BIOL PSYCHIATRY 1992;32:847-849
847
EDITORIAL
The Addiction to Drug Companies
In December 1959, the last year of the Eisenhower administration, Senator Estes Kefauver (D.--Tenn.), chairman of the Antitrust Subcommittee, heralded a year-long investigation of the drug industry with the declaration that the public was not only being overcharged for drugs, but was being bilked of over $250 million a year for useless and sometimes harmful medicines (Subcommittee on Antitrust and Monopoly 1960). In 1960 there followed a sensational expos6 of the unfettered promotional, marketing, and pricing practices of the drug industry. At that time the margin of profit for the drug companies, at 10.6% of sales, was the highest of 44 manufacturing industries, second only to cement production. The New EnglandJournal of Medicine, itself the beneficiary of an enormous volume of drug advertising, mildly editorialized, "This overconcern with the commercial aspects of existence seems to have invaded even the pharmaceutical industry, to the point where the production and pricing of drugs and the manner of their presentation have aroused more than ordinary interest." In that very year the Food and Drug Administration conducted several criminal prosecutions, confiscated $1.5 million worth of illicit drugs, stopped the sale of some useless drugs, and initiated scores of actions, but it was apparent that much more needed to be done. The lengthy Kefauver hearings resulted in modest regulatory changes, intended to curb the more flagrant abuses. Now, over 30 years later, the drug industry, which expends $5 billion a year in drug promotion (Consumers Union 1992), is still marketing too many drugs of questionable value, with legal and regulatory resources inadequate to cope with the magnitude of the problem. The major drug companies have grown into huge international cartels, with vast resources, considerable influence in government circles, and vigorous lobbying activity. In the USA, marketing still relies mainly on detail men or women (Avorn and Soumerai 1983), media advertising, and mailings, but there has been an increasing interest in less direct promotion, with more emphasis on public relations, cultivation of good will, and support of research in the universities. Increasing numbers of academic specialists are retained as consultants, support is given tt~ psychiatric meetings, fellowships and prizes are endowed, and entire symposia are instituted in conjunction with professional meetings, or as separate events (Waud 1992; Chren et ai 1989); excellent high-calorie breakfasts and lavish buffet dinners are provided. Even when these are conducted under the auspices of a university or professional society, the funds are rarely unrestricted, more often closely targeted to requirements that speakers be drawn from an approved roster. In some countries professional meetings have become entirely dependent on such support. Travel stipends and honoraria are freely dispensed, journal supplements are arranged and supported, and in several instances entire research institutes are placed under university management, sometimes with the provision that the supporting drug company hold first rights to exploitation of discoveries. Aside from all these special and particular projects, professional psychiatric societies such as the American Psychiatric Association, the American College of Neuropsychopharmacology, and our own Society of Biological Psychiatry are becoming increasingly dependent on drug-company support. © 1992 Society of Biological Psychiatry
0006-3223/92/$05.00
848
B~OL PSYtTHIATRY 1992;32:847-849
Editorial
The APA now derives less than half its operating income from membership dues (England 1992). Drug companies claim, quite rightly; that their enterprise and competitive zeal have yielded important new products to benefit the public, and that years of unprofitable investigation lie behind their expensive new drugs; but abuses in pricing and marketing still occur, with no legal restraints. The Reagen and Bush years~ with their great confidence in corporate enterprise and the free market, ~ctually discouraged government intervention, and even tried, without success, to divert research support away from government into the private sector. In 1991 the drug industry spent $7 billion dollars for research (Pharmaceutical Manufacturers Association 1991), one fifth of which was extramural, often for clinical trials. About $1 billion of the total research expenditure goes into neuroscience or psychiatry. Drug research supported by drug companies is usually both objective and useful, but the question remains whether clinical trials should remain so largely dependent on support from interested agencies who tend to be more interested in short-term benefits than, say, long-term side or toxi~: effects. The income, the status, the future, of many investigators, particularly the beginners, may be dependent on these sources of support. Subject to the restraints of law, public image, ~nd ethics (Brickner 1989; American Medical Association 1991 t American College of Physicians 1990; Landefeld et al 1992), the concern of any drug cotnpany is primarily in profit, the marketing of its own products, and the cultivation of interest in related areas. As every candidate for public office knows, it pays to advertise. The drug industry is more involved with applied research and shortterm gains, than in unremunerative basic science. The overall influence of the industry (Bowman 1986; Goldfinger 1987) is to emphasize drug treatment at the expense of other modalities: psychotherapy, social approaches, nutritional, herbal, and natural remedies, rehabilitation, general hygienk measures, nonpatentabk, drugs (like lithium), or other alternative approaches. It focuses attention on disorders t~aat are treatable by drugs, and may promote overdiagnosis. It re~nforces the practice of dealing with disease by treatment of symptoms, and diverts interest from prevention. The profession should be alert ~o these concerns: in some instances they will require corrective action. Meanwhile, in the aftermath of the elections urgent measures on national health policy will be debated and enacted. As interested pardes, we should not permit comfortable enticements to influence our commitment to the public interest. Joseph Wortis t Andrew Stone 2 State University of New York t Stony Brook, NY Veterans Administration Medical Center2 Philadelphia. PA
The advice and assistanceof Gene Bishopare gratefullyacknowledged.
References Administrative Prices: Hearings before the Subcommittee on Antitrust and Monopoly of the Committee of the Judiciary, US Senate (1960): Washington, DC: US Government Printing Office. American College of Physicians (1990): Physicians and the pharmaceutical industry. Ann Intern Med 112:624-626.
Editorial
BIOL PSYCHIATRY 1992;32:847-849
849
American Medical Association, Council on Ethical and Judicial Affairs (1991): Gifts to physicians from industry. JAMA 265:501. Avorn J, Soumerai, SB (1983): Improving drug therapy through educational outreach: A randomized clinical trial of academically-based "detailing." N Engl J Med 308:1457-1463. Bowman MA (1986): The impact of drug company funding on the content of continuing medical education. Mobius 6:66-69. Bricker EM (1989): Industrial marketing and medical ethics. N Engl J Med 320:1690-1692. Chren M-M, Landefeld S, Murray T (1989): Doctors, drug companies, and gifts. 3AMA 262:34483451. Consumers Union (1992): Pushing drugs to doctors. Consumer Reports 57:87-94. England MJ (1992): American Psychiatric Association, report of the treasurer. Am J Psychiatry 149:1431-1434. Goldfinger SE (1987): A matter of influence. 316:1408-1409. Landefeld S, McKianey P, Chren M, et al (1992): Gifts to doctors from for-profit companies: Effects, ethics, action. Presentation, Soc Gen Med Annual Meeting. Pharmaceutical Manufacturers Association ( 1991): Annual Survey Report 1989-199 I. Washington DC, pp 19-23. Waud DR (1992): Pharmaceutical promotions---a free lunch? N Engl J Med 327:351-353.
847
EDITORIAL
The Addiction to Drug Companies
In December 1959, the last year of the Eisenhower administration, Senator Estes Kefauver (D.--Tenn.), chairman of the Antitrust Subcommittee, heralded a year-long investigation of the drug industry with the declaration that the public was not only being overcharged for drugs, but was being bilked of over $250 million a year for useless and sometimes harmful medicines (Subcommittee on Antitrust and Monopoly 1960). In 1960 there followed a sensational expos6 of the unfettered promotional, marketing, and pricing practices of the drug industry. At that time the margin of profit for the drug companies, at 10.6% of sales, was the highest of 44 manufacturing industries, second only to cement production. The New EnglandJournal of Medicine, itself the beneficiary of an enormous volume of drug advertising, mildly editorialized, "This overconcern with the commercial aspects of existence seems to have invaded even the pharmaceutical industry, to the point where the production and pricing of drugs and the manner of their presentation have aroused more than ordinary interest." In that very year the Food and Drug Administration conducted several criminal prosecutions, confiscated $1.5 million worth of illicit drugs, stopped the sale of some useless drugs, and initiated scores of actions, but it was apparent that much more needed to be done. The lengthy Kefauver hearings resulted in modest regulatory changes, intended to curb the more flagrant abuses. Now, over 30 years later, the drug industry, which expends $5 billion a year in drug promotion (Consumers Union 1992), is still marketing too many drugs of questionable value, with legal and regulatory resources inadequate to cope with the magnitude of the problem. The major drug companies have grown into huge international cartels, with vast resources, considerable influence in government circles, and vigorous lobbying activity. In the USA, marketing still relies mainly on detail men or women (Avorn and Soumerai 1983), media advertising, and mailings, but there has been an increasing interest in less direct promotion, with more emphasis on public relations, cultivation of good will, and support of research in the universities. Increasing numbers of academic specialists are retained as consultants, support is given tt~ psychiatric meetings, fellowships and prizes are endowed, and entire symposia are instituted in conjunction with professional meetings, or as separate events (Waud 1992; Chren et ai 1989); excellent high-calorie breakfasts and lavish buffet dinners are provided. Even when these are conducted under the auspices of a university or professional society, the funds are rarely unrestricted, more often closely targeted to requirements that speakers be drawn from an approved roster. In some countries professional meetings have become entirely dependent on such support. Travel stipends and honoraria are freely dispensed, journal supplements are arranged and supported, and in several instances entire research institutes are placed under university management, sometimes with the provision that the supporting drug company hold first rights to exploitation of discoveries. Aside from all these special and particular projects, professional psychiatric societies such as the American Psychiatric Association, the American College of Neuropsychopharmacology, and our own Society of Biological Psychiatry are becoming increasingly dependent on drug-company support. © 1992 Society of Biological Psychiatry
0006-3223/92/$05.00
848
B~OL PSYtTHIATRY 1992;32:847-849
Editorial
The APA now derives less than half its operating income from membership dues (England 1992). Drug companies claim, quite rightly; that their enterprise and competitive zeal have yielded important new products to benefit the public, and that years of unprofitable investigation lie behind their expensive new drugs; but abuses in pricing and marketing still occur, with no legal restraints. The Reagen and Bush years~ with their great confidence in corporate enterprise and the free market, ~ctually discouraged government intervention, and even tried, without success, to divert research support away from government into the private sector. In 1991 the drug industry spent $7 billion dollars for research (Pharmaceutical Manufacturers Association 1991), one fifth of which was extramural, often for clinical trials. About $1 billion of the total research expenditure goes into neuroscience or psychiatry. Drug research supported by drug companies is usually both objective and useful, but the question remains whether clinical trials should remain so largely dependent on support from interested agencies who tend to be more interested in short-term benefits than, say, long-term side or toxi~: effects. The income, the status, the future, of many investigators, particularly the beginners, may be dependent on these sources of support. Subject to the restraints of law, public image, ~nd ethics (Brickner 1989; American Medical Association 1991 t American College of Physicians 1990; Landefeld et al 1992), the concern of any drug cotnpany is primarily in profit, the marketing of its own products, and the cultivation of interest in related areas. As every candidate for public office knows, it pays to advertise. The drug industry is more involved with applied research and shortterm gains, than in unremunerative basic science. The overall influence of the industry (Bowman 1986; Goldfinger 1987) is to emphasize drug treatment at the expense of other modalities: psychotherapy, social approaches, nutritional, herbal, and natural remedies, rehabilitation, general hygienk measures, nonpatentabk, drugs (like lithium), or other alternative approaches. It focuses attention on disorders t~aat are treatable by drugs, and may promote overdiagnosis. It re~nforces the practice of dealing with disease by treatment of symptoms, and diverts interest from prevention. The profession should be alert ~o these concerns: in some instances they will require corrective action. Meanwhile, in the aftermath of the elections urgent measures on national health policy will be debated and enacted. As interested pardes, we should not permit comfortable enticements to influence our commitment to the public interest. Joseph Wortis t Andrew Stone 2 State University of New York t Stony Brook, NY Veterans Administration Medical Center2 Philadelphia. PA
The advice and assistanceof Gene Bishopare gratefullyacknowledged.
References Administrative Prices: Hearings before the Subcommittee on Antitrust and Monopoly of the Committee of the Judiciary, US Senate (1960): Washington, DC: US Government Printing Office. American College of Physicians (1990): Physicians and the pharmaceutical industry. Ann Intern Med 112:624-626.
Editorial
BIOL PSYCHIATRY 1992;32:847-849
849
American Medical Association, Council on Ethical and Judicial Affairs (1991): Gifts to physicians from industry. JAMA 265:501. Avorn J, Soumerai, SB (1983): Improving drug therapy through educational outreach: A randomized clinical trial of academically-based "detailing." N Engl J Med 308:1457-1463. Bowman MA (1986): The impact of drug company funding on the content of continuing medical education. Mobius 6:66-69. Bricker EM (1989): Industrial marketing and medical ethics. N Engl J Med 320:1690-1692. Chren M-M, Landefeld S, Murray T (1989): Doctors, drug companies, and gifts. 3AMA 262:34483451. Consumers Union (1992): Pushing drugs to doctors. Consumer Reports 57:87-94. England MJ (1992): American Psychiatric Association, report of the treasurer. Am J Psychiatry 149:1431-1434. Goldfinger SE (1987): A matter of influence. 316:1408-1409. Landefeld S, McKianey P, Chren M, et al (1992): Gifts to doctors from for-profit companies: Effects, ethics, action. Presentation, Soc Gen Med Annual Meeting. Pharmaceutical Manufacturers Association ( 1991): Annual Survey Report 1989-199 I. Washington DC, pp 19-23. Waud DR (1992): Pharmaceutical promotions---a free lunch? N Engl J Med 327:351-353.
