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You have full access to this open access article. Americans spend a large amount of money on the purchase of prescription drugs. Small wonder, then, that patients, and the physicians caring for them, are grateful for access to free drug samples. These samples can enable therapeutic trials of necessary drugs, avoiding the expense of paying for a full course of a drug that might have to be discarded after the first dose leads to a side effect. A frequent justification provided by physicians is that use of free samples provides access to necessary drugs for patients who could not otherwise afford them. Strong evidence links use of samples to suboptimal drug choice. And these samples come with an expectation of access to physician and staff time by sales representatives for the companies that supply the drugs. Thus, it is not surprising that policy analysts are examining whether the costs of having access to these samples outweigh their putative benefits. These surveys can be used to generate estimates applicable to the overall US population and many important subgroups. Research using these data has begun to be published, including an analysis of data from the MCBS by Tija et al. Together, these studies give an important window to the epidemiology of free sample use, which previously has been described only in limited populations. The study by Tjia et al. First, it focuses on the Medicare population. The frequency of chronic disease in older individuals makes them particularly vulnerable to medication costs. Moreover, this type of research has great policy relevance, since the structure of this federal program can be modified, either administratively or legislatively, in response to new research information. Since the question was put in place in , changes in sample use following the advent of Medicare Part D in can be examined. The work of Tjia et al. Indeed, there is actually an inverse relationship between income and likelihood of accessing free samples, although this gradient is not significant after adjusting for other demographic data, having a pharmacy benefit, and comorbidity. Non-Hispanic Whites are more likely to access free samples than other racial and ethnic groups, a pattern that is reminiscent of other disparities in health-care situations requiring subjective judgments. However, the fact that free samples are not well targeted does not mean that they are not an important source of drugs for persons with limited resources—it simply means that many samples go to persons who have adequate resources. Other studies, by Cutrona et al. Indeed, Alexander et al. Again, it is not possible to determine if the sampling causes the increased drug costs by inducing use of excessively costly drugs or is a response to that increased burden. This finding will likely be interpreted to indicate that samples are being used to avoid this reason for nonadherence. However, as the authors note, it is also plausible that the use of free samples either causes, or is at least symptomatic of, the use of expensive drugs when less expensive ones would be as effective. Thus, the use of free samples may cause the CRN, rather than attenuate it. How should physicians, health-care organizations, and policy makers react to these data? It is clear that they do not give a definitive answer regarding the question of whether the benefits of having a free sample cabinet outweigh the costs. However, just as one cannot wait for definitive randomized trials when treating medical illnesses, evidence-based practice dictates that decisions should be made with the data at hand. These decisions should give great weight to the systematic evidence that samples induce the use of expensive drugs when less expensive ones would work as well or better. They should consider the acknowledged dangers of dispensing drugs without appropriate labeling regarding dosing and appropriate counseling regarding specifics of use and potential side effects. It seems clear that in some cases, particularly in large organizations such as many academic primary care practices, the sample process should be eliminated or at least extensively reworked. Many health-care organizations have taken this bold step, and we applaud them. We believe this action provides important benefits to trainees, encouraging the use of evidence-based medication choices rather than simply selecting from what is available in the sample cabinet today and role modeling a healthy separation of clinical practice and pharmaceutical sales representatives. Moreover, these large organizations can systematize the process of using the patient assistance programs provided by most pharmaceutical companies to assist those patients whose needs cannot be met by their income or insurance coverage. Smaller practices may find it harder to abandon the sample cabinet. In addition to the debatable benefits for patients unable to purchase medications, the convenience of being able to initiate drug therapy without an immediate trip to the pharmacy is likely valued by many patients. Most importantly, the physician should not let the samples available dictate what is prescribed. The presence of free samples must not interfere with the practice of evidence-based medicine. On a policy level, it is appropriate to seek additional data. Although descriptive epidemiology of the type presented by Tjia et al is essential, it does not answer questions about the net and individual effects of using drug samples. This will require patient level data regarding the appropriateness and cost of the drug sampled versus alternatives, physician and patient motives for sample use, and potential and actual adverse effects of such dispensing. This type of detailed observational study may be more useful and feasible than randomized trials, which would identify net benefits, but might not capture either individual patients who benefit from the samples or system level harms. The evidence that this expense improves health-care processes or outcomes is currently limited to anecdote. Indeed, these dollars may well discourage the use of evidence-based medicine. If, however, there are many individual patients who benefit from the free sample system, even while it increases overall medical costs and discourages evidence-based practice, then new approaches should seek to preserve these benefits while addressing the harms. Since it seems unlikely that the goal of universal affordable access to needed pharmaceuticals will be met anytime soon, partial solutions should not be shunned. Some authors have advocated the substitution of free vouchers that would allow free samples to be dispensed with the same pharmacist oversight that paid prescriptions receive. If technology can allow these programs to be as accessible as an unlocked, poorly organized sample closet, we may be able to improve both access to drugs and evidence-based prescribing. Arch Intern Med. Article PubMed Google Scholar. Wolf BL. Drug samples: benefit or bait? The value of pharmaceutical representative visits and medication samples in community-based family practices. J Fam Pract. Perceptions of the influence of prescription medicine samples on prescribing by family physicians. Med Care. Do drug samples influence resident prescribing behavior? A randomized trial. Am J Med. Effect of antihypertensive samples on physician prescribing patterns. Fam Med. PubMed Google Scholar. Evaluating sample medications in primary care: a practice-based research network study. Google Scholar. Medicare beneficiaries and free prescription drug samples: A national survey. J Gen Intern Med. Characteristics of recipients of free prescription drug samples: a nationally representative analysis. Am J Pub Health. Characteristics of patients receiving pharmaceutical samples and association between sample receipt and out-of-pocket prescription costs. Adverse drug events in ambulatory care. N Engl J Med. Rabin R. Free Drug Samples? Bad Idea, Some Say. The New York Times Company. Barry P. Download references. Clement J. You can also search for this author in PubMed Google Scholar. Reprints and permissions. Whittle, J. Download citation. Published : 07 May Issue Date : June Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Download PDF. Use our pre-submission checklist Avoid common mistakes on your manuscript. Author information Authors and Affiliations Clement J. View author publications. About this article Cite this article Whittle, J. Copy to clipboard. Search Search by keyword or author Search. Navigation Find a journal Publish with us Track your research.

Pharmaceutical marketing: the example of drug samples

Buying MDMA pills Vestfall

Official websites use. Share sensitive information only on official, secure websites. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Branded drug samples are one of the most important promotional tools that pharmaceutical manufactures employ. Sample provision is closely intertwined with visits by drug reps; detailing visits convince physicians to try new products, while sampling maintains the flow of prescriptions. Only drugs with the highest profit margins are sampled. Although physicians believe that samples save patients money, patients who receive samples have higher overall out-of-pocket costs. Most studies have found that patients in financial need are least likely to receive samples. Pharmaceutical marketers pitch samples as a low-risk way to deal with diagnostic uncertainty. In fact, there is no evidence that samples aid diagnosis. Sample availability may compromise patient safety by reducing compliance with guidelines and steering patients towards newer drugs, for which adverse effects have not been well-delineated. Although physicians believe that samples improve adherence for low-income patients, branded samples do not improve access or adherence Samples are not a charitable activity, but are instead a highly effective form of drug marketing. Sampling of branded drugs increase drug costs for everyone. Only a cohesive effort by clinicians, legislators and policymakers can end this practice. Evidence supports a ban on sample distribution of branded products. Some argue that samples decrease prescribing quality and increase overall prescription drug costs \[ 1 — 3 \]; while others argue that free drug samples are beneficial for patients \[ 4 , 5 \]. In fact, drug samples are a powerful marketing tool. This paper will discuss the purpose and effect of sampling, and how samples are viewed by physicians and by industry. Additionally, we will make recommendations for restricting or banning sampling. A survey of U. A survey of 33 family medicine teaching units in Quebec found that most physicians accepted samples \[ 10 \]. Sample use varies across specialties and indications; for example, the use of free samples is higher in dermatology compared to other specialties \[ 11 \]. Little research on sampling appears in the medical literature; a comprehensive survey of literature from to identified 23 research papers. Most papers focused on physician attitudes towards sampling, and the majority of those studies found that physicians viewed samples favorably \[ 12 \]. Sampling is a well-established marketing strategy in many consumer-facing industries, including food and beverages, luxury cosmetics, and print media \[ 13 — 15 \]. Samples appeals to both informational and affective needs in customers, and increase the probability that the customers will choose the sampled brand in the future \[ 16 , 17 \]. One study of six sales data sets found that providing a wide variety of new product samples in stores increased sales immediately, an effect that persisted 2—8 weeks later \[ 18 \]. Sampling is more effective than coupons or other marketing tactics and produces sustained changes in purchasing habits that can last up to 12 months \[ 19 \]. The intermediary role played by physicians mirrors other business-to-business B2B relationships. B2B marketing strategies focus on building sustained personal relationships with gatekeepers and decision-makers within a supply chain who influence how the product reaches individual consumers \[ 21 \]. In an era of increasing regulations on physician—pharma interactions, samples play a crucial role in maintaining these gatekeeper relationships. Sample provision is closely intertwined with visits by drug reps. Drug reps bring small quantities in order to have a reason to visit physicians every other week or so. Detailing visits are an acquisition tool to convince physicians to try new products, and sampling maintains the flow of prescriptions \[ 23 \]. When physicians meet with pharmaceutical representatives, they increase the number of samples they dispense \[ 24 \]. Pharmaceutical companies optimize profitability by tracking the use of samples to ensure that they are not being given out so generously that sales are cannibalized rather than enhanced \[ 6 , 26 \]. Sample drops, in conjunction with detailing, have the highest return on investment ROI among marketing tactics \[ 27 \]. Why do physicians think it is beneficial to accept samples? Physician surveys have identified several motivating factors, including reducing costs for patients, evaluating treatment efficacy, demonstrating proper use, starting therapy promptly, increasing patient convenience and satisfaction, improving patient compliance, and treating short-term medical problems \[ 28 , 29 \]. Sample closets often serve as communal medicine cabinets, supplying physicians, office staff, friends, and family \[ 25 , 30 , 31 \]. Samples are dispensed most often to patients who are newly diagnosed, or were previously diagnosed but were prescribed a different drug on a previous visit \[ 19 \]. Early-career physicians are a particular target, as well as physicians working with high-uncertainty disease categories, including asthma and allergies \[ 7 \]. Pharmaceutical representatives provide information, flattery, and samples to persuade clinicians that they are making wise therapeutic choices \[ 26 \]. Samples may be a seductively simple way to deal with diagnostic uncertainty; they can decrease physician anxiety and increase dependence on sample drops. Samples are not cost-effective, either. Although physicians and some patients believe that samples save patients money \[ 33 \], samples do not provide long-term financial benefits. Patients who receive samples have higher overall out-of-pocket costs \[ 34 \]. Also, most studies have found that patients in financial need are least likely to receive samples. In one analysis of patients over 65 with government-funded insurance in the United States, higher-income patients were more likely than low-income patients to receive samples over a year \[ 35 \]. A survey of 32, patients also found that samples predominantly go to wealthier, insured patients \[ 36 \]. The strongest predictor of receiving samples is the number of office visits, not financial need \[ 38 \]. Samples habituate physicians to prescribe specific drugs. An analysis of physician prescription decisions found that samples positively influenced prescribing decisions in two ways: by increasing base prescription rates and enhancing physician susceptibility to detailing visits \[ 39 \]. Subsequent studies found that sample availability positively influences physician adoption of targeted drugs \[ 40 , 41 \]. One modeling study inferred that sampling was effective in physicians who saw patients with private insurance but not for those who saw patients with Medicare government-funded health insurance for elders in the U. The availability of samples can lead physicians to prescribe drugs that differ from their preferred treatment. A cross-sectional U. Each hypothetical scenario was accompanied by a list of available samples. A systematic review of 19 studies of interactions between practicing physicians and pharmaceutical companies found that lower physician prescribing quality was associated with industry interactions, including the acceptance of free drug samples \[ 42 \]. Acceptance of samples begins early in training \[ 11 \]. Premedical students are exposed to sampling activities while participating in volunteer activities. Sample closets in residencies counter evidence-based prescribing. A randomized trial of 29 internal medicine residents found that residents with access to sample closets were less likely to prescribe unadvertised drugs and over-the-counter drugs than residents without sample access, since a generic alternative was available \[ 44 \]. Boltri et al. In Vermont, primary care physicians who had sample closets were less likely to prescribe the preferred antihypertensive according to current guidelines \[ 46 \]. A study of family medicine clinics found that physicians at a clinic that allowed samples were much more likely to prescribe sampled medications than at two similar clinics that did not allow samples \[ 47 \]. Gifts to physicians have been shown to bias prescribing, but many physicians do not consider samples to be gifts \[ 1 , 48 , 49 \]. Physicians seem to view the practice in isolation from other detailing efforts, although samples, like all gifts, beget social expectations. Besides influencing prescribing patterns, sample availability may compromise patient safety by reducing compliance with guidelines and steering patients towards newer drugs, for which adverse effects have not been well-delineated. Adverse effects from samples are not tracked consistently with regular pharmacovigilance data \[ 50 \]. Although physicians believe that samples improve adherence for low-income patients, branded samples do not improve access or adherence. Samples are usually for expensive, chronically used drugs, and may drive up overall costs \[ 51 \]. For example, sample use has increased among insulin users in recent years, and is associated with higher per-prescription costs over nonusers of samples \[ 52 \]. Samples may have increased prescription rates for expensive insulin delivery systems that provide little or no benefit in patient outcomes. Samples can lead to discontinuity in treatment after patients run out of samples of a drug they cannot afford. Receiving day samples of generic drugs, on the other hand, increases adherence \[ 53 \]. Adherence to generic drugs is higher than to branded drugs, probably because patients can afford them \[ 54 \]. A pilot project by a managed care organization found that physicians prescribe generic drugs more when the sample closet is filled with generics \[ 55 \]. Many practices fail to store sample drugs safely. Some hospitals have allowed pharmaceutical representatives to stock and monitor sample closets \[ 56 \]. In the U. There are environmental concerns as well. Waste generated from drug samples is estimated to be metric tons per year \[ 58 \]. Sampling is banned in many academic institutions, including the University of Michigan health system and Stanford University Medical School \[ 59 \]. Some physician practices refuse samples as well \[ 60 , 61 \]. However, physician dispensing of drug samples is still considered acceptable by the American Medical Association and the American Academy of Family Practitioners \[ 62 \]. Because many offices have reduced in-person interactions, including drug rep and patient visits, samples can now be shipped directly to patients. This new guidance makes it easier for pharmaceutical companies to distribute samples in spite of decades of evidence that samples cause harm. With little guidance at the national level, the decision of whether or not to accept samples in private practice is largely left to individual physicians. Samples are not a charitable activity, but are instead a highly effective form of drug marketing. Samples remain the largest marketing investment among most companies. Pharmaceutical companies would not invest so much in optimizing sampling distribution if they did not see a return on investment from these strategies. The sampling of branded drugs increases drug costs for everyone. While some countries, states and other jurisdictions have laws and regulations that address gifts to physicians, drug sample provision is always excluded. This needs to change: samples are gifts. In the meantime, individual prescribers have the power to change this practice by refusing samples. Laws that address gifts to prescribers should always include samples as gifts. ECA, MS contributed in the drafting and revision of this manuscript. AF-B, MD contributed in the drafting, revision and submission of this manuscript. Both authors read and approved the final manuscript. Emily Couvillon Alagha MS has no disclosures; Adriane Fugh-Berman MD is a paid expert witness at the request of plaintiffs in litigation regarding pharmaceutical marketing practices. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Find articles by Emily Couvillon Alagha. Find articles by Adriane Fugh-Berman. Received Oct 6; Accepted Oct 31; Collection date Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. 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Buying MDMA pills Vestfall

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