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“The Sample Problem.”
If you are a practicing physician, you are familiar with the following scenario:
You need to start a patient on medication, but the patient has no insurance or prescription drug coverage, so you look to see what’s in the “sample closet.” Your first choice medication is not there (as it has been on the market for, say, longer than a month), so you give the patient a sample of what is there (Chances are it will be an S-isomer, maybe starting with a Z or X, perhaps ending with the letters CD or CR) giving the patient a 30 day’ supply in a large shopping bag. In a month (hopefully), the patient returns, but that medication is no longer in the closet, so you give her something similar; maybe you make note of this in the chart, maybe not . . .
. . . . . . .
Many physicians say that they see reps solely for the purpose of providing medication to indigent patients or patients lacking prescription drug coverage. Samples are also used out of convenience and sometimes as “starter packs” to assess for efficacy and side effects. All of us working in the U.S. are familiar with the difficulties and frustrations involved in caring for over 45 million uninsured individuals. However, the following should be kept in mind:
Samples are promotional. Over half of industry’s promotional budget (promotional, not charity) is spent on samples. And for good reason: Nothing is more important for a rep than to get his or her samples into the “sample closet.” Once a physician gives out a sample she is more likely to use that medication in the future.
What’s the problem with this?
The problem is that samples are almost exclusively the newest, most expensive medications (seen any samples for HCTZ recently? Or even an ACE inhibitor?), and this results in patients being given—and ultimately prescribed—expensive medications when older, cheaper, and just effective alternatives exist.
Samples lead to inappropriate prescribing:
Adair, et al, in a randomized trial, found that residents who were randomized to use samples were less likely to prescribe over the counter medications and more likely to prescribe advertised drugs than residents randomized to agree not to use samples.
Chew, et al, found that in the treatment of hypertension, over 90% of physicians would dispense a sample that differed from their preferred drug choice.
Boltri, et al, found that following prohibition of sample use in their practice, use of first line anti-hypertensive therapy increased from 38% to 61%.
Are those samples really going to “indigent” patients?
Westfall, et al, found that 96% of physicians and staff had taken samples for personal or family use in the preceding year.
Tong and Lien found that almost 60% of reps had provided samples to individuals other than physicians; almost 50% had self medicated or provided samples to friends or relatives.
And then there’s JCAHO and the pesky little issues of proper documentation, record keeping, and storage, as mandated by the Joint Commission on Accreditation of Healthcare Organizations. For this reason alone, many hospital clinics have banned samples altogether. Consider the occasion of a drug recall: Do you know where your samples are?
Furthermore: When a pharmacy dispenses a drug, prescriptions are labeled with patient’s name, date, dosage, and directions; patients also receive printed information with instructions on administration, interactions, side effects, and warnings. What do your patients get with their samples?
Waste! Sample packaging is extremely wasteful(NEJM, 1999). The waste from samples is as much as 5X as much as that from drugs dispensed from a pharmacy(Pharmacother 2000).
It is not “samples vs. nothing.” It is not the case that foregoing samples means foregoing medication altogether. There are alternatives:
Patient Assistance Programs. These programs, offered by pharmaceutical companies, have become much easier to use. See Patient Assistance Programs Page.
Generics. Many medications have gone generic in the past few years, and many more medications will be coming off patent soon. It is sometimes hard for physicians to know when a generic is available (and don’t count on a rep to tell you!) One easily recognizable signal that a medication is coming off patent is the appearance of an isomer (for example, esomprezole, better known as Nexium) or a long acting form (for example, Ambien CD, a slow release form of Ambien. Did we need that?). RxOutreach is a patient assistance program that provides generic medications.
While many physicians say “I could not survive without my samples,” those who have done away with them are surprised to find that they don’t even miss them (not to mention the all that extra space made available, free of both samples and reps!). Send us your testimonials!
“Why We Don’t Have Free Samples.” A downloadable document to let your patients know that you care.