The high costs of "free" drug samples.

Pharmaceutical companies give physicians drug samples because it influences prescription writing and maximizes profits. Physicians in turn accept drug samples because of mistaken beliefs and psychologically impactful social pressures elicited by interactions with drug companies. Yet, physicians' acceptance of drug samples risks bad clinical decision-making, endangers physicians' reputation, and likely contributes to runaway health-care costs. To guard against these risks, physicians should decline drug samples and, even more importantly, health-care institutions and physician organizations should ban the multi-billion dollar practice of drug sample distribution. Over 90% of physicians have some relationship with the pharmaceutical industry, from contacts with drug representatives to research collaborations and beyond.1 Most physician–industry relationships are above-board and hugely beneficial. The collaborative physician–industry development of novel biologics like imatinib and infliximab are prime examples.2, 3 Yet some physician–industry relationships are more unseemly and can harm patients as well as undermine physicians' reputation. To protect the health and probity of physician–industry relationships, the 2013 Physician Payments Sunshine Act requires intensified reporting by physicians about their industry relationships, including any value transfers >$100.4 Starting in fall 2014, the Centers for Medicaid and Medicare Services posted such disclosures publicly, surely engendering a wider popular conversation about which physician–industry interactions should end. Physicians' receipt of drug samples, however, are explicitly exempted from Sunshine Act reporting, even though the pharmaceutical industry invests >$5 billion yearly in the practice.5 Physician's receipt of drug samples is in fact largely unregulated nationally, which leaves individual physicians to choose a stance on the acceptance of such gifts. Each physician or physician practice must ask, “Are samples educational gifts or manipulative bribes or both?” Pharmaceutical companies provide drug samples because it is effective business practice: physicians are more likely to prescribe a drug received as a sample.6 This is not surprising: extensive evidence shows gifts of any value strongly influence recipient's behavior.7 What is surprising is the extent to which physicians allow drug samples to corrupt decision-making: physicians are more likely to use medications given as samples even if that choice is irrational or not otherwise their first choice.8, 9, 10 It is difficult to envision another circumstance in which physicians would pass up the best choice for patients so willingly. Beyond saddling patients with second-choice treatments, additional reasons to worry drug samples imperil patient safety include lost opportunities for pharmacists to educate patients about proper medication usage or to oversee proper storage and post-expiry disposal of medications.11 Physicians' acceptance of drug samples not only undermines quality of care, it also likely increases the costs of care as pharmaceutical companies provide samples of expensive name-brand drugs and not less expensive generic alternatives, which are thus prescribed less.12 This is no small problem: excessive physician prescription of expensive name-brand drugs is a major driver of health-care costs.13 Patient safety and affordable health care are not the only things jeopardized by physician's acceptance of drug samples: drug samples also endanger physician's reputation. In one study,14 patients said they would trust physician's prescriptions less if industry contacts preceded it while another study showed that 31% of patients disapprove of physician's receipt of drug samples.15 As drug samples can undermine quality of patient care, increase costs, and gamble with physician's reputation, why do physicians welcome drug samples and the well-dressed industry representatives who deliver them into our offices? Some physicians believe, fallaciously, that drug samples reduce prescription costs for poor patients. This is untrue: poor patients are less likely than wealthy patients to receive drug samples,16 and free drug samples often transition to paid prescriptions that can drive significant extra costs per patient per month.12 Thus, paradoxically, drug samples may play on physician's altruism while undermining care for the poor. By contrast, pharmaceutical company's support for charitable organizations and compassionate release of needed medications are valuable contributions to clinical care for the poor. Although many physicians admit drug samples influence their prescribing habit,17 some physicians view themselves as invulnerable to the biasing influences of drug samples.18, 19, 20 It is understandable that generally well-intentioned physicians believe they are free of bias, but ultimately disappointing that physicians would be so poorly convinced by clear evidence to the contrary. Still other physicians enjoy the easy availability of drug samples for themselves and their families.21 It is unlikely that easy access to samples exerts a strong financial pull on physicians, but the sense of obligation incurred by receipt of even such small gifts likely cements the pseudo-social bond between physicians and pharmaceutical industry representatives. The power of this bond should not be underestimated. Subtle social connections with agreeable-looking pharmaceutical representatives do influence physician behavior,20, 22 and, I suspect, contribute to physicians' reluctance to face the conflict of interest inherent in receipt of samples.23 Despite the downsides of physician–industry entanglement over drug samples, there is hope that physicians will find a better way. Twenty-three percent of physicians decline drug samples already,24 and a thoughtful account from a family practice group in Oregon of how they disentangled from drug company samples suggests it is doable and relatively pain-free.25 Chimonas and Kassirer11 wrote in 2009 that as the medical “profession begins to slowly extract itself from the influential grip of industry, it must also deal with the undue influence of free samples”. Their focus on “the profession,” and not individual physicians, is spot-on. Individual physicians should decline drug samples, absolutely. Yet, given the social pressures that contribute to the historical reluctance of physicians to disentangle themselves from the manipulative effects of drug samples, it is unlikely real change will occur until there is a centralized physician-led movement against drug samples. Physician boards and specialty organizations should ban the acceptance of drug samples and advertize this new freedom from unwelcome bias to our patients. Many academic institutions have already taken this step25, 26 and hopefully private institutions will follow. In time, drug samples and the bias enclosed in each blister-pack will go the way of physician's advertisements for smoking27: our longstanding acceptance of drug samples will be an almost-unfathomable tale about which we shake our heads and wonder aloud, “How could we have done something so misguided for so long?”