Direct-to-Consumer Pharmaceutical Advertising

If you watch cable television in the USA, chances are pretty good that you regularly see commercials that include phrases like:

• "Women who are nursing or pregnant should not take..."
• "Common side effects may include..."
• "...should not be taken in combination with..."
• "...may cause drowsiness..."
• "Ask your doctor about..."

As an experiment, get a piece of paper and a pen and watch a solid hour of TV today. Pick a channel like USA Network or TNT or some other general programming format. Note how many commercials there are during this hour and then note how many of those commercials are for pharmaceutical products. Afterward, pull your hair out in frustration over the absurdly large proportion of advertisements you're exposed to every single day for drugs. This is the result of the phenomenon known as direct-to-consumer advertising.

DTC advertising for prescription drugs is a relatively new concept. Before the 1980s, certain restrictions imposed by the Food and Drug Administration made it difficult if not impossible for drug manufacturers to advertise to the general public. The types of claims that could be made as well as the disclaimer requirements made it simply impractical to even try, so major pharmaceutical companies targeted their advertising to medical professionals. In 1997, however, the FDA lifted many of these restrictions on DTC advertising, opening the gates for literally hundreds of millions of dollars worth of ads for prescription drugs to flood the airwaves. In 2005 alone -- the last year for which solid figures are available -- pharmaceutical companies spent $4.2 billion on DTC advertising¹. While this in itself is a huge amount of money, it definitely pays off for the companies who utilize DTC marketing: it was estimated in 2001 that every one dollar ($1) spent on DTC advertising generated more than $2 of additional sales². If you include advertising to physicians, this amount increases to $5.

One of the big things that provided the impetus for the drastic increase in DTC drug advertising in the 1990s was the aging baby boomer population of the United States. With the majority of baby boomers being born in the late 1940s, these people were approaching middle age, and their health care needs increased correspondingly. Pharmaceutical companies correctly guessed that this independent-minded demographic would appreciate being given more of a say in their health care decisions. Rather than relying solely on what their doctors would tell them, they would come pre-armed with at least some knowledge about the different types of medications available to them. That Viagra -- designed to treat erectile dysfunction primarily in middle aged and older men -- appeared in 1998 (a year after the FDA restrictions on marketing were relaxed) with a massive marketing campaign is not coincidental.

On paper, there's nothing really wrong with the concept of DTC advertising. After all, if you run a business that makes something, you obviously want to sell whatever that is. If you aren't advertising to consumers, why bother advertising in the first place? How are people even going to know what you have in the first place? And it's not like anyone has to buy what you're selling...that's the whole point of the free market, right? People can pick and choose what they want to do with their money.

There's something a bit different about the concept of DTC pharmaceutical advertising, however. Almost every medication you see advertised on TV is available only by prescription. It's not like laundry detergent where you can just go into a store and buy it. You need to make an appointment with your primary care physician, go there, and specifically ask about the medication. The way I've always conceived of visiting the doctor is that you have a particular complaint, the doctor checks you out, and gives you a prescription for something to help you out (if necessary). At no point does it naturally occur to me to say "hey, I saw this on TV and I think it might help me, can I have some?" If we are to follow the intentions of DTC advertising, however, this is exactly what you are supposed to do.

At the end of the day, however, it's still up to your doctor to decide whether or not they prescribe a medication to you. You can go to the doctor's office and ask for Xanax all you want, it doesn't necessarily mean she's going to give it to you. Or does it? In 2005, the results of a study about this very subject were published. Patients in California and New York with symptoms of major depression were sent to their primary care providers to ask either (a) for Paxil or (b) for any type of antidepressant. Of the group that asked for Paxil, 27% received it. Among the group that asked for any antidepressant, only 1% got it.³ It is worth noting that almost half of the patients in the first group received no prescription at all while 74% got at least some sort of antidepressant in the other group.

The important thing, though, is that people are getting the help they need, right? Who cares if a more expensive brand name gets advertised and someone gets it as long as it makes their life better? Indeed, a lot of doctors feel that DTC advertising has had a positive effect in that it allows them to have better conversations with their patients⁴ and that it helped their patients take a more active role in their own health⁵. On the other hand, these same physicians felt that their patients were less informed and more confused about the benefits and drawbacks of the medications they asked about.⁵.

Unfortunately, in many instances, it seems as though a lot of people aren't really getting the help they need. An FDA study found that 52% of primary care physicians feel pressured to prescribe a medication because of something the patient saw or heard as a result of DTC advertising.³ Perhaps even more astonishingly, nearly the same proportion (45%) prescribe placebos just to get patients off their backs.⁶. Worse, physicians are often paid directly by drug companies to prescribe particular medications, even if they aren't for their intended purpose (i.e. "off-label" use).⁷ All of this comes despite the acknowledgement by a senior vice president of the drug company GlaxoSmithKline that "the vast majority of drugs -- more than 90% -- only work in 30 or 50 per cent of the people."⁸

An amazing 42% of the money spent on prescription drugs on the entire planet is spent in the United States⁹. And yet for all the money that we spend on prescription drugs, the United States is currently ranked 50th in the world for life expectancy.¹⁰ By contrast, Japan is ranked 3rd and prescription drug spending per capita is half of what is spent here.¹¹ Some of this is due to the fact that we are charged more for certain prescriptions here than in other countries, but even that doesn't explain everything, since the Japanese pay 38% more for name brand prescriptions and a whopping 105% markup on generics compared to us¹¹. What is going on?

The main issue is that the majority of drugs that get heavy DTC promotion are not things like cancer treatments, antibiotics, or vaccinations, which all of the major pharmaceutical companies manufacture and sell and make money on. DTC advertising is primarily reserved for things like antidepressants, anti-anxiety medications, sleep aids, birth control, and erectile dysfunction medications: in short, primarily what are called "lifestyle drugs." Now let me say that I have spent most of my life dealing with depression, anxiety, and sleep difficulties, so I know that these medications do have legitimate purposes and that they can help people live better lives. My point is that except in very rare instances, depression, impotence, and a desire to inhibit reproduction are not life-threatening illnesses. Does it surprise anyone to learn that the US has the highest rates of use for all of these types of medications (except birth control) in the world?^{12, 13, 14} Would it further surprise anyone to learn that the United States is one of only two countries on the planet to legally allow DTC pharmaceutical advertising (the other being New Zealand)?

For people who recognize my name because of other write-ups that I've done, you'll know that I don't get on soapboxes. This time, I'm getting on a soapbox. Direct-to-consumer pharmaceutical advertising has helped to create a country addicted to prescription medications, despite the fact that these prescriptions admittedly do not work in many instances and are provided by physicians who don't know how to say "no" to pushy patients or who accept bribes to dispense them, even for purposes for which they are not intended. The famous "sexologist" Dr. Laura Berman is a huge advocate of the use of Viagra as a treatment for a semi-fictitious disorder called Female Sexual Dysfunction (as if all issues pertaining to a lack of desire for sex in women can be distilled to one root cause), despite the fact that Pfizer -- the company that makes Viagra -- has long since ceased all testing of the drug on women due to a lack of evidence to support its usefulness for them.¹⁵ Perhaps unsurprisingly, Dr. Berman at one point received up to $75,000 per day to promote the use of Viagra in women.¹⁶ The race to find a female equivalent for viagra is the next commercial holy grail for pharmaceutical companies, and if it is ever found, we can be assured of its ubiquity on broadcast television.

While I understand that the revenues gained by these companies due to DTC advertising are partially used to research medicines for major life-threatening illnesses, it's clear that the quality of life in this country has not been improved as a result. Indeed, the vast majority of lifestyle drugs have horrific side effects. If you were hungry and I told you that I had a sandwich I could sell you that had at least a 50% chance of satiating your hunger, but that it had a chance of making you nauseated, impotent, and give you the desire to commit suicide, would you take it from me? And yet this is what people routinely accept and indeed demand at the prompting of DTC advertising. The good news is that for every side effect you suffer, you can usually get another prescription to help out with it. And then for the side effects you acquire as a result of mixing medications, you can get still another prescription. Indeed, this "prescription multiplication" is one reason why Americans on average fill 12 separate prescriptions a year.¹⁷ The natural outgrowth of all of this is a less healthy population as well as an epidemic of prescription drug abuse.

I am not the kind of person who generally favors more governmental regulation of anything. It's against my nature, especially when it comes to the restriction of free speech. However, I've come to believe that DTC pharmaceutical advertising ought to be severely restricted if not banned altogether (like it is pretty much everywhere else). If it is allowed to continue, it should only be after a medication has been on the market for at least two years. Television commercials should not feature happy, smiling people running and laughing through fields of grass while a voice-over actor with a friendly baritone informs us that you could possibly shit out your lungs and kill your neighbors if you take the drug: these commercials should be frank and matter-of-fact about the risks and benefits of each medication. Finally, I would limit pharmaceutical advertising budgets to 5% of the money those companies invest on research for life-threatening diseases like cancer, HIV, ALS, etc (for example, a company with $4B R&D budget could spend no more than $200M on advertising, which is at the lower end of the amount many companies spend to promote a single drug in a year).

I won't pretend to have all the answers, but one thing I know for sure is that what we have going on right now as it relates to the marketing of prescription drugs sure as hell isn't working.