Ask Your Doctor if this Blog is Right for You

I have a few personal questions I’d like to ask:

• Do you have psoriasis?  Psoriatic arthritis?  Rheumatoid arthritis?
• Do you have ulcerative colitis?  Crohn’s disease?
• Do you have metastatic breast cancer that is estrogen receptor positive?
• Do you have “bedroom problems?” Male pattern baldness?
• Do you have type 2 diabetes and obesity?

Because if you have any of these, I’ve got the PERFECT medication for you. 

Perhaps you get your information on medications from the same place most people get theirs: commercials on television.  All of these types of drugs are now or have been advertised via mainstream media.  You’ve seen the commercials: the ones with the attractive, happy and healthy looking people whose lives have been changed by the latest and greatest new drug.  The commercial always ends with the laundry list of warnings about what the wonder drug can do to you, like:

• Don’t take this drug if you are allergic to this drug (duh!).
• Please tell your doctor if you have any of the following symptoms
  • Severe abdominal pain
  • Blood pressure elevation
  • Excessive bleeding
  • Erections lasting more than 5 hours
  • Pregnancy resulting from prolonged erections
  • Stool or urine glowing in the dark
  • Head explosions
  • Unusual obsessive thoughts about llamas
  • Corrosive flatulence
  • Death.

I promise! I won’t.

The drug industry spent $6.88 Billion on direct-to-consumer advertising in 2021, and that number promises to only go up. $6.88 Billion to tell us about drugs for conditions most of us don’t have.  Seriously, just how common are these conditions?  Some of them are fairly common, with type 2 diabetes affecting 10% of the US population (and resulting in a huge cost in suffering and life lost).  Psoriasis is also fairly common, affecting 3% of the US population (but causing far less harm than diabetes).

But some of these conditions (which are frequent users of DTC) are  much less common:

• 0.1-0.2% of Americans have psoriatic arthritis
• 0.25-1% have rheumatoid arthritis
• Ulcerative colitis affects 35-100 people per 100,000.
• Crohn’s disease affects 100-300 per 100,000.

Additionally, these medications are all prescription drugs, meaning that the vast majority of people watching the product cannot actually get the product without significant help.  In case you missed it, it takes a doctor to prescribe these drugs.  

So these ads are targeting a very small percentage of the US population.  How small?  Here are the numbers:

• There are 332 Million people in the US
• The number of practicing doctors is just under 1 million (about 0.3% of the population)

But even this number is an overestimate, as it accounts for all doctors, which is not accurate.  Your psychiatrist or pediatrician don’t prescribe medications for your Crohn’s disease, psoriasis, or breast cancer.    So if we look at the appropriate doctors for the drugs, there are:

• 12,116 Dermatologists (0.004% of the population)
• 6,265 Rheumatologists (0.002%)
• 16,274 Hematologist/Oncologists (0.005%)
• 15,469 Gastroenterologists (0.005%)

So why are the drug companies spending so much money, using so much of the evening news commercial time for a product that treats a small percentage of the population and is prescribed by a minuscule fraction of people in the US?  

Obviously, the answer is money.  Lots and lots of money.

In 2022, the average cost of new drugs released in that year was a whopping $20,000 per year.   New chemotherapy drug costs dwarf that, coming in at $15,000 per  month ($180,00 per year).   Pharmaceutical company revenue in 2022 ranged from $10 billion to more than $100 billion (the winner being Pfizer, which profited greatly off of the pandemic).

Wait a minute.   $20,000 per year?? How can a company charge prices that only the ultra wealthy can afford?  That would be like a grocery store charging $50 for a can of soup, or $1000 for a steak.  Who would go there?  Who could afford it?   And this is the situation in our glorious healthcare system: we have a product that is so expensive that nobody can afford to get sick.  

Of course, nobody actually pays those prices for those drugs.  They just run it through their insurance and, like magic, the price is cut to something much more affordable.  But while insurance companies do have special discounts from the pharmaceutical companies (and extort “rebates” from them for inclusion on their formularies…more on this later), they still are paying huge prices for the drugs (as witnessed by pharmaceutical company profits).  When only a small segment of people need an expensive drug, insurers can spread the cost to all of their policy holders and dilute the costs.  That’s how insurance works.

And if the costs get too high, don’t worry about the insurance companies. They just raise their premiums and pass the cost back to the consumer.  

Yeah, our system is very sick.  But that’s for another article.

Back to the subject of this article, direct-to-consumer (DTC) pharmaceutical ads. The U.S. is one of two countries (the other being New Zealand) that allow marketing of drugs directly to consumers.  This started in the 80’s, when a drug company wanted to pitch their version of ibuprofen against the popular drug Motrin.  This company made an ad that simply stated that the drug was identical to Motrin, only cheaper.  The drug (Rufen) was successful in bypassing the rules of the FDA to get their ad on television, but not so successful at bringing down the Motrin empire.  

But that ad opened the floodgates and DTC pharmaceutical ads became a ubiquitous part of television viewing and part of our culture.  Prior to this, advertisements of drugs were to only to doctors, either in medical journals or via in-person visits by drug reps.  This was the glory days for drug reps, when every doctor’s office was overflowing with pens, note pads, and a myriad of other paraphernalia bearing the name of the latest and greatest antibiotic, blood pressure medicine, or antidepressant.  Those trinkets (as well as other, not-so-ethical forms of marketing) were outlawed in 2009, so the glory days for drug pens are a thing of the past.  Sigh.

Marketing to doctors by drug companies still happens (at a rate more than 3 times the DTC ads), but with much stricter rules (beyond the lack of pens). They cannot claim anything that is not an approved statement by the Food and Drug Administration, and they have to explain the risks and possible side effects of the drugs to the doctors in detail. Drug reps are very careful about this. This practice spilled over to the DTC ads for drugs, resulting in the laundry-list of possible side effects at the end of every commercial.  Companies are not allowed to make positive claims without explaining the risk. 

So is there a benefit to DTC ads?  Absolutely.  I’ve had patients get vaccinated for Shingles because of the latest ad campaign.  There have also been times when an ad piqued my interest and motivated me to read up on a new drug for a disease I may or may not treat (if nothing else but to have answers for the questions I will undoubtedly get from my patients).  

But there is a sinister side to this, with ads clearly shown to increase the spending on drugs, and with patients preferring newer, more expensive drugs to the older proven drugs that come at a fraction of the cost.  Also, the high profitability of certain drugs has made it far less likely that new antibiotics or blood pressure medications will be developed, when the profits from the super-high cost speciality drugs are huge (thanks largely to DTC marketing).

Still, it’s hard to pin the high cost of prescription drugs on DTC marketing.  It’s probably only a small part of the equation when compared to the profit-driven, stock share maximizing mindsets of the pharmaceutical and insurance industries.   While banning DTC ads (as suggested by the American Medical Association) would be met with rejoicing from many, it would not fix the root problems that are burying Americans in medical debt.  Those problems are far bigger and will take a bunch of blog posts to explain.

In the mean time, maybe you should ask your doctor if moving to Canada is right for you.