washingtonpost.com

Drug Firms Still Lavish Pricey Gifts On Doctors
Ethics Debated As Freebies Flow

By Bill Brubaker
Washington Post Staff Writer
Saturday, January 19, 2002; Page E01

A week ago last night, about two dozen doctors gathered for cocktails and dinner at the Plaza Hotel in New York, guests of a pharmaceutical company that planned to solicit their "advice" and "feedback" on the treatment and management of depression.

The doctors didn't have to rush home after dinner. Forest Laboratories Inc. treated them to an overnight stay at the Plaza, where even the least desirable rooms -- those without Central Park views -- go for about $250 a night.

Saturday morning, after a free breakfast, the doctors participated in a four-hour discussion about depression, which can be treated with Forest's best-selling product, Celexa. Then, after a free lunch, each doctor was offered a token of Forest's appreciation: a check for $500.

The Plaza event, and a more modest one that Pfizer Inc. sponsored Jan. 11 at the Improv comedy club in downtown Washington, illustrate how the pharmaceutical industry spends an estimated $2 billion a year on events for doctors in the United States.

Despite a barrage of direct-to-consumer ads for drugs, only doctors can write the prescriptions needed for a sale.

Drugmakers have been wining and dining physicians for years, and the practice has been controversial enough to prompt periodic reviews by Congress and the American Medical Association. The issue was raised again Wednesday when board members from the AMA and the Pharmaceutical Research and Manufacturers of America, an industry trade group, met in Washington.

Timothy T. Flaherty, a Wisconsin radiologist and chairman of the AMA's board of trustees, said he's satisfied with the association's 12-year-old ethical guidelines on gifts. But, he said yesterday, "this is an issue that may be reopened."

The guidelines say physicians should accept gifts worth only "in the general range of $100" and that serve a "genuine educational function" and "entail a benefit to patients."

Last summer, the AMA launched a campaign -- funded largely by the pharmaceutical industry -- to reeducate the nation's 700,000 doctors on ethics.

The guidelines offer some wiggle room. Doctors who have been deemed "advisers" to drug companies, if only for a few hours, can accept honorariums and travel perks, for example. Forest Laboratories calls its advisers "advertising/marketing consultants" in the confidentiality agreements they are asked to sign.

Rep. Fortney "Pete" Stark (D-Calif.), who introduced a bill that would eliminate corporate tax deductions for perks given to doctors, called the AMA guidelines "window dressing."

"It's 'how to play golf often without having to call attention to the fact that the pharmaceutical companies are paying your greens fees,' " Stark said.

A study published in 2000 in the AMA's journal concluded that doctors who have regular interactions with drug companies are influenced in their prescribing behavior by the gifts and perks they accept.

"From a business point of view, the drug companies do this because it works," said Julia Frank, a Washington psychiatrist.

Critics say the practice helps drive up the use of expensive prescription drugs, a major factor in the escalating cost of health insurance.

Pharmaceutical company executives say frequent interaction with doctors is necessary to gain insights into how their drugs can be more effective.

"We don't have -- on staff -- doctors with all of the expertise in the areas that we work," Forest President Kenneth E. Goodman said before the meeting at the Plaza. "When we have a product where we are designing clinical studies . . . we go to outside experts to seek their advice.

"We might share with them clinical data and talk about . . . how could this be positioned in the market? You know, is this good data from a marketing standpoint? Is there something that would cause you to prescribe this product for your patients?"

Ultimately, drug company executives say, the perks and gifts they give to doctors can boost corporate profits.

"Although Celexa is a product with a highly favorable profile for the treatment of depression, product virtues do not produce sales unless prescribers are informed and reminded of them," Forest Chairman, Howard Solomon, wrote in a letter to shareholders, published in the company's 2001 annual report. "And in markets with powerful competitors with immense budgets, it requires competitive budgets and super-competitive skills and highly motivated representatives to convey product information."

Forest reported profits of $215 million for its last fiscal year -- an increase of 91 percent over the previous year, with Celexa its biggest money-maker. The antidepressant competes against Eli Lilly's Prozac (now available in a generic form) and Pfizer's Zoloft, among others.

Nothing in the AMA guidelines discourages doctors from accepting as many free breakfasts, lunches or dinners as they want.

Typical is the "evening of education and fun" Pfizer offered Washington-area doctors Jan. 11 at the Improv. Pfizer's invitation said the evening would begin with a reception, dinner and lecture on "antimicrobials and the treatment of respiratory tract infections." Then the lights would go down for Kathleen Matigan -- "voted female comic of the year."

The AMA guidelines say free meals must be "modest" and have an educational component.

How does the AMA define "modest"?

"It's a meal that you would typically go out to on a Tuesday night with your family," said Andrew M. Thomas, a physician and Ohio State University educator who is a member of the AMA's working group on ethical guidelines. "Probably not something that's at a five-star restaurant."

The guidelines do not rule out five-star treatment -- or honorariums -- for doctors who provide "genuine" -- not "token" -- services as company advisers.

"The drug companies have invented this terminology -- advisory committee -- to get around the AMA guidelines," said Richard J. Brown, a retired New York psychiatrist. "Putting the doctors on an advisory committee avoids the ethical issue. You know, it's like you're on board with them."

Brown is a critic of freebies, yet he makes the free-dinner rounds. "I no longer treat patients or write prescriptions so I am not influenced in that sense," he said.

He recalled a "summit" in southern California last year, sponsored by Wyeth, at the Ritz-Carlton, Laguna Niguel in Dana Point, Calif.

"They paid for a weekend at this resort plus air transportation -- ah, the whole schmeer," he said. "They spared nothing. It was just outrageous. They also gave me -- are you seated? -- $2,000 to attend."

The summit was called to announce new clinical data on Effexor XR, an antidepressant. All 120 guests were Wyeth "advisers," though some didn't serve in that capacity at the event, company spokesman Douglas Petkus said.

Petkus said that while Wyeth supports the AMA's ethics campaign, "the guidelines are not specific enough to be a practical guide for everyday practice in our industry."

Some doctors say drug companies are more interested in promoting products than gaining clinical insights.

"I don't think it's appropriate for doctors to even accept trivial gifts from these companies," said Dan C. English, a retired surgeon who taught bioethics at the Georgetown and the University of Maryland medical schools. "These gifts are an attempt to influence physicians to prescribe and overprescribe based on what the companies have done for them."

Others say the perks don't influence them at all. "Doctors will do what's best for their patients," the AMA's Thomas said.

Stanley S. Moles, a Largo, Fla., cardiologist, doubts that many doctors would prescribe a drug based on information they got over a prime-rib dinner.

"The guy that's giving the talk has been paid by the company to give that report," he said. "These guys are biased."

Moles said he routinely declines invitations to such events.

"I'm invited almost every day to a fine gathering to hear a 30-minute talk," he said. Thursday night, he had invitations to two dinners in Tampa -- at Ruth's Chris Steak House (Merck & Co. Inc.) and Fleming's Prime Steakhouse and Wine Bar (GlaxoSmithKline).

Moles chuckled. "Well, I did go to one about three years ago. They bugged me and bugged me and in a weak moment with a pretty sales rep I told her: 'I'll only go if you send a limo with a bottle of champagne.' And Merck sent a limo with a bottle of champagne and I took another cardiologist to an Italian restaurant in Tampa."

Gregory Reaves, a Merck spokesman, said such limo rides are not permitted under the company's gift-giving policy.

What is permitted? "I can't discuss this," Reaves said, "because of the competitive and strategic activities that we deal with."

2002 The Washington Post Company