Exploring the relationship between direct-to-consumer pharmaceutical marketing and addiction
Try flipping through a magazine or watching a few minutes of TV without coming across an advertisement for a prescription drug. Not easy to do. Whatever ails you, there’s a pill for it and Big Pharma is marketing it aggressively.
While direct-to-consumer (DTC) advertising of prescription drugs is common in the U.S., we are actually only one of only two countries in the world that allow it (the other is New Zealand). And the practice is relatively new.
Think back to the nineties. Remember how television and magazine ads for prescription drugs began to proliferate? That’s because FDA regulations were loosened in 1997, expanding pharmaceutical companies’ ability to advertise DTC.
For decades, prescription drug makers had promoted their products exclusively to health care professionals, who were expected to interpret drug information for their patients. Before the new regulations passed, ads could only be run along with lengthy consumer information warning of risks and side effects, so few companies used them. Under the revised FDA rules, rather than providing a full disclosure, companies only needed to meet an “adequate standard” when it came to describing risks to consumers.
Thus, for 15 years, DTC advertising has been an experiment whose effects we’re still making sense of. There’s no simple relationship between DTC ads and substance use disorders, but their connections are worth investigating.
Overall, it appears that DTC ads have been a contributor–by no means the only contributor–to a cultural shift whereby normal feelings are pathologized and taking drugs from your doctor is both safe and normal. It is a shift that has definite implications for addiction and substance use disorders.
DTC ads sway consumers and doctors
The FDA conducted two consumer surveys of U.S. adults to measure the influence of DTC advertising. The results:
- Among respondents who had seen a doctor with the past three months and remembered seeing an ad for a prescription drug, approximately 40 to 50 percent said that an advertisement for a prescription drug had caused them to seek more information, for example, about the drug and their health.
- More than a quarter (27 percent) of survey respondents in the first survey and 18 percent in the second survey who had seen a doctor in the last three months said that an ad for a prescription drug had caused them to ask a doctor about a medical condition or illness that they had not talked to a doctor about before.
- Approximately 7 percent of respondents said they visited their doctor because of something they read or saw, or because of an ad for a prescription drug.
- Forty-two percent of respondents agreed strongly or somewhat agreed that DTC ads make it seem as though the drug will work for everyone.
The FDA also surveyed 500 physicians, who said that they often felt pressured to write prescriptions by patients who had seen DTC ads.
DTC ads are big business
Unsurprisingly, spending on DTC ads shot up to $1.2 billion in 1998, more than triple from the previous year. The upward trend continued until 2007, when spending topped $5 billion, before leveling out in 2008 and 2009, a decline that has been attributed to the financial slowdown.
And of course, DTC advertising is big business because it works. In 2008, the House Commerce Committee found that every $1,000 spent on drug ads produces 24 new patients. Additionally, a 2003 research report found that prescription rates for drugs promoted with DTC ads were nearly seven times greater than those without such promotion.
Some say the golden age of DTC advertising has ended, at least in its familiar form. That’s because pharmaceutical companies (like everyone else) are having to learn to advertise in today’s more fragmented market, one that includes a wealth of constantly changing outlets and the rising tide of social media. However, DTC ads are still the most prominent type of health education that the public encounters.
DTC ads raise questions about current trends in substance use and abuse
So how do DTC ads impact substance use disorders?
We know that we’ve seen an unprecedented upsurge in prescription drug abuse, particularly opioid painkillers. Those familiar with the addiction field can now rattle off the shocking statistics from memory:
- An estimated 2.4 million Americans used prescription drugs non-medically for the first time within the past year, which averages to approximately 6,600 initiates per day (NSDUH)
- Approximately 1 million emergency department visits in 2009 could be attributed to prescription drug abuse, with roughly 343,000 involving prescription opioid pain relievers, a rate more than double what it was five years earlier (DAWN)
- Nearly half of young people who inject heroin surveyed in three recent studies reported abusing prescription opioids before starting to use heroin (NIDA)
- More people die from overdoses of prescription opioids than from all other drugs combined, including heroin and cocaine (CDC)
Just yesterday, the CDC released data showing that overdose deaths since 2007 have increased most rapidly among middle aged women, deaths caused overwhelmingly because of prescription opioids. We at The Institute Blog have posted personal stories about the impacts of prescription drug abuse, in addition to local and regional trends and state-level policy solutions.
Many of these deaths and substance use disorders are the result of a prescription pad. Dirk Hanson says it well:
“It’s almost unthinkable that in an era preoccupied with ‘evidence-based’ medicine and ‘best practice’ advice, one of the worst drug problems in the United States flows right out of our health care system. Unlike other major epidemics such as those connected to methamphetamine, crack cocaine or other illegal drugs, our prescription opioid problem is full of irony and agony, because it has been fueled, to a certain extent, by the actions of well-intended medical doctors.”
However, the drugs that are being advertised DTC are not generally the ones that are being abused. And again, generally speaking, they’re not the ones people are dying from.
The top three types of abused prescription drugs are opioids (like Vicodin), depressants (like Xanax), and stimulants (like Adderall). While stimulants occasionally find their way into DTC ads, the other two types are largely absent.
The top ten advertising spends by pharmaceutical companies in the first quarter of 2012 are pictured below.
These drugs treat depression, pain associated with arthritis, and high cholesterol. They are neither opioids nor benzodiazepines and they are not widely abused.
This complicates the discussion of advertising DTC as related to prescription drug abuse and the current overdose epidemic. If the drugs being abused aren’t the ones being marketed, where’s the connection?
DTC ads support certain (inaccurate) ideas about prescription drugs
What seems likely is that DTC ads contribute to a culture that supports certain ideas about prescription drugs. The first is that they’re safe.
Recently, Urban Outfitters withdrew from its shelves tongue-in-cheek merchandise that clearly smirked about prescription drug abuse. These shot glasses and flasks, each emblazoned with a giant Rx, demonstrated the widespread cavalier attitude about prescription drug use and abuse that has grown up in the last decade.
Lack of awareness about the danger of prescription drugs leads to casual abuse. In its 2011 Drug Control Strategy, The Office of National Drug Control Policy commented, “These misperceptions [that prescription medicine is safe], coupled with increased direct-to-consumer advertising, which may also contribute to increased demand for medications, makes effective educational programs even more vital to combating prescription drug abuse.”
Another idea perpetuated by DTC advertising is that the use prescription drugs, especially over the long term, is normal and necessary for most people. Aging, social anxiety disorder, heartburn, restless leg syndrome, and overactive bladder are all examples of symptoms or normal physiological events that are now presented to consumers as syndromes requiring continual treatment.
DTC ads suggest that all people are entitled to relief from physical and emotional discomfort. DTCs also underemphasize behavioral and lifestyle changes to address symptoms. These ideas clearly support drug-taking behavior, which may pave the way for abuse and dependence for some people.
As the FDA’s consumer surveys show, many people believe that everyone could benefit from the advertised drug andthat there are few drawbacks to taking it. Critics have argued that DTC ads misrepresent the balance of potential harm and benefits of any particular drug. This lack of information can lead to serious problems down the road, as evidenced by the many conversations taking place on (and off) line among people who have had difficult experiences with anti-depressants like Paxil and Welbutrin, both marketed DTC.
But really, of course pharmaceutical companies send these types of messages. Of course they downplay the potential harms of a medication. Their job is to sell a product.
As Marcia Angell, a former editor of the New England Journal of Medicine, once put it, “[Drug companies] are no more in the business of educating the public than a beer company is in the business of educating people about alcoholism.”
Should we outlaw DTC ads?
Many have called for a ban on DTC ads. Some European countries have scoffed at our allowance of it, saying that DTC ads drive up prescription drug prices (they do) and endanger the public health. A few points, though:
- Over-the-counter drugs have always been advertised DTC. Changing our regulations of prescription medications would not change much of the medication marketing that the public is now exposed to.
- Many have argued that DTC has helped reduce prejudice associated with mental health conditions by encouraging individuals to seek help. Behavioral health screenings in primary care are not universal (nor will they become universal anytime soon), which means that DTC ads offer patients a starting point for conversations about sensitive subjects with their doctors.
- Researchers have speculated that a ban on DTC advertising would result in pharmaceutical companies pouring more resources into advertising to medical professionals. Purdue’s promotion of Oxycontin is an impressive story of marketing prowess (including distributions of branded promotional items such as OxyContin fishing hats, stuffed plush toys, and compact discs (“Get in the Swing With OxyContin”)) and was conducted almost exclusively for healthcare professionals. The fallout from this marketing has been significant and, in many cases, tragic. Eliminating DTC could increase spending for this type of advertisement.
Below, “Oxycontin Poster Children” illustrates some of the marketing materials Purdue Pharma distributed to physicians (and some of the long-term outcomes for the patients they highlighted).
One (unlikely) solution
One suggestion to amend the current state of DTC advertising is for pharmaceutical companies to conduct campaigns about certain classes of drugs rather than the brands themselves. This scenario would truly improve consumer knowledge about treatment options and encourage help-seeking.
However, pharmaceutical companies have no impetus to run such advertisements. Their profits lie in selling more of their own particular drugs. At the end of the day, the decision to advertise a drug now is a marketing one, not a public health one, and most drugs are not advertised.
What do you think?
Has DTC contributed to problems with substance abuse and addiction? The question is not a simple one. Tell us in the comments section. We would love to hear from you.
Many thanks to Justine Coyne, who contributed additional reporting for this post