The pharmaceutical industry spends billions of dollars each year on handing out free samples of their expensive brand name drugs to physicians, who in turn hand them out to their patients.  As I’ve written about here and here, the obvious marketing truth is that no company would be doing this unless the strategy resulted in a significant increase in sales of those drugs.  When you’re looking at a global market for pharmaceuticals expected to top $1.1 trillion by next year, that’s a substantial incentive to keep up this practice. Still, very few physicians believe that doctors accepting billions of dollars in free drug samples annually has the slightest bit of influence on the way they practice medicine. Except, of course, when it’s those other docs out there who are accepting the freebies. 

Some studies have reported this pervasive sense of righteous denial among medical professionals, including one undertaken by the American College of Obstetricians and Gynecologists (ACOG) and later published in The Journal of Medical Ethics.*

This study set out to assess the opinions and resulting practice patterns of obstetrician-gynecologists regarding the acceptance and use of free drug samples and other free incentive items offered to them by Big Pharma drug reps.

Over 92% of the physicians studied thought it proper to accept free drug samples. After all, patients love them, right?

But surprisingly, one-third (33%) of the same ACOG respondents admitted that their own decision to prescribe a drug would probably be influenced by accepting these drug samples. Other studies also confirm this admission: once the free samples of high-priced meds are used up by their patients, physicians who gave out those free samples in the first place are indeed more likely to pull out the prescription pad and order a (no longer free) course of the expensive brand name drug.

A well-known example is a 2005 study (Adair et al) out of the University of Minnesota in which physicians with access to free drug samples were not only found to be less likely to prescribe cheaper generic (non-advertised) drugs than those docs who did not have such access, but were also less likely to recommend over-the-counter medications that would have been appropriate alternatives to the expensive prescribed meds – thus paradoxically increasing total drug costs for patients who had started off with the free samples.

About 77% of physicians surveyed in the ACOG study also thought that accepting free “informational meals” provided by a drug company was just fine, roughly the same percentage (75%) who insisted that receiving a free anatomical display model (clearly branded with the drug company’s corporate logo, of course) was acceptable, too. And over half (53%) saw absolutely nothing wrong with becoming a well-paid drug company consultant (what the industry likes to flatteringly refer to as “Thought Leaders” or “Key Opinion Leaders“).

As bioethicist Dana Katz and his colleagues explained a similar observation in the American Journal of Bioethics in 2003:

“When a gift or a gesture of any size is bestowed, it imposes on the recipient a sense of indebtedness. The obligation to directly reciprocate, whether or not the recipient is directly conscious of it, tends to influence behavior.”

But just as we suspected,  the ACOG respondents were more likely to claim that the average doctor’s future prescribing habits would be far more  influenced by accepting these items than their own acceptance would be.

The established marketing practice of Big Pharma spending on free samples may in fact be slowing down. In 2007, drug companies spent $8.4 billion on samples to leave behind in doctors offices. But by 2011, these companies spent just $6.3 billion.

The reasons that doctors give out these samples seem obvious: about 94% of the ACOG docs who distributed drug samples to their patients told researchers that they did so because of patients’ financial need and for convenience (76%). Some doctors cite the usefulness of letting a patient try out a short trial of a new drug to observe potential side effects or efficacy.

But fewer docs list the reason as “physicians’ knowledge about the drug” – in other words, they did not know whether or not the sample product was the most appropriate treatment (63%).

In fact, we know that doctors admit to handing out free samples of specific drugs that may not actually be what they would choose to recommend to patients if they didn’t already have a drawer full of the samples on hand.

The ACOG study participants agreed, judging free samples to be “influential on future prescribing practices.”

In 2007, the Association of American Medical Colleges held a symposium at Houston’s Baylor College of Medicine called “The Scientific Basis of Influence and Reciprocity.”  This event was designed to explore how objectivity was affected by gifts, favors, and influence. One of the participants in the symposium presented the findings of an experiment using functional MRIs of the brain in people playing a “two-person trust game.”  The findings suggest that specific areas of the brain actually react when a person receives a favor or gift from another. In other words, accepting even a pen, pad, coffee mug or free drug sample may generate an unconscious bias toward trusting that what a drug company rep says about his or her product is true.

Despite the fact that the vast majority of the ACOG study’s physicians admitted accepting free stuff from their drug sales reps, one-third (34%) of them paradoxically agreed that these interactions with industry should be more strictly regulated.

The study authors’ conclusion:

“The widely accepted practice of receiving and distributing free drug samples needs to be examined more carefully.”

Canada’s University of Victoria drug policy analyst Alan Cassels is the author of the book Seeking Sickness: Medical Screening and the Misguided Hunt for Disease.  He concludes even more bluntly: