Do direct-to-consumer drug ads undermine efforts to cultivate 'thrifty' healthcare consumers?

Critics have been railing against direct-to-consumer ads for prescription drugs since the 1990s. Opponents of the ads, many of whom are medical providers, argue they contribute to unnecessary anxiety and self-diagnosis among patients, inflate demand for expensive brand name drugs that may not be medically necessary and contribute to a culture of over-utilization.

Supporters, on the other hand, say the ads help cultivate a new class of informed healthcare consumers who use the information the ads provide to hold meaningful conversations with their physicians. Money earned by drugmakers as a result of increased sales due to DTC ads also helps support the research and development required to produce new important drug therapies.

The debate surrounding DTC drug ads is contentious and has captured increased attention amid the current presidential race as candidates vying for both the Democratic and Republican nomination discuss the need to control the rising cost of prescription drugs. 

One man's constipation embodies the problem

An ad that debuted during the 2016 Super Bowl perfectly epitomizes the problems fostered by DTC drug ads, according to critics.

The ad, called "Envy," features a middle-aged man walking around a crowded city, lamenting his constipation. He's visibly envious of those around him for their apparent ability to go to the bathroom, including a man coming out of a café bathroom flashing a thumbs up, a dog squatting beside a tree and a woman smiling, walking down the street with toilet paper stuck to her shoe.

Drugmakers Daiichi-Sankyo and AstraZeneca paid for the commercial to market Movantik, a drug that treats opioid-induced constipation, which is not actually named during the commercial.

Critics latched onto this ad in particular because it seems to represent everything that is wrong with America's culture of over-consumption of prescription drugs and illuminates DTC advertisements' role in it: The commercial is for a drug that is intended to relieve a negative side effect of other drugs that are not only widely over-prescribed but are also frequently abused, leading to tens of thousands of deaths per year. On top of that, the spot aired during the Super Bowl, meaning its financers spent nearly $5 million dollars getting it on TV, blasting the opioid-induced constipation man to millions of viewers.

The White House was quick to criticize the commercial, saying it could contribute to the national epidemic of opioid abuse, which is also a significant contributor to heroin addiction. "Next year, how about fewer ads that fuel opioid addiction and more on access to treatment," White House Chief of Staff Denis McDonough tweeted Feb. 8.

The U.S. is one of just two countries that allow pharmaceutical companies to market drugs directly to consumers, the other being New Zealand. Around the rest of the world, drugmakers market their products to physicians. The FDA first legalized DTC drug ads in 1985, but their use only really became prevalent in 1997 when the FDA mollified some of its rules regarding the level of detail drug companies had to provide about side effects, according to the World Health Organization.

Since then, advertising prescription drugs to consumers has become a multibillion dollar industry. According to STAT, in the last four years alone, prescription drug ad spending soared by more than 60 percent, reaching $5.2 billion in 2015. This is a marked increase from the year prior, when the industry spent $4.5 billion on DTC ads, market research firm Kantar Media found.

Do DTC ads work for or against efforts to develop a "thrifty" healthcare consumer?

Many healthcare professionals say the ads are far from helpful. They argue DTC ads fuel demand for expensive brand name drugs among consumers, leading to a significant rise in national drug spending.

In 1999, the American Medical Association issued a statement that said, "Physicians must remain vigilant to assure that direct-to-consumer advertising does not promote false expectations." As the drug marketing industry continues to grow, the AMA has taken a more aggressive stance. In November, the association called to ban DTC ads outright, arguing the proliferation of the ads "drives demand for expensive treatments despite the clinical effectiveness of less costly alternatives."

"Today's vote in support of an advertising ban reflects concerns among physicians about the negative impact of commercially-driven promotions, and the role that marketing costs play in fueling escalating drug prices," AMA Board Chair-elect Patrice A. Harris, MD, said in a statement in November.

The concerns outlined by the AMA — the promotion of false expectation among patients and increased demand for expensive medications — directly oppose the broader goal spurred by the Affordable Care Act to develop thriftier healthcare shoppers and reduce utilization of unnecessary medical services and drugs.

Furthermore, the high cost of prescription drugs — which is at least partially influenced by demand — is also the public's top health priority, according to an October poll from Kaiser Family Foundation. These concerns are warranted, as the prices for both generic and brand name drugs have risen steadily over the past few years. In 2015, total drug prices experienced a 4.7 percent hike, according to the Altarum Institute for Sustainable Health Spending.

Drug pricing is multifactorial. While it's unfair to exclusively pin the increasing prices of prescription drugs on growing patient demand fueled by DTC ads, "if the ads didn't result in increased utilization of these drugs, [the pharmaceutical companies] wouldn't run them," says Mike Schatzlein, MD, senior vice president of St. Louis-based Ascension Health, and president and CEO of St. Vincent's HealthCare in Jacksonville, Fla.

In the same Kaiser Family Foundation poll, 28 percent of the public reported asking a physician about a drug they saw advertised, and 12 percent said their physician prescribed it. For some of these patients, the medication that was ultimately prescribed might have been the best option. But in other cases, physicians feel pressure to provide the desired medication when it is not medically necessary, lest they risk harming their relationship with the patient. What's more, Dr. Schatzlein says the ads create unnecessary anxiety among patients, who hear symptoms of a disease on TV and then believe themselves to have it.

"The ads put physicians in a position where they have to talk the patient out of something he or she wants," says Dr. Schatzlein. "That's more difficult than it might seem, and it's more time consuming."

The importance of providing patients with information so they can have meaningful conversations with their physicians is not overlooked by opponents of DTC drug ads. Most just believe 30-second TV commercials are not the way to do it.

"Our preferred way of educating patients is by healthcare providers — doctors, pharmacists, mid-levels," says Dr. Schatzlein. "The main reason is because they are motivated by the best interest of the patients. The DTC pharma ads are run for the purpose of selling more drugs. So in no way can they be objective, and certainly they don't have access to the medical history or physical information on a patient because they are spraying these ads to the entire population."

Among supporters, DTC ads are seen as a viable information source for consumers

On the other hand, a lack of a physician's communication skills may have something to do with the uncomfortable tension that arises when patients arrive for an appointment and begin talking about drugs they saw on TV.

"The physician is still the one in charge, regardless of the information out in the public space," says Debbie Landers, senior vice president at Jarrard Phillips Cate & Hancock, a strategic communications and engagement firm for healthcare providers. "The physician is the one who ultimately decides whether or not to prescribe the medication," and if the drug is not necessary, the physician must know how to politely but effectively convey why he or she will not prescribe it.

Those who support the advertisement of prescription drugs on TV argue the ads do align with the push to arm consumers with healthcare information, as medication is an integral part of healthcare and consumers should know their options. The TV ads, like the internet, open the door to new opportunities to obtain information, whereas in the past patients were limited to the information their physicians gave them during visits.

"If you think back about the days when the only option you had was walking into to doctor's office, 100 percent of your health was in their hands to decide," says Ms. Landers. "Now you can walk in and have a smarter conversation about everything that is going on with your health that would affect the treatment option that the doctor picks for you. It's all about being more prepared and aware of what your options are."

Physicians aren't losing control to DTC drug ads, Ms. Landers says, they just need to adjust their communication approach to be supportive of patients who approach them with information gleaned from such ads.

Is the good of DTC drug ads lost in translation?

The relationship between physicians, their patients and pharmaceutical ads is nuanced and complex. The ads are so prevalent that even if consumers tried to avoid them, they probably couldn't. Their influence may be equally unavoidable, whether they spark more informed and meaningful conversations about healthcare options between patients and providers, or merely increase patients' desires for prescriptions for specific brand name drugs.

While the predominant sentiment among providers regarding DTC ads is negative, the reality is the ads are probably not going away, at least not any time soon. In fact, marketing for prescription drugs is undergoing increasing proliferation in other mediums, such as the internet and social media. So as the AMA and other organizations wage their fight against DTC ads, providers will benefit from preparing to talk to patients about the medications they showcase.

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