Case Example- Doctor Utilizes a Sample of Starter Medication
“ Mrs. Jones, I feel that you are going to benefit greatly by taking antidepressant medication and I would like to start you on XYZ medicine. You should take it once per day . These are possible adverse effects…Most people do very well on it. I am going to give you a 10-day supply of medication and then we will see how things are going. Do you have any questions?”
Mrs. Jones, who has been anxious and depressed to start with, may have some additional anxiety about starting a new medication. She may feel hopeful that this doctor seems to understand her and believes that the medication ( plus any psychotherapy that is going to take place ) will give her relief from her suffering. She probably is pleased that she has been given a “gift”, the free medication sample.
The doctor is pleased. He or she has diagnosed the depression as one that should be helped by medication. While there were several excellent antidepressant medications, which could be prescribed, the one that he chose has had very good reviews in the literature and he has some samples to give to the patient. He is glad to see that she perked up when she received them and was pleased to be giving her the free starter dosage package.
The patient returns in a week to 10 days and while the depression most probably hasn’t fully lifted yet, if she is tolerating the medication reasonably well which most people do, he will write her a month supply of medication and continue the follow-up which may involve psychotherapy. ( He might even give her some additional starter packages if he had them on hand )
Is There Anything Wrong With This Story?
Many psychiatrists in my generation were trained in this kind of an environment. It actually felt gratifying when working in clinics to give people in lower socio-economic groups free medication to start them off or medication to supplement their paid prescriptions which even a co-pay payment would be a burden. In fact , it almost seemed therapeutic to give any patient a free sample of medication even well off patients. When the SSRIs first came out, they were understood to be superior choices for most people with much less side effects. There are no generic choices of this class of medication so a sample seemed better than nothing or better than the inferior older medication of the tricyclic type some of which did have a generic version.
Unfortunately, there is another view of what is going here. What the patient may view as a free starter package , the US pharmaceutical industry views as “Sampling Medications“ and it is one of the most important components of their drug-marketing program. Over 50 % of money spent for marketing goes into sampling It also has been shown that doctors are often willing to spend time with drug company sales representatives in order to obtain samples to give to their patients Furthermore samples have been shown to cause significant increases in new prescriptions for new drugs being marketed.
The doctor in the above example may very well feel that he prescribed the best possible medication for the patient and maybe he did. The doctor may also feel that he has seen several pharmaceutical representatives and listened what they all had to say before taking the samples and then read some objective research . Maybe he didn’t even talk to the pharmaceutical representatives and the sampling process does not unduly influence him. Perhaps also this doctor saved some money for some of his patients who were feeling the financial crunch of the economy.
The emerging objective research suggests however that sampling is having an influence on the practice of medicine quite different than this individual doctor and maybe other individual doctors perceive is happening
Most Samples Don’t Go to Uninsured and Low Income Patients.
Studies have shown that poor or uninsured patients are less likely than those with wealth or insurance to receive free drug samples. In addition physicians, office staff and pharmaceutical sales representatives receive many of the samples intended for patient use.
Some states have laws that samples can only be used patients .
Samples Don’t Save People Money
Samples of course are not available for less expensive generic medications Samples are generally only available for newer brand name drugs. Research has shown that doctors who use samples tend to use more expensive drugs. Once a patient is started a particular drug and it is working, they will usually continue on it, often for long term
Doctors May Not Choose Their First Choice Medication When Samples Are Available
One study showed that doctors who had samples for patients did not prescribe their usual first choice medication. In other words they were influenced by the availability of the samples to even choose one brand over another brand
Availability of Brand Name Samples Makes Prescription of Generics Less Likely
Other research has showed that physicians were three times more likely to prescribe the usually cheaper generic medications to uninsured patients after drug samples were removed and no longer available to them . Therefore it does appear that prescribing patterns are correlated with samples that are available
Other Potential Problems with Samples
Samples are often not properly labeled for the individual patients. Therefore medication errors or misuse are more likely. The storage of samples may not be done properly as would be in a pharmacy. Maintaince temperature and elimination of outdated medication may not be as efficient.
A Word About Generic Medications 
The pharmaceutical companies develop new medications and patent them They deserve to profit from their research, development and marketing. This encourages them to develop still newer and better drugs. After a period of what used to be 20 years and now is down to 12 years their patent expires. Other companies can now make the exact medications know as the generic version. These versions can be offered for much less money since the market is now competitive. This topic is much more complicated than this summary as mirror images or other versions are patented with possible special advantages . There are claims and counter claims of generics not being bioequivalent or as safe as the original. We are talking about a multi billion-dollar industry.
How To Address the Sampling Issue
Many people would like the sampling of medications be completely eliminated from medical practice in the country today. I doubt that this is gong to happen. Even if it came about by being incorporated in the new healthcare legislation. I don’t think the billions of dollars that this program costs would be directed towards lowering medication costs or towards educating doctors about new drugs or the value of generics.
Clinics and large practices are increasingly organizing their collection of samples to support patients who cannot afford medications. Having pharmaceutical companies contribute directly to such stockpiling and not have contributions of samples be related to discussion with doctors is thought by some people to be a good idea.
Particular attention needs to paid to the sampling of resident doctors ( doctors in training) who may be more susceptible to being influenced by such practices. Although sometimes it is the younger doctors who completely reject this practice on principle.
It behooves any physician who utilizes samples to consider whether they are being subtly influenced ( unconsciously, if you wish ) to favor the high price drug over a less expensive drug that they don’t have a sample, especially a generic drug.
Good psychiatric technique would suggest that if samples are used, the doctor should discuss the pros and cons of using this medication and the potential long term costs of it .In fact the pros and cons of using a generic vs. new expensive brands should always be discussed in detail with the patient.
Adendum
On the same day that I published this blog, there was an article on the front page of the business section of the New York Times ( January 13th ) stating that a group of members of the House of Representatives plan to ask Congress to block business deals in which they say makers of name-brand drugs directly or indirectly pay generic makers to delay competition from cheaper generic alternatives. It is reported that the Federal Trade Commission has estimated that such deals currently cost American consumers $3.5 billion a year. This is another illustration of the financial incentives to the pharmaceutical industry , whether by sampling or such deals, to keep doctors and patients away from generic drugs.
Your comments on any aspect of this issue are very welcome.