From the Los Angeles Times
SELLING THE PATIENT
Next step: Create the demand
Direct, emotional ads for prescription drugs are everywhere. But they're
just one way to get to the consumer.
By Melissa Healy
Los Angeles Times Staff Writer
August 6, 2007
WITH vast and profitable markets up for grabs, drug companies are
aggressively reaching beyond doctors and taking their marketing messages
directly to consumers.
Some of their promotional strategies have become hard to miss. Nightly news
broadcasts -- a beloved habit for aging Americans -- are brought to you by
the makers of prescription medications for high cholesterol, arthritis,
Alzheimer's disease and erectile dysfunction; an Internet search for a
specific symptom, or a visit to any popular health site, will bring up
sponsored links and blinking ads for at least one prescription medication
used to treat that symptom; fans of NASCAR see Viagra advertised every time
No. 6 Mark Martin's car rounds the track. And women paging through a
magazine for tips on reducing clutter can scarcely avoid the faces and
personal stories of actresses who are managing their depression,
osteoporosis or hot flashes with a brand-name pill.
In 1997, the FDA loosened regulations governing the advertisement of
prescription medications directly to consumers. The change set off explosive
growth in marketing aimed at a general audience long on interest and --
compared with physicians -- short on professional skepticism. Today, drug
makers spend roughly $5 billion a year to run advertising campaigns that use
many of the same appeals that marketers use to sell breakfast cereal and
A study published in the Annals of Family Medicine's January-February issue
analyzed the messages of 38 advertisements then running during prime-time TV
and found that 95% used emotional appeals to sell the medication, often
framing prescription-drug use as a means to regain lost control over some
aspect of life. None mentioned lifestyle change as an alternative to product
use, although roughly 1 in 5 advertisements suggested it might be a useful
complement to the drug. One in 4 described the causes of the disease the
advertised drug treats, who is at risk for it or how frequently the
condition occurs in the population. The study's authors, led by UCLA
researcher Dominick L. Frosh, suggested that without such information,
consumers would have little reason to see prescription medication as a
solution that involves risks as well as possible benefits.
In all, 58% portrayed the advertised drug as a medical breakthrough -- a
pharmaceutical twist on Madison Avenue's "new and improved" message.
"It is time to ban direct-to-consumer advertising of prescription drugs,"
wrote Dr. Kurt Stange, editor of the Annals, in an accompanying editorial.
The advertisements consumers see "distort the relationship between patients
and clinicians. [They] manipulate a patient's agenda and steal precious time
away from an evidence-based primary care clinician agenda that is attempting
to promote healthy behavior, screen for early-stage treatable disease and
address mental health."
Even after 23 major pharmaceutical companies agreed to a new slate of
voluntary guidelines limiting their advertising, Stange wasn't buying it.
Self-monitoring, he wrote, "is not working . . . and cannot realistically be
expected to work."
PhRMA, the drug manufacturers' industry group, says direct-to-consumer
advertising empowers patients to take an active role in their healthcare and
spurs them to discuss symptoms, diseases and treatment options with their
doctors that might otherwise go unraised. The industry group frequently
cites a 2002 survey of consumers that found that 43% were spurred by a
prescription-drug ad to look for more information about the drug or their
Although direct-to-consumer advertising has spurred the most political and
professional debate, it is only the most visible means of prescription-drug
marketing aimed at the consumer. To build markets and encourage consumer
loyalty to their products, drug makers have invested heavily in a tactic
known to public relations professionals as "third-party marketing." Through
voices, groups and activities that seem independent of them -- but
frequently are not -- drug companies have found another way to get their
messages to consumers.
ACCORDING to an article published in the British Medical Journal in 2003,
the top five public relations firms specializing in healthcare earned $300
million in 2002. These firms "are expert at 'third-party technique' --
helping the drug industry separate the message from what could be seen as a
self-interested messenger," wrote authors Bob Burton and Andy Rowell.
Last October, a commentary in the New England Journal of Medicine detailed
one little-noticed third-party marketing venture. Underwritten by Eli Lilly,
the campaign was designed to increase the use in hospitals of a drug
commercially known as Xigris, for the treatment of sepsis, or blood
poisoning. A preliminary study had suggested some safety concerns with
Xigris, and an FDA advisory panel had urged more thorough study of the drug
before its approval. But in 2001, the FDA approved its entry into the
market. The controversy appeared to sap first-year sales of Xigris, which
fell short of Lilly's expectations.
Lilly's response was to secure the services of a small public relations
firm, New York-based Belsito and Co. Belsito would begin spreading the word
to physicians and media outlets specializing in medical news that Xigris was
being rationed and that physicians were being "systematically forced,"
because of the drug's high cost, to decide which patients would live and
which would die. A $1.8-million educational grant from Lilly would fund the
creation of a group of physicians and bioethicists -- named the "Values,
Ethics and Rationing of Care Task Force" -- to study this rationing and its
ethical implications. And a Surviving Sepsis campaign was launched "in
theory to raise awareness of severe sepsis and generate momentum toward the
development of treatment guidelines," wrote Dr. Peter Q. Eichacker and two
fellow investigators based at the National Institutes of Health, in the NEJM.
Lilly's financial inspiration of the campaign aimed at physicians, patients
groups and the media was not apparent to many of the audiences reached. But
its effect was quite clear, concluded a case study of the campaign done by
the Council of Public Relations Firms: Sales of Xigris "have begun to trend
upwards. Through the first quarter of 2004, Xigris sales were up 36%."
In such campaigns, public relations companies operate as off-site extensions
of a drug company's marketing department. But sometimes, the relationship of
a drug company and a third-party voice is more complex. The tie between
patient-advocacy groups and drug companies is a good example.
Drug makers richly support the nation's proliferating patient-advocacy
groups, and only a handful of the charitable organizations refuse the
sponsorship of pharmaceutical firms, says Georgetown University's Dr.
Adriane Fugh-Berman, who has studied these ties. That link presents rich
marketing opportunities for corporate sponsors with an interest in reaching
the patients the organizations advise and represent, Fugh-Berman says. But
it also raises real questions about the independence of patients groups, she
In marketing trade publications, the value of patients' groups is widely
touted. As friends and allies to potential customers, groups dedicated to
patients who suffer from a specific condition can be powerful marketing
tools. Patients seek information and emotional support from these groups,
and trust them as an unbiased source of advice. Groups that empower patients
to seek treatment are eager to foster awareness of their disease and, in the
process, expand their membership. When they are successful, patients groups
have a natural market-building effect.
But drug makers have the deep pockets, and patients groups -- until they're
very large and well-established -- are constantly scrambling for money. As a
result, according to those calling for reform, the relationship is not
always an alliance of equals.
"There's an inherent conflict of interest," says Merrill Goozner, editor of
Integrity in Science, a publication of the Washington-based watchdog group
the Center for Science in the Public Interest. "The question becomes, 'Are
you doing the best for the patients you represent, or are you doing the best
for your sponsors?' "
Goozner says that patient-advocacy groups are especially vulnerable to
carrying drug companies' messages, untempered by skepticism, directly to
their members. "They're desperate" for a cure or treatment, he says. "And no
one likes to be told that this latest breakthrough is not all it's been
cracked up to be," especially when it's being pushed by a company that's
been generous with funding, he adds.
Last October, the magazine New Scientist published a survey gauging the
dependence of randomly selected U.S. patients' groups on drug manufacturers.
Combing through the tax returns, annual reports and voluntary disclosures of
29 nonprofit patient-advocacy groups, the publication found that most
accepted financial backing by companies developing or producing drugs used
to treat patients supported by the group. In some groups, such as the
American Heart Assn., the drug makers' financial backing was huge ($23
million in 2005) but represented a small portion (4%) of revenue. For seven
groups, donations from interested drug companies represented more than
one-fifth of revenue. The Depression and Bipolar Support Alliance said it
received more than half of its 2005 funding from the drug industry, and the
Colorectal Cancer Coalition got 81% of its funding from drug makers.
New Scientist's probe found that some donations appeared directly tied to
marketing interests. In 2003 and 2004, when the drug giant Pfizer was
developing a drug to treat restless leg syndrome, it was a major donor to
the Restless Legs Syndrome Foundation. But in 2005, after Pfizer announced
it had abandoned development of the potential drug, its donations to the
patient group dried up.
Many of the best-known groups, including the Alzheimer's Assn., American
Cancer Society and American Diabetes Assn., typically have a board of
physicians who vet the scientific accuracy of the information they provide
to patients. And most solicit "unrestricted" grants that allow them freedom
to use the drug makers' donations as they see fit.
But even large groups often provide a gateway to the products of corporate
sponsors, say those who have surveyed them. Many list FDA-approved medicines
available to treat the disorder that is their focus and provide Web links
that lead patients directly to marketing sites. And many offer their
corporate sponsors access to their members, a potential gold mine of
The corporate-donor pitch posted on the website of the national infertility
patient group, Resolve, is typical of many patient groups. "Whether you
become a site sponsor, a resource partner, or a sponsor of Resolve's chats,
[the group's website] is the ideal place for your company to market its
products and services to thousands of men and women across the country," the
appeal states. Among the benefits the group lists for becoming a member of
the group's "Corporate Council" are access to data on utilization of the
group's programs and services and "the opportunity to establish topics and
sponsor special briefings for patients, the medical community and public
policy makers." Serono and Organon, both makers of prescription medication
used to treat infertility, are among the group's corporate sponsors.
Patient groups also mobilize patients -- sometimes armies of them -- to push
for coverage of prescription drugs by insurance companies and states'
Medicare and Medicaid agencies. To pharmaceutical companies, this can make
or break the market prospects for a new drug because 80 million Americans --
among them, the heaviest prescription-drug users -- receive healthcare
coverage through Medicare and Medicaid, and roughly 155 million have
prescription drug coverage through private insurance companies.
Strength in numbers
WHEN insurers balk at reimbursing patients for new prescription medications,
these groups typically swing into action, rallying sufferers to appear
before public and consumer panels, contact lawmakers, and provide media
outlets a human face to attach to a cause. Infertility patients mobilized by
Resolve, for instance, have been extremely effective in extending states'
insurance coverage of infertility treatments. Groups such as the Depression
and Bipolar Support Alliance have fielded experts and patients who have done
the same for psychiatric conditions. And a wide range of patient groups,
most with substantial backing from the makers of erectile dysfunction drugs,
have mounted successful campaigns to get wary insurers to cover drugs such
as Levitra, Viagra and Cialis.