Doctors Ditch Drug Samples to Avoid Influencing Treatment

Dec. 1, 2008— -- Who doesn't like freebies, especially when it comes to pricey pills?

But free medication samples, which at first glance look like a win-win-win situation for manufacturers, doctors and patients, can have hidden costs. Doctors might pick a sub-optimal drug simply because they have a sample. Plus, only makers of expensive brand-name drugs are doling out samples. And leaving pharmacists out of the equation might raise the risk of errors.

"Doctors think they're saving their patients money and helping them by giving out free medication," says David Miller, a general internist at the Wake Forest University School of Medicine in Winston-Salem, N.C. Paradoxically, Miller says, "they are likely costing those patients more money down the road."

Recognizing that, health systems around the country are beginning to curtail the practice, a major marketing tool. In January, a study in the journal PLoS Medicine estimated that in 2004, drugmakers handed out free samples to U.S. doctors with a retail value of nearly $16 billion, equal to more than a quarter of their marketing budgets that year.

Samples Widely Used

More than 90 percent of U.S. doctors receive free samples, and more than half of older patients report getting at least one in a given year, Miller and co-authors wrote in September in the Southern Medical Journal. Miller hasn't handed out samples since at least 2000, when his practice moved and lost space to store them.

"It struck us that it was a great natural experiment," Miller says.

Miller and his collaborators looked at whether the loss of the samples closet changed what the internists prescribed. They found that the doctors were three times more likely to prescribe less-expensive generics to uninsured patients after they lost the samples closet.

"There is a perception out in the general public and in the medical community that drug samples are a great way to provide free medication to people who have trouble affording it," Miller says.

But, he says, samples spur doctors "to prescribe these more expensive brand-name drugs." Without samples, Miller says, "their decision on what drug to prescribe is what's best for the patient." Besides, he says, many stores sell 30 days' worth of generics for $4, and community and drug industry resources aid patients who can't pay that.

Other research suggests that most samples go to insured patients. In a study in Pediatrics in October, Sarah Cutrona of the Cambridge Health Alliance in Massachusetts found that few needy children got samples, because they couldn't afford the doctors who dispense them.

And in the February issue of the American Journal of Public Health, Cutrona and her co-authors reported that 13% of insured Americans received at least one free sample in 2003, compared to 10% of those uninsured for part or all of the year.

Responding to the Pediatrics study, Ken Johnson, a top official of the Pharmaceutical Research and Manufacturers of America, a trade group, said: "While it is true that poor and uninsured patients are not the only recipients of drug samples, a patient's financial situation is a factor physicians often consider when distributing such samples."

But Georgetown University Medical Center physician Adriane Fugh-Berman says the idea that a ban would hurt the needy is "a delusion, a rationalization." Getting doctors to stop taking samples is tough, though, says Fugh-Berman, director of PharmedOut, a publicly funded project to inform doctors about drugmakers' influence. They might nix lunches and pens from drug reps, but "they really, really clutch on the samples. It's an unacknowledged gift for physicians and their staff and their families to use."

The University of Pittsburgh Medical Center and Schools of the Health Sciences have created a unique compromise, part of a new conflicts-of-interest policy. While acknowledging that free samples boost drug sales, the new policy notes that "this practice provides invaluable assistance to some patients to quickly begin a course of treatment or to determine which therapeutic option is most beneficial."

By April 1, none of the medical center's 530 practice sites will accept samples from drug reps. Instead, doctors can turn to the eSample Center, a "virtual sample closet" launched last month, says Barbara Barnes, a medical center vice president. Pitt doctors can order samples online from participating makers, who ship them for free. "We feel that the direction that we are moving in will give physicians a greater choice of samples," Barnes says.

Instituting a Ban

The Charlotte-based Carolinas HealthCare System went a step further Jan. 1, when it banned its more than 700 doctors from accepting or dispensing samples. At first, says internist Peter Justis, who helped develop the ban, "I can tell you, doctors were not very happy with this decision, nor patients."

Two main factors led to the ban, Justis says: concern about free samples' effect on treatment decisions and most doctors' failure to fill out the "cumbersome" paperwork required when they dispensed drugs.

For those who can't pay to try a drug, Carolinas doctors have vouchers for some pills that cover a prescription at a store. With 24-hour pharmacies nearby, Justis says, that shouldn't inconvenience anyone.