manner.

If you banned those lunches, you might incent pharm companies to do just that.

Why would they go to those efforts now? Right now they can offer up a nice lunch, and give presentations that are mostly marketing fluff and strategic messaging with good data and pearls embedded. You won't see the "alternative source" you're talking about until it's a necessary option for Pharm.

The argument I'm presenting is going for the big problem first, then see if the problem improves. If there were still widespread problems after the guys getting 50K+ were dealt with, then start going for the smaller offenders.

I definitely see your point and why you push for it. It makes sense. You want to eliminate Pharm "sponsoring" down until it's at a very low level (a $10-$20 lunch, say). I just say get rid of that last nugget too. Then we don't have to talk grey areas.

Its common sense and it does follow a medical model, among several law enforcement models. You treat the most serious problems first. You don't worry about a guy's metabolic status who's 5 lbs overweight if the guy can't breathe. You attack the breathing problem first.

Good analogy.

For me, this is about smoking. We can quit smoking entirely, or limit ourselves to two cigarettes a week. How much damage does two cigarettes a week really do? Not much, but why not just quit entirely? And if we can't quit those last two cigarettes, well, we have a problem.

 

[whopper]

The anti-drug rep dinner tub thumpers live in a fantasy world where everyone goes home each night and reads JAMA and NEJM of medicine cover to cover so they know about all the latest pharmaceutical innovations, so they're not still prescribing Minoxidil for blood pressure

Doctors should be reading journals, and if cover to cover even better.

However even reading the Green Journal, NEJM, the JAMA among several others cover to cover do not give up to date info on medications in an quick & easy manner. Several of them print data on cutting edge advancements, of which can take several years to trickle down to clinical importance.

Let's take the latest issue I received of the Green Journal which arguably is perhaps the best psychiatric journal currently printed (May 2009, Vol 166, No 5). The last issue was focused on Borderline Personality Disorder. No where did it have up to date addendums on all psychotropic medications. It did though have a nice pencil drawing on p. 529 by Alfred Kubin. There's an article, "Genomewide Association Studies: History, Rationale, and Prospects for Psychaitric Disorders" on p 540. Great article, it will have relevant applications on a public health level. Direct clinical relevance for a clinical psychiatrist? not much if at all. Another article, p. 575 Capturing the Ebb and Flow of Psychiatric Symptoms with Dynamic Systems Models--again great article, does this article affect clinical practice? The pharm rep telling me about the Risperdal Consta Deltoid injection or the Seroquel XR presentation gave me more clinically relevant data.

There was of course several excellent articles, some of which will influence my clnical judgment, but none of them would have provided me the quick updates pharm reps provide which are useful which may have been just days to weeks old.

If you banned those lunches, you might incent pharm companies to do just that.

Same problem though. Its still the pharm companies giving the data. Someone really ought to make an Up to Date like program for psychiatry, and incorporate psychotropics independent of pharm companies. That IMHO would greatly aid in the fight against pharm advertising.

Many of the folks who consider this okay, but I have a hunch most of these people would have a problem with this same office just accepting a $600 check each year from the Pharm company.

$600 vs $600 worth of food coupled with clinically relevant presentations aren't the same thing. E.g. the pharm rep showing the nurses, and talking to hospital administration on the references on how to inject Risperdal Consta is directly clinically relevant. You can't just tell a nurse--here Risperdal Consta--inject. The administration, doctor, pharmacy & staff have to know about its need for proper storage, proper delivery etc. Doing it over a lunch will save time for all those involved and would be cost effective.

 

[nancysinatra]

In reality, most of the advances in medicine have had to do with pharmaceutical drugs.

I thought most of the advances in modern medicine that actually made any difference were in the realm of public health and safety? Smoking cessation is a big deal in the last 50 years.

You could make a case for antibiotics and vaccines I guess. But psych meds??? Even drugs in general? Which ones are you referring to?

 

[nancysinatra]

Many people here are describing medicine as a "business," but I thought physicians had an obligatory fiduciary relationship towards patients, in which we must advocate for THEM not for ourselves, despite this not always being easy or rewarding to us. You can't just change the model of medicine because the times change or it isn't easy to practice the fiduciary model.

People are talking about "perks" and being entitled to this and that because they are so underpaid, but this sentiment is pretty much felt the world over, I'm sure. I find it odd that a specialty that is so keen to recognize "entitlement" in patients doesn't root it out in itself. I also don't think it makes a very strong argument for doctors taking freebees when many patients can't even afford their drugs.

A stronger argument is that an attending's time should be compensated, or that there is some nuts and bolts information to be learned from the interaction with the drug rep that isn't usually presented in a journal.

 

[surftheiop]

I thought most of the advances in modern medicine that actually made any difference were in the realm of public health and safety? Smoking cessation is a big deal in the last 50 years.

You could make a case for antibiotics and vaccines I guess. But psych meds??? Even drugs in general? Which ones are you referring to?

If it werent for Big Pharmacy doctors couldn't do much more than tell people to live healthy and tell people they were sick. Aside from psychotherapy pretty much all medical treatments require things that big pharmacy spent the money to develop/test.

 

[whopper]

A stronger argument is that an attending's time should be compensated, or that there is some nuts and bolts information to be learned from the interaction with the drug rep that isn't usually presented in a journal.

That's the argument I agree with. A lecture with a lunch or dinner where useful data is presented is far different than a free all expense vacation with little if any educational value.

Getting a case where someone was receiving hundreds of thousands of dollars in perks, was unethically advertising a medication (and I've seen cases of that), not reporting their pharm income which violated contractual obligations is not the same as a guy sitting through a lunch that cost $10 or a dinner that cost $60 where useful & relevant data was presented that is typically not presented in journals.

But IMHO, its the above that's causing people to want a total ban on pharm advertising.

 

[nancysinatra]

If it werent for Big Pharmacy doctors couldn't do much more than tell people to live healthy and tell people they were sick. Aside from psychotherapy pretty much all medical treatments require things that big pharmacy spent the money to develop/test.

Uh, this is not exactly true. In psych we have ECT. Outside psych patients often can only be treated with surgery. Plus, things that actually extend life often do revolve around lifestyle, like not smoking, wearing seatbelts, eating less saturated fat, getting a screening mammogram, etc. I'd be happy if I'm wrong, but I think it's been shown that public health interventions have been the most effective tools at extending life in the modern era. Vaccines have also helped, no doubt.

You could make a larger argument for the need for medical technology, anesthesia and hygienic standards, but you can't credit pharma for all of that. A lot of inventions were stumbled upon anyway--penicillin, ether, etc. Pharma's not been the only player in medical advances.

 

[notdeadyet]

If it werent for Big Pharmacy doctors couldn't do much more than tell people to live healthy and tell people they were sick. Aside from psychotherapy pretty much all medical treatments require things that big pharmacy spent the money to develop/test.

Because Big Pharm does some good for the world doesn't mean that we have any moral requirements to let them go about marketing willy nilly.

In fact, does Big Pharm really produce more quality drugs now than they did in the 1990's, now that they spend twice the money on advertising that they do on R&D?

And I'm with nancysinatra on the point that the biggest life-savers we've been seeing of late have come in decidedly non-pill form...

 

[surftheiop]

Uh, this is not exactly true. In psych we have ECT. Outside psych patients often can only be treated with surgery.

You could make a larger argument for the need for medical technology, anesthesia and hygienic standards, but you can't credit pharma for all of that. A lot of inventions were stumbled upon anyway--penicillin, ether, etc. Pharma's not been the only player in medical advances.

Good luck doing surgery and ECT w/o big pharm innovations ......

And your right that innovations do come from other sources as well, but many of them would never be able to be mass produced and reach the market w/o big pharma. Finding the miracle drug is the cheap part- figuring out how to mass produce it and running clinical trials is where it gets pricey. If big Pharm wasn't the cash cow it is there is no way it could take the financial risks of drug development. High risks must yield high rewards or else they wouldnt be taken.


Penicillin is quite the exception b/c most of its development was done in government labs seeing as there was a war going on and the government had a huge incentive to develop antibiotics. (although Merck did alot of the early research they didnt get the breakthrough production techniques).

 

[whopper]

In fact, does Big Pharm really produce more quality drugs now than they did in the 1990's, now that they spend twice the money on advertising that they do on R&D?

The newer meds often times have some aspect of superiority, though IMHO, the cost is not worth the benefit.

Take for example Citalopram. Cost $4/month, even cheaper if you buy a 3 month supply--which will run you $10.

Compare that to Escitalopram, cost $95.99/month (which actually isn't that high compared to some of the other antidepressants).

Most of us know that Escitalopram while superior isn't really much of a difference. For several, the $4/month med will handle the problem just fine.

Why don't doctors try the cheaper one first, and only go to Escitalopram if Citalopram is causing problems? Most don't. In fact, I'm the first one I know of that actually started this approach where I did residency. I got sick & tired of seeing attendings giving out Lexapro to a patient who was noncompliant because they couldn't afford that same med in the first place--then get worse--then go to inpatient, then get prescribed the same exact med again. I'm the only one of I know of that does this at my current hospital. For some reason, several where I currently work always give Effexor--in all cases. I don't understand their reasoning.

In several cases...
You got a medication that handles the problem most of the time for $4/month vs one just a few percentage points better for $300/month, yet several doctors are not factoring this into their decision making process.

A colleague of mine & I were ranting about how terrible we thought some people were at their jobs, and that neither he or I would consider ourselves geniuses, but the simple fact that both of us put 30 seconds of thought into the medication decision process vs the others that put almost nothing made the big difference.

There is a time & place for the most expensive medication--but IMHO hardly anyone reserves them for that special occasion. They pull them out first, then keep the patient on it when the $4/month med would've handled the job just as well.

 

[maugham]

That a medical doctor(psychiatrist) would feel the need to have a pharmaceutical representative demonstrate a deltoid injection is very sad indeed. That this "training" with free food is not immediately recognized as pure hucksterism on the part of the drug companies is even sadder. There are easier ways to learn about giving Risperdal Consta injections that don't involve compromising your principles.

 

[whopper]

Hmm, that doctor would be me.

There are thousands of medications out there. If an advance in delivery is made on one, very few doctors can know of it within a few days unless they're told about it--because its not being printed in the journals.

As I mentioned--I would've found out about it eventually--perhaps several months later. Reading journals which don't carry up to date delivery methods nor reading textbooks such as K&S which are updated perhaps 1-2 times/decade wouldn't have given me the data in a timely manner. CMEs while useful in keeping doctors up to date often do not give descriptions on specific medications to stay away from commercialism.

I read AJP, Clinical Psychiatry news, The Carlat Report, and the AAPL journal each issue I get, most of them cover to cover. I at times read NEJM & Biological Psychiatry when I can, though not every single issue. (Though have taken a break in the past 2 months due to studying for the board exam). Out of all the clinical doctors I know, I'm probably in the upper brackets with the amount of journals I read.

Of course--maybe you could enlighten me as to how I could've found out about it within a shorter period of time without the drug rep and doing something very very much out of scope of practice.

And as I mentioned above--I have not gone to any pharm dinners or lunches since I graduated. I've been seeing reps on my own, on my own time & getting nothing for it other than information because they can sometimes give some useful data. I also suggested an alternative method that did not involve pharm companies--someone making an Up To Date like program-but for psychiatry, not IM that covered medications that would overcome my own desire to see a pharm rep. I mentioned this in other threads, but I have seen other doctors who read journals, and still haven't heard of some of the new meds or their newer FDA approvals, delivery methods, applications etc.

As for hucksterism, I do not find a company giving me up to date directions & developments on a medication that must go through FDA rules "pure hucksterism", no more than I find reading a brochure about a new DVD player printed by the DVD company that must follow truth in advertising laws a complete & utter lie. There is some advertising bias, but the data does create some useful purpose in gauging the medication vs others. That data should of course be coupled with other forms of data.

 

[Therapist4Chnge]

Take for example Citalopram. Cost $4/month, even cheaper if you buy a 3 month supply--which will run you $10.

Compare that to Escitalopram, cost $95.99/month (which actually isn't that high compared to some of the other antidepressants).

You are assuming that your average GP/FP saw/read that it was the S-enantiomer of Citalopram. Unfortunately in these cases the information isn't as readily distributed. Sadly some $4 generics are often the better (with peer reviewed research support) choice than the sparkley new psychotropics....particularly in regard to some of the TCAs and older anti-psychotics.

$4 off-patent meds don't pay for those expensive steak dinners. 😀

 

[whopper]

You are assuming that your average GP/FP saw/read that it was the S-enantiomer of Citalopram

I'm not talking GPs or FPs. I'm talking psychiatrists. In fact Forrest advertised something to the effect that Lexapro was the #1 prescribed antidepressant among psychiatrists. At my own place of residency first 3 years, pretty much every psychiatrist I knew of was giving it out, even if the patient could not afford it. MY year as chief--I told residents my opinion was use Citalopram unless they had a specific reason to try something else, and factor in if the patient could actually afford the medication, and how to get it if they could not and needed it.

 

[kugel]

I read AJP, Clinical Psychiatry news, The Carlat Report, and the AAPL journal each issue I get, most of them cover to cover. I at times read NEJM & Biological Psychiatry when I can, though not every single issue.

I'm finding email "alerts" to be very useful in keeping on details about FDA approvals and dosing choices. I very often get alerts from business journals and news reports about these things because those articles are rushed into print for the stock tip - but provide me with info about the meds. Also, I learn about lawsuits and potential liability issues this way.

I've never been against using reps as one source of info, but I won't take anything from them except published journal reprints. Like ANY info source, you have to wary of the bias and agenda.

 

[whopper]

That's a good tip. I'm liking that its unorthodox even more.