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Most of us pop a pill on a daily basis whether for chronic pain or a headache, we normally don't think anything else of it. However, everything from the pill you're taking to the reasons you're taking it might be influenced by someone else. The patient-doctor-drug-company link has become a complex issue due to the nature of advertising laws, prescribing habits and methods of drug education.

"There are techniques that pharmaceutical manufacturers [use] to influence behaviour," says University of Victoria drug policy researcher Alan Cassels. Everything from "the way they set the research questions [to] fund[ing] the clinical trials. When those trials are done, they use them to do presentations and to otherwise influence the physicians." While Cassels suggests that the actions of pharmaceutical companies fall off the radar of legislation or regulatory purviews, the extent to which this is a reality is a contentious subject.

DTCAs are the champions

Direct-to-consumer?advertising (DTCA) involves advertising prescription-only drugs directly to the patients-turned-consumers. Illegal in Canada, but thriving in the U.S., the pharmaceutical industry spends over $4-billion a year on DTCA-an amount that has been growing since it first took off in 1996.

While companies are restricted in terms of the content of their ads, that doesn't prevent Canadians from seeing the ads in imported American media.

"There are different laws in the United States that apply and it's far more liberal," explains Professor Jillian Clare Cohen-Kohler, of the Leslie Dan Faculty of Pharmacy at the University of Toronto. "It's a funny situation where even though our own laws and regulations don't permit as much advertising as we see, we're still getting it through television and other mediums which can transcend borders."

Canadian companies have managed to subvert the law by running "disease awareness" ads, which never actually explain what the drug does, but which usually entice the patient-consumer with the phrase "talk to your doctor."

One example is the 2003 Viagra commercial which features the following series of images: A shining sun, a pasture of green grass, a clear, blue sky, white-washed houses standing neatly in a row and very, very happy men jumping around ecstatically-even orgasmically-to Queen's "We are the Champions." The phrase "talk to your doctor" appears in small letters at the bottom of the screen, although the T.V. does not explicitly name the product. The ambiguity of drug advertising strikes again.

While informing patients about prescriptions that are available to them is not necessarily harmful, some academics insist that there can be such a thing as too much information-particularly when it negatively impacts other aspects of medical care.

"That's the problem-people are getting bombarded with information that they may not necessarily need. On the other hand, some direct-to-consumer advertising might be beneficial. I don't want to say all of it's bad, but if you want to weigh the balance it's probably going to be more negative than good," says Cohen-Kohler.

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"When doctors are being lobbied, so to speak, by the pharmaceutical industry, they do tend to prescribe their drugs more, as studies have documented in recent years" ,says Cohen-Kohler. "They can be influenced by the pharmaceutical industry in a variety of ways-if they're going to conferences sponsored by the industry, even if they have pens from the industry, or more obviously if they have lunches sponsored by the industry."

Presently, the pharmaceutical industry is involved in physician and drug rep education. However, the educators are often under the payroll of the company. Furthermore, drug company influence compromises independent advice, which then compromises patient benefits.

"It's up to the doctor, to [each] individual practitioner, to counsel the patient appropriately. There's lots of reasons why people do need pills, not to say that people shouldn't be taking pills, but they need to be taking the right pill at the right time for the right condition," says Cohen-Kohler.

Currently, no legislation regulates whether or not doctors can accept gifts from drug companies and proper regulation of such actions remains to be seen.

"The main thing that could be regulated is the need for transparency. Physicians need to know that when an expert is speaking about a drug, that he's on the payroll of the company," says Cassels.

In recent years, pharmaceutical companies have fallen under heavy criticism for their close links to doctors. However, some argue that these links are over-valued and that to see doctors as accesories of the pharmaceutical companies is to incorrectly undermine their ability to treat and diagnose patients or, ultimately, to do their job.

Doctors are "free to make individual treatment decisions based on their clinical judgment informed by evidence-based guidelines [from pharmaceutical companies]," says a spokesperson for the pharmaceutical company Amgen, Ashleigh Koss, in an interview with the Los Angeles Times Oct. 23, 2007.

Doctors, patients and patient-societies: the love-triangle that knows no law

Professional associations and patient groups are created to raise awareness and knowledge about their respective diseases. They also provide support to victims or those who may be supporting victims and, more importantly, give advice to patients. This advice, however, can sometimes be affected by external factors such as material gifts.

"[It] isn't controversial-in my world, it's pretty well-known-that the bulk of these patient groups receive some of their funding from drug companies," Cassels says.

All drug companies are linked to a professional association or patient group and the groups themselves may be linked to other interests.

"It's not just the drug companies. The Osteoporosis Foundation gets a lot of money from the Dairy Foundation, because they think it's a feel-good message that women need to drink lots of milk to prevent osteoporosis. Dairy companies want to make sure that message gets prominence, even though it's controversial. There are some physicians that say people with osteoporosis should not drink dairy, [but] that message will never get through, because they're getting money from dairy lobbies," Cassels says.

Companies, such as Amgen, assert that informed decision-making should be at the focus of prescribing habits and insist that they are vigilant about providing information.

"Amgen has been working closely […] to ensure that the information contained in the approved labelling for [erythropoiesis-stimulating agents, a medication] accurately reflects the current state of knowledge of these important products and to develop a comprehensive and feasible clinical study program to complement our existing pharmacovigilance program," said Roger Perlmutter, M.D., Ph.D., executive vice president of Research and Development at Amgen, in a press release dated Nov. 8, 2007. "In the current label revisions, we have endeavored to include as much information as possible so physicians and their patients can make informed treatment decisions."

Keep on popping those pills

Along with the barrage of external influences, the patients themselves are also playing an increasingly important role in prescription practices.

"The average American is exposed to ten drug ads per day on T.V. ten times a day. Somebody in a very slick looking, highly produced, emotive advertisement is telling you that you have restless legs, you might have depression, you might have early signs of Alzheimer's," Cassels says. "The sheer volume of this advertising is not making people healthier. In fact, people probably distrust their own health and feel like they need a pill to be a better person."

The idea that there is a pill for everything is an easy one and plays into a modern cultural need for instant, quick-fix solutions.

"People are being conditioned to think that they need a pill for everything. […] It's not so simple that we just pop pills, although the industry would like us to pop pills because then they sell their product, so we have to be very careful," Cohen-Kohler says.

As pills become specifically consumer products, the focus is drawn away from health.

It's all about the flow of information; between drug companies, doctors and patients, the question is not so much where the information is coming from, but the effect it has on those who know about it.

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