This is the question raised at least every 2 months in our NHS psychosis team. Most of us will go without a second thought (I have to admit, I usually do. There are free M&S sandwiches, fruit, biscuits and pastries; “That’s all the moral compass I need”, I like to joke). We have the usual good-humoured argument between the affable-and-popular psychiatrist, and the angry nurse (also popular – we know she usually has the patients’ best interests at heart). “I don’t think you can say it’s exactly like having the tobacco industry deliver your anti-smoking training. We just have to listen to a brief spiel and then we can have our business meeting.” “Have you registered it with the Trust?”. “I don’t think we have to” (eyes roll). “The Trust has rules”, “No, the Medical Director is relaxed on this one”.
Drug lunches make you feel good. The rep is always very personable and apologetic. They give a short-ish presentation which always makes you feel better about the medications. It appears they work better than you thought! The rep’s data are surprisingly impressive and clear. There are graphs and smiling faces. It is what we would all want for our clients. It’s only afterwards when you try to check the sources – which no one really has time to do – you find out they’ve presented a charming parallel universe only vaguely related to evidence. They have given the best possible polish to the literature, it must have taken a team of twenty to find that phrase, that graph, that answer to an obvious question. Shockingly, it’s a sales pitch! But we all think of it as “training”.
These arguments happened so often that myself and like-minded colleagues set out to settle them once and for all. Do Trusts have rules? Do they keep records? Are all Trusts the same? In short, does anyone care?
And we should care. We used Freedom of Information requests to all 52 Mental Health NHS Trusts in England, asking what their policies are about 7 different drug rep activities, from freebies and lunches to conferences abroad and part-time jobs. These last two might sound unlikely, but we know several psychiatrists who regularly present their experiences treating patients with certain medications at international conferences (subsidised fees and expenses, of course), and these same psychiatrists have been paid as a jobto write up the results. All very affable. As part of our investigation, we also asked; “Do Trusts keep records about the activities of the pharmaceutical industry?” and “Can you prove it by showing us the records?”
Most Trusts had some sort of policies, but there was huge variation in what the policies covered, with only 23% of Trusts dealing with all seven company activities we looked at. 29% of Trusts covered 3 or fewer of our activities. 23% leant heavily on, or relied entirely on, the ‘Code of Practice of the Pharmaceutical Industry’ written by the Association of the British Pharmaceutical Industry. Between 51% and 73% of Trusts said they allow talks, training, and sponsorship of meetings.
Impressively, five Trusts ban all drug reps and pharma activities, demonstrating that it’s not impossible for Trusts to close their doors to onsite sales activities by Big Pharma. It can be done.
Sales talks by company reps were frequent, averaging 36 per Trust per year; I have to say my personal view is this is probably a small fraction of the actual figure, because most staff don’t think they need to register or declare talks. But they should –since 2015 NHS Trusts have been required to keep a “Conflicts of Interest” register (like the one MPs have). We asked for these as well. 14% of Trusts told us they didn’t actually hold a register, nor did they keep any records of these activities (despite it being mandatory). Only 22% of Trusts actually sent us the register.
Well, we also asked Trusts about their spending on two specific types of medicines, two that we felt probably wouldn’t be used so much if doctors were using a cold, dispassionate evaluation of the evidence:
1. Branded medication (the equivalent of buying a £3 packet of paracetamol rather than a 40p generic own-brand one). Trusts varied amazingly on this, from 0% to 74% of the entire medicines budget, accounting for 33% of said budget on average.
2. Long-Acting Injectable anti-psychotics (LAIs; otherwise known as “depot”, injections for people who may forget to or may be reluctant to take their tablets regularly). On LAIs, Trusts varied enormously again in how much of their budgets they spend on LAIs, from 13% to 77%; on average 44% of the entire medicines budget. How can there be such vast differences between Trusts, if they are all using the same evidence-base?
We asked Trusts which drug companies received the largest share of their medicines’ budget, and how much they actually spent on these medicines; we compared this data with the information we had on which drug companies gave the most training or sponsorship activities in each Trust. The same pharmaceutical company received the most money from the budget in every single Trust. Can you guess which company this is and which products they sell? It was Janssen, the company which sells 2 of the 4 most widely-used LAIs available in the UK. Janssen were the company that did the most sales pitches in 57% of Trusts. We found that where Janssen was the top trainer, they earned nearly double per Trust on average (£1,035,328 versus £637,361) compared to where a different firm did the most promotion. That’s half a million quid a year more per Trust.
It is worth noting here that Janssen (owned by Johnson and Johnson) paid out a total of $2.3 billion in 2012 in America because of a series of scandals around their sales tactics for anti-psychotic medication risperidone (one of the two LAIs). The Huffington Post have an excellent online mini-book about the whole saga. Issues included: deliberately targeting doctors to prescribe risperidone to patient groups for whom it was not licenced, such as children (5.5% of young boys taking risperidone will develop gynecomastia (growing women’s breasts). It was a bit like the UKs PPI scandal – there were helplines (“Call 1-800-respiridal”). They were also not allowed to target older adults with dementia, again because it was not licensed (it caused higher rates of strokes). They did so anyway; they had an “ElderCare” sales team. 46% of their profits from Risperidone ($1.08 billion yearly in 2000) came from children and older adults.
Other highlights include: a commercial contract between what became EMBASE, (online scientific literature database and set of journals, owned by Elsevier until 2010), to promote risperidone through ghost writing and favourable articles (e.g. minimising the gynecomastia problem); Illegal cashbacks to the largest chain of dementia care homes in the US, “Omnicare” every time they used risperidone. Janssen is also currently in court starting in Oklahoma as a major player in the opioid scandal. The New York Times reports how “in redacted court documents, Oklahoma has accused Janssen of targeting patient groups for opioid sales, including veterans, older adults and children”.
The man most responsible for the marketing of risperidone at Janssen (Alex Gorsky) has been chairman and chief executive of its parent company, Johnson and Johnson since 2012. Johnson and Johnson were forced to pay out $4.7 billion in 2018 because it knew of a link between its baby talc and cancer, as well as $57 million for its vaginal mesh scandal, and around $1 billion for its hip replacements scandals.
So now you know who Janssen are, how do you feel about them being the company whose salespeople do by far the most “training” in the NHS?
On a personal level, I found the scale of the problem of drug company sales talks being so endemic in our NHS pretty surprising. My NHS colleagues and I honestly saw drug companies as fairly benign and felt their talks had little impact on us or on prescribing habits. But research suggests this sort of fooling of ourselves is common– research shows that doctors think sales talks don’t affect their own prescribing practices, but they do believe that it affects other doctors.
And the warning signs about the risks of Trusts spending public cash in ways which benefit the pharmaceutical industry rather than patients were evident long before our study. In 2005, a House of Commons Health Committee noted “the amount the Department of Health spent providing independent medicines information to prescribers was the equivalent of 0.3% of the approximately £1.65 billion a year that the pharmaceutical industry spent on marketing and promotional efforts” (p. 39). That huge figure gives an indication of how much companies think they will get back.
My biggest gripe about drug lunches is that they skew the direction of treatment. Because they give the impression the meds work better than they actually do, the team ends up blaming the client for their not getting better. “Stephen still isn’t better, so perhaps he isn’t taking his meds as reliably as he says. We had better put him on a depot”. Once on a depot (LAI), people do not quickly get off, despite the long-term physical health risks associated with all these medicines. And most importantly of all, the medicine is seen as the main part of treatment, the bulk of what we do. Other aspects which are proven to be very important and effective, such as Psychological input, Family Interventions, or generally sorting out clients’ social situations are neglected. Not surprisingly, these interventions are rarely given serious consideration in presentations by pharmaceutical rep talks.
The emphasis on medication as the mainstay of treatment, a position which promotes the interest of the companies which make and profit from these medications, means that other approaches are often overlooked, even when considering such serious concerns as suicide and the controversial use of electrical shocks as ‘treatment’ (“ECT”). In previous studies we found that Trusts don’t keep records of whether people who committed suicide in their care had been offered psychological therapy (you can be sure they investigate whether they were offered medication or not). Another study showed that although the law says people who get ECT should be offered psychological therapies before they get their ECT, most don’t get offered it, and Trusts do not keep records of whether this is happening.
In 2009, the Royal College of Physicians recommended banning the ever-present drug company sales-talks, and pointed out the deeply concerning nature of doctors relying on vested-interest sales talks to get their up-to-date training. They advocated properly funded independent post-qualification medical education. Ten years on, this still looks unlikely.
So will you be going to future drug lunches?
Dr Chris Harrop, Clinical Psychologist, West London NHS Trust
All views are my own