Direct-to-consumer drugs: The new opiate of the people?

By DITA DE BONI

What more can be said in the perennial debate over direct-to-consumer advertising of pharmaceuticals?

Plenty, according to a study issued late last week by the drug manufacturing industry body, outlining "considerable public health benefits" of the practice.

The study - DTC Advertising can Enhance Public Health - released by the Researched Medicines Industry (RMI), purports to show that a spin-off of the heavy sell on lifestyle drugs through the mass media has been that giant drug manufacturers have taken on the financial burden for publicising a disease or condition - sparing the tightly stretched public health dollar.

But exactly what message is the public being subjected to? And to what extent are doctors intermediaries between drug companies and consumers eager to alleviate the most sensitive of complaints?

Figures supplied by Pharmac show the high recall rate of current DTC campaigns is having flow-on effects for the medical profession.

Based on the experience of doctors in both the US and New Zealand (the only two countries to allow DTC advertising), surveys have shown a fairly consistent 90 per cent of doctors feel pressured to prescribe medications that consumers request, 80 per cent assent to patient requests and 31 per cent prescribe a drug that would not be their first choice.

There is no doubt that the current slew of DTC ad campaigns is highly effective in convincing consumers that a) conditions exist and b) treatments for those conditions - such as baldness, impotence and obesity - are but a doctor's visit away.

A study in the US in 1998 found 63 per cent of consumer respondents had requested a prescription drug by name, and a high percentage of those could identify the conditions that 10 heavily advertised drugs were intended to treat.

The question remains as to whether the public good created by the ubiquitous nature of DTC, which pushes into the open former unmentionables like erectile dysfunction, prostate enlargement and herpes, is outweighed by creating an unnecessarily high demand for lifestyle drugs, some that cost considerably more than those now-subsidised but arguably under-marketed treatments available through the Ministry of Health.

Meares Taine's pathos-laden Xenical campaign has won with consumers (15,000 patients are registered in the Xenical Comprehensive Weight Management Programme set up by Roche), and also won the gold pinnacle award at the 2000 Advertising Effectiveness Awards for "carefully crafted objectives, robust strategy and appropriate tactical implementation plans," according to convener of judges Sandy Burgham.

"Xenical was elevated from a non-entity to a household name, and among 30 countries, New Zealand leads in sales per capita of obese," she said.

But is this necessarily a good thing? It may have sold the product, but how many of the ads make clear that gastro-intestinal effects are found in almost one-quarter of all users - in severe cases faecal incontinence and oily spotting?

And, as another source in the medical industry bemoans "what qualifies as obesity? We all want to be thin - there's a blasted multibillion-dollar industry based on promising that dream. How many realise exercise and proper eating are an integral part of [the drug programme's] success?"

The RMI says 65 per cent of patients following the programme stay on it for a minimum of four to six months and adhere to lifestyle changes - "double the number compared to people receiving dietary or exercise advice alone."

Television DTC advertising - which now consumes almost half the US' yearly $US2 billion spending on prescription drug advertising - is not as prevalent in New Zealand as the print quotient of such ads, perhaps because of New Zealand's relatively small $10 million DTC pharmaceuticals industry.

But television is where the balance of DTC comes into the firing line, because it is almost impossible to creatively include contraindications within the body of the ad (0800 numbers and website addresses suffice in New Zealand). Still, 30 per cent of all DTC advertising - including print - falls foul of standards set down by the ministry's Medsafe advertising guidelines.

The RMI's Terrence Aschoff contends the offending ads fail on "technical details" only and will improve over time, but some studies in the US, where DTC has been legal for more than 10 years (as opposed to New Zealand's three), show alarming rates of quasi-accuracy in the main promotional text of magazine advertising.

US print DTC ads must contain comprehensive, if not unreadable, contraindications overleaf, and regulations are stricter than in New Zealand. But even from 28 recent US examples, only half were judged to convey important information on harmful effects in the main promotional text, with even less judged to "fairly describe both risks and benefits." One reviewer called 39 per cent of ads "more harmful than helpful."

Are the ads valuable enough - even if they give an incomplete story - if they prod consumers to seek treatment for conditions they would otherwise not be aware of?

The case of asthma drug Flixotide, from Glaxo Wellcome, is one cited by the RMI as reaching groups of people with poorly controlled or previously undiagnosed asthma, "especially among lower socio-economic groups."

A Flixotide campaign begun in 1998 generated 24,000 calls to an 0800 number, with almost 10,000 respondents completing a telephone questionnaire. Most were experiencing symptoms of "uncontrolled" asthma.

Later in the year, 37 per cent of 400 respondents had gone to their doctor as a result of receiving an information pack about Flixotide (following the 0800 call). Just over 50 per cent subsequently converted to the new medication.

Pharmac spokesman Wayne McNee says that though some people may be reached with television advertising, he wonders about the quality of information they receive.

"Are they aware of an illness, or of a brand? Flixotide is just a brand - no better than any other - but its promotion in this way is driving patients away from their regular medication."

The fact remains that of the 17 prescription medicines that have been the subject of television campaigns in the past four years, only seven are subsidised through Pharmac.

With consumers shouldering the bulk of the financial burden of lifestyle drugs, the prevailing attitude in a user-pays environment seems increasingly to be more choice, more information.

And like consumers of any product and service, the overarching motto will remain, for now, "do your homework" and "buyer beware."