Probably about half the readers have seen these initials before, but less of you know where it originated. Robert Heinlein created this shorthand in his 1966 novel – The Moon is a Harsh Mistress. Many have adopted this acronym for regular usage.

The NY Times has an important article about pharmaceutical companies and “free lunch” today – Drug Makers Pay for Lunch as They Pitch.

Free lunches like those at the medical building in New Hyde Park, N.Y., occur regularly at doctors’ offices nationwide, where delivery people arrive with lunch for the whole office, ordered and paid for by drug makers to the tune of hundreds of millions of dollars a year.

Like the “free” vacation that comes with a time-share pitch attached, the lunches go down along with a pitch from pharmaceutical representatives hoping to bolster prescription sales. The cost of the lunches is ultimately factored in to drug company marketing expenses, working its way into the price of prescription drugs.

Doing business over lunch is a common practice in many fields, but drug makers have honed it to perfection, particularly since 2002, when the drug industry adopted a new code banning many other free enticements — golf outings, athletic tickets, trips and lavish dinners for doctors. The code gives approval to modest meals in the course of business. And conventional wisdom in both the pharmaceutical industry and the medical profession is that a lunch is too small to pose an ethical problem. But a growing number of critics say that even those small lunches should be banned.

A former pharmaceutical representative, Kathleen Slattery-Moschkau, called lunch “incredibly effective” in lifting pharmaceutical sales for the companies where she worked, Bristol-Myers Squibb and Johnson & Johnson.

“We got the numbers of what the physicians were prescribing. If I brought in lunch one week, I could see the following week if that lunch had an impact,” Ms. Slattery-Moschkau said.

I admit that I will eat drug company bought lunches at conferences. I actively try to resist their pitch, and often act obnoxiously to the reps. However, I clearly understand that they are buying face time. Perhaps I can resist (although I probably am deluding myself), but we know that the lunches do make a difference.

Should we ban free lunch? Perhaps we should, this group feels strongly that we should – No Free Lunch. Perhaps the truth is somewhere in between.

While understanding the financial benefit of free lunch, I do worry about the implications of buying “face time”. We really need a better way to get exposed to drug information.

Read the article, and then think about your own lunch practices.

Gimme an Rx! Cheerleaders Pep Up Drug Sales

As an ambitious college student, Cassie Napier had all the right moves – flips, tumbles, an ever-flashing America’s sweetheart smile – to prepare for her job after graduation. She became a drug saleswoman.

At game time, Onya cheers on the Washington Redskins. But she saves some of her energy for her job in pharmaceutical sales. Drug companies have found that former cheerleaders like Penny Otwell are good at persuading doctors.

Ms. Napier, 26, was a star cheerleader on the national-champion University of Kentucky squad, which has been a springboard for many careers in pharmaceutical sales. She now plies doctors’ offices selling the antacid Prevacid for TAP Pharmaceutical Products.

Ms. Napier says the skills she honed performing for thousands of fans helped land her job. “I would think, essentially, that cheerleaders make good sales people,” she said.

Anyone who has seen the parade of sales representatives through a doctor’s waiting room has probably noticed that they are frequently female and invariably good looking. Less recognized is the fact that a good many are recruited from the cheerleading ranks.

Known for their athleticism, postage-stamp skirts and persuasive enthusiasm, cheerleaders have many qualities the drug industry looks for in its sales force. Some keep their pompoms active, like Onya, a sculptured former college cheerleader. On Sundays she works the sidelines for the Washington Redskins. But weekdays find her urging gynecologists to prescribe a treatment for vaginal yeast infection.

The sad thing is that the companies probably know what they are doing. They want to influence our prescribing habits. I have previously reference Dr. Robert Cialdini’s work on Influence. This web site gives a nice summary – Influence

I recommend reading the entire page, but will quote the key portion

People prefer to say yes to individuals they know and like. This simple rule helps to understand how Liking can create influence and how compliance professionals may emphasize certain factors and/or attributes to increase their overall attractiveness and subsequent effectiveness. Compliance practitioners may regularly use several factors.

Physical attractiveness–is one feature of a person that often may help to create some influence. Although it has long been suspected that physical beauty provides an advantage in social interaction, research indicates that this advantage may be greater than once supposed. Physical attractiveness seems to engender a “halo” effect that extends to favorable impressions of other traits such as talent, kindness, and intelligence. As a result, attractive people are more persuasive both in terms of getting what they request and in changing others’ attitudes.

As I said above – the drug companies are not stupid. We physicians have a responsibility to understand what the companies are doing. We have an ethical obligation to not use drug reps as a source of information. No matter how cute, perky and nice, they have one job. They are trying to persuade us to use their product.

We have a different job; we have an obligation to prescribe the most appropriate drug for the clinical condition. Information provided by the pharmaceutical industry is, one can always assume, the result of positive spin. To borrow from Bill O’Reilly, my practice is a no spin zone.

Health Officials Hail Battle Against TB

Health officials hailed a global partnership against tuberculosis on Thursday that is providing developing countries with $70 million in investments and technology to help them produce low-cost drugs to fight the disease.

The project, led by the World Health Organization, pools the resources of drug companies, universities and international organizations to target a particularly lethal strain of TB — one that has become resistant to traditional drugs.

”It’s a success story. Four years ago there was no treatment for multi drug resistant-tuberculosis available in many countries of eastern Europe, South America and Africa,” said Marcos Espinal, head of WHO’s anti-TB partnership.

Nice to blog on an upbeat story that includes the pharmaceutical industry. And make no mistake – this is an important story!

Big Drug Makers See Sales Decline With Their Image

The drug industry’s image problems are beginning to hurt pharmaceutical companies where it matters most – at the bottom line.

A year after Merck’s withdrawal of its arthritis medicine Vioxx led to an industrywide credibility crisis, the Food and Drug Administration is blocking new medicines that might previously have passed muster. Doctors are writing fewer prescriptions for antidepressants and other drugs whose safety has been challenged, like hormone replacement therapies for women in menopause.

Meanwhile, insurers and some states are taking advantage of the backlash against the industry to try shifting patients to older, generic drugs, arguing that they work as well as newer and more expensive branded medicines. Overall, prescriptions continue to rise slightly, but an increasing share of prescriptions are going to generic drugs. Also, consumers seem to be less responsive to aggressive drug marketing.

“A lot of the demand that the industry has created over the years has been through promotion, and for that promotion to be effective, there has to be trust,” said Richard Evans, an analyst covering drug stocks at Sanford C. Bernstein and Company. “That trust has been lost.”

Physicians generally understand the benefits of the pharmaceutical industry. However, the quest for big profits sometimes leads the industry to make questionable decisions.

I believe that the pharmaceutical industry (and some companies more than others) has sometimes focused too much on short term profits rather than long term viability. Short term thinking plagues much of our economy.

I certainly do not worry about drug company profits – that is not my problem. Nor do I worry in them no longer funding research – they must find new products to increase profits.

As generally happens in a “free market”, some companies will adjust more smoothly than others. The companies who understand the long view will succeed by providing us therapies which we need and can use.

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Disclaimer: I have never bought a drug company stock and believe it would be unethical for me to knowingly do so. I do have mutual funds in my retirement portfolio – some of which probably own drug stocks.

Why are we taking so many pills?

That might not matter if there were no downside. But even as direct-to-consumer advertising has drummed up unprecedented demand for drugs, two defenders of America’s health – physicians and the Food and Drug Administration (FDA) – have let down their guard.

The result, he says, has been tragic, with unsafe drugs such as Vioxx, which some feel may be responsible for as many as 100,000 deaths let loose on the market.

Beyond such headline-grabbing cases, Critser says, lies the unknown long-term effects of indiscriminate drug taking. The real clinical trials of many FDA-approved drugs, Critser says, are taking place among the unsuspecting Americans who are routinely using them.

While Critser certainly resorts to hyperbole (but then who am I to criticize hyperbole), he makes some very important points.

1. I was asked if there is an existing generic statin. Lovastatin is available as a generic. It does seem to have inferior properties to simvastatin and atorvastatin.

2. My commenting friend – Chlorthalidone man – comments:

Don’t forget the “me too” drugs like ARBs. They work essentially the same way.

Of course even Medrants gets suckered in my clever advertising.

No my friends, ARBs are just non-generic ACE-I.

No value.

As often happens, Chlorthalidone man takes a complex issue and asserts its simplicity.

ARBs are a bit different from ACE inhibitors. Most important they have a different side effect profile.

In nephrotic syndrome, one sometimes can decrease proteinuria to a greater extent by using a combination of an ACE-I plus an ARB.

I generally use ACE-I as my first line therapy – but am glad to have ARBs as an alternative under 2 major situations – intractable cough and angioedema.

So I think the point that Chlorthalidone man really wants to make (and here I used editor’s license because after all this is my blog!) is that ARBs rarely should be used prior to failing ACE-I. But I do not consider them me too drugs, but rather second line drugs (to replace poorly tolerated ACE-I). The exception is in proteinuria when the combination excels.

Medication costs are one problem (amongst many) which plague our current health care system. We (physicians) often look forward to the time when medications lost patent protection. Simvastatin (Zocor) loses protection very soon – Lipitor or Generic? Billion-Dollar Battle Looms

Starting next June, insurers and government agencies will have the opportunity to save billions of dollars by moving patients from Lipitor, a cholesterol-lowering drug by Pfizer that is the world’s top-selling medication, to an inexpensive generic version of Zocor, a similar but less potent drug now made by Merck.

Some insurers are already planning ways to move patients from Lipitor to generic cholesterol drugs after Zocor loses its patent protection. But Pfizer, which plans to use marketing muscle and clinical data to fight that migration, says that Lipitor has unique benefits and is worth a premium price, especially for patients at high risk of heart attacks.

Both medicines belong to a class of drugs known as statins, which are the nation’s best-selling medications, with almost 150 million prescriptions expected to be filled this year at a cost of $16 billion. The insurers, and some cardiologists, say that switching patients from Lipitor to generic Zocor will be a safe way to cut costs in an era of skyrocketing pharmaceutical prices.

In many cases, they say, patients who now take the most commonly prescribed dosage of Lipitor – 10 milligrams daily – can reduce their cholesterol just as much with Zocor. Lipitor costs $2 or more a day, while generic Zocor will probably cost 35 cents or less.

“If I was taking a statin, I’d want to take the cheapest one, as long as I get to the goal that I wanted to get to,” said Dr. Scott Grundy, a researcher who has consulted for both Merck and Pfizer. Dr. Grundy led a federal panel that in 2001 wrote guidelines for treating people with high cholesterol.

What do we really know? We know that statins lower cholesterol and stabilize plaques. For the non-phyisican readers let me explain in more detail.

Evidence over the past 15 years shows that lowering LDL (bad) cholesterol decreases the production of atherosclerotic plaques (fatty deposits) in blood vessels. Thus, having a lowered cholesterol decreases the risk of heart attacks. But we also know that for those plaques already present patient on a statin less often have plaque rupture.

Plaque rupture is important, because when plaques rupture they send out signals to platelets. Platelets (the blood cells which initiate clotting) then stimulate the formation of clots. These clots are the actual causes of heart attacks.

Thus, statins help us in 2 ways, decrease plaque formation, and making plaques less likely to cause heart attacks. Now please remember that I have carefully couched my explanation in decrease and less likely. Patients on statins can still have heart attacks, statins only lower the probability of such events.

Simvastatin is a very good statin. It is possible (although I am not convinced) that Lipitor has some advantages. However, the advantage of Lipitor is unlikely to be so great as to justify the extraordinary cost difference.

If cost does not matter, then I would probably use Lipitor. However, for most patients saving money on a medication will allow the patient to also eat, or fill another prescription. Thus, when examining the totality of the average patient, I will favor generic simvastatin. In fact, simvastatin is the preferred statin in the VA formulary – so I used it regularly already.

The big news here is that the savings for patients on fixed incomes is substantial. These savings will impact overall quality of life – and that is good news!

Please read the entire article to understand the marketing battle which will ensue.

Doctors can find cheap or free drugs for patients (Americal Medical News subscription required)

Many physicians are aware that hundreds of public and private programs throughout the U.S. offer free or discounted medications to patients with low incomes. Now several medical organizations and the nation’s drug industry are teaming up to let doctors know that they can access many of them in one place.

The Partnership for Prescription Assistance launched a major new initiative last month when it began informing doctors directly about an easy way to access these assistance programs. The partnership, a coalition of national, state and local organizations led by the Pharmaceutical Research and Manufacturers of America, had focused on getting the information to patients and pharmacies since its launch in April.

The web site looks interesting (althought I have not personally used it) – The Partnership for Prescription Assistance. This site has functions for physicians and patients. Check it out!

Roy Poses, over at Health Care Renewal, has written an outstanding piece on pharmaceutical costs – Most Drug Expenditures for “Me-Too” Drugs. Roy has written a wonderful important piece – please go read it.

Tense? Lonely? There’s Promise in a Pill

In his hilarious stand-up routine, Chris Rock talks about the ubiquitous television drug commercials that “keep naming symptoms till they get one that” the viewer’s got. Sometimes, he says, the ads don’t even tell you what the pill does: “You see a lady on a horse or a man in a tub, and they just keep naming symptoms: ‘Are you depressed?’ ‘Are you lonely?’ ‘Do your teeth hurt?’ ” He adds that one commercial he saw went, “Do you go to bed at night and wake up in the morning?”

“They got that one!” he says. “I got that. I’m sick. I need that pill!”

Mr. Rock’s observations are almost too close to the actual truth to be considered satire, as Greg Critser’s provocative new book, “Generation RX,” makes clear. Indeed, baby boomers and their offspring have become the most medicated generation ever, devoted consumers from cradle to grave of every manner of pharmaceutical imaginable – pills that not only cure real diseases, but that also promise, in Mr. Critser’s words, to “do everything from guarding us against our excesses of drink, food and tobacco, to increasing our children’s performance at school, to jump-starting our own productivity at work, to extending our very time on this mortal coil.” Boomers, who grew up using drugs recreationally, have become a generation that lives almost full time in the Valley of the Dolls: bombarded by direct-to-consumer ads, they are happy to self-medicate, and their cost-conscious H.M.O.’s are happy to substitute antidepressants for expensive talk therapy, prescriptions for repeated doctor visits.

This book looks to be an interesting addition to our ongoing discussion about big Pharma.

Although Mr. Critser skims a little too briefly over the stories of specific drugs like Vioxx and Seldane that have been recalled for serious safety reasons, he does an effective job of showing why the F.D.A.’s speeded-up review process, combined with Big Pharma’s aggressive pushing of its drugs, has led to such tragic cases. He also raises important questions about the possible damage that the long-term use of pharmaceuticals may cause – from liver damage to cascading drug interactions to the more intangible psychological effects of young people relying on antidepressants and attention-deficit-disorder drugs to cope with the stresses of life.

“The principal forces that have so deeply pharmaceuticalized American life are hardly likely to abate anytime soon,” he writes. “Managed care over the next decades will continue to depend heavily upon pills as a proxy for physician care. Cost-conscious employers and insurers will make sure of that. As will Wall Street – particularly as baby boomers begin to cash in their retirement funds, which have been floating on that nice, easy cushion of double-digit pharmaceutical company returns for two decades. The average pharma C.E.O. will feel the heat and continue to do what he has been doing, only faster.”

As a general internist, I should do my best to limit the number of drugs my patients receive. I try to rely on good evidence that each additional drug will add benefit. This is the great challenge in the complexity of patient care in 2005. I hope that quality measures will address this problem.