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Who pays for “free” medication samples?


A student recently started one of my patients on the oral contraceptive pill YAZ. When I asked why that particular birth control pill was chosen instead of all the alternatives, I was shocked by the response: “We have samples.”

The student was referring to the medication samples that are delivered to clinics by representatives of pharmaceutical companies for distribution to patients by doctors. The “drug reps” (formerly “detail men”) who deliver samples usually meet with a doctor in the clinic to talk about the medication or another product of the company while the doctor signs for the delivery. Some purported benefits of samples include the ability of patients to try out medications for free and increased access to expensive medications for patients without coverage or the means to pay for them.

I asked if the patient was concerned about the recent media coverage of the increased blood clot risk in women taking pills like YAZ that contain the progesterone analogue drospirenone.  But the student was not aware of these reports, or of the evidence that drospirenone use is associated with an increased risk of blood clots compared with some other oral contraceptive pills. The trainee then countered by pointing out that YAZ was the only oral contraceptive pill that we had in the clinic and wondered aloud if the patient could afford the other pills.

While the patient in this case actually had coverage for medications and so was happy to leave without a sample, what happens when samples of medications that patients cannot afford inevitably run out? The medication cabinet at our clinic contained samples of medications that were more expensive than available alternatives. For example, we had dozens of boxes of the antidepressant Cipralex (escitalopram) which is a medication that is very similar (and actually contains the same molecule) as the inexpensive medication citalopram. Both oral contraceptive pills and antidepressants are intended to be taken for months or years – and antidepressants can actually make people worse when taken for brief periods of time and then stopped abruptly – so it is unclear to me how giving a sample that will last weeks will benefit patients.

The YAZ incident also made me wonder what effect the samples in our medication cabinet were having on our students. Our implicit endorsements of these medications by stocking them in clinic might increase future prescribing of these medications by students when they enter independent practice, regardless of whether they are the best choice for patients.

The endorsement is likely to be even more obvious to patients. If a patient is handed an expensive brand name product that contains a commonly used medication such as the anti-inflammatory ibuprofen, she may believe that product is superior to the multitude of alternatives that contain exactly the same medication. The next time that patient goes to a pharmacy she may recognize the product and end up paying several times more than necessary.While it is difficult to determine how often this plays out, pharmaceutical companies seem to think samples are effective based on the amount of money invested in them.

Part of the reason brand name medications cost more than generic products or store brands is marketing costs. These costs include the leakage of drug samples to clinicians who take samples for their personal use or to give to family members or friends. Patients pay for the “free” samples  if they  result in them being started on more expensive medications that may be harmful.

For these reasons my practice recently decided to stop distributing samples to patients just as some of our colleagues have done in the past few years. Unlike most initiatives to improve care and student education, this one is free and easy. We also no longer have to meet with drug reps or tidy our medication cabinet which regularly became overstuffed with samples and useless marketing aids such as prescription pads preprinted with medication names. When I recently disposed of the samples and marketing aids I realized I was throwing our patients’ money in the garbage. But I figured that was better than dumping YAZ samples on our patients.

Nav Persaud is a lecturer in the Department of Family and Community Medicine at the University of Toronto.

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37 comments

  1. Ritika Goel

    Great piece, Nav. Drug samples are possibly the pharmaceutical industry’s smartest tool. Many astute physicians who refuse to listen to drug reps still accept samples – in fact, I just came across a website to directly order drug samples! It seems harmless enough, and in fact seems like a service to your low income patients while seemingly avoiding the influence of the pharma rep’s spiel, but the brand recognition and familiarity created for both the patient and provider is really all the company wants. Samples are actually the best way to achieve this – much more so than educational sessions. Our family practice is also pharma-free with no drug reps, no drug samples, and no pharmaceutical merchandise. The tide will slowly turn.

    • conchita fonseca

      HI, I work at a CHC in Ottawa with a significant refugee/new arrival population.%featured% I would personally love to have a pharma-free practice but I do find drug samples helpful in “tying” clients over until their drug benefits kick in or they get a job. For example, I have treated patients with free bp medications for a few months with the free samples and then changed them over to a cheaper drug when they have access to drug benefits. I feel that our tylenol/advil samples are particularly helpful for kids with fevers/etc. %featured% On the upside we do buy some generic medications and vitamins as well ie. vit D, folic acid, etc, so we usually have nice stock of bought medications, free samples and drug compassionate programs. I admit that it’s not always easy to remember and convince clients to switch to cheaper drugs. I’m interested to know how other practices with many uninsured/no benefit clients manage to handle this?

      • Nav Persaud

        Great comment Conchita. I distributed samples to patients until recently and I think that some patients benefited from them. But I think the overall effect of samples on patients was negative. Samples that last weeks for medications that need to be taken for years or decades end up costing patients money. Several studies suggest that samples are associated with poor prescribing habits.

        • Jeremy Petch

          Ritika and Nav – I’d appreciate knowing what you are doing for your patients who cannot afford medications. I assume that as good clinicians you are not just letting your patients go without medications they need (or maybe you are, in which case I think you’ve made a grave miscalculation in balancing benefits and harms).

          Are you relying on some kind of ‘comfort fund’ like we have at St. Michael’s Hospital to cover these patients? If so, it’s worth being clear about this. Most family docs who don’t work in academic or specialized programs don’t have access to special funds like these, and so for them, refusing all samples means having to watch some of their patients go without.

          Should docs who have alternative ways of getting medications to patients in need avoid samples? Maybe. Should those who don’t? I don’t think so.

          • Nav Persaud

            Samples do not provide the much needed access to medications for patients who cannot afford them. Sadly some patients who require longterm access to medications for conditions like hypertension, depression, and schizophrenia sometimes go without them and this will continue to happen regardless of whether samples that last weeks are distributed by their care providers. A person with schizophrenia does not need to sample antipsychotic medications. The solution to this serious access problem that should never happen anywhere – and certainly not in Canada – is not more samples.

  2. Rob S

    I am a pharmaceutical representative and I feel sorry for your patients. What a shame it is not to work hand in hand with the pharmaceutical industry and pharmaceutical representatives. You paint such a negative view of an industry that has helped millions, if not billions of patients live healthier and longer lives.

    The physicians I respect the most are the ones that are comfortable in being challenged by representatives in thinking about altering their prescribing practices for the best of their patients. There is nothing wrong about being challenged so that practitioners can make a wiser choice in treating their patients.

    And – what’s so bad about marketing? Marketing is all around us and it’s part of our lives. If not for sales and marketing, no investors would invest in the pharmaceutical industry. And – where would innovation for future medications come from?

    You have a very narrow viewpoint, and no idea of what actually occurs at our end in the pharmaceutical industry. We hold the utmost respect for all physicians and patients.

    With your stance, only patients will suffer in the future.

    • Yan Xu

      Hello Rob,

      Very interesting perspective. I’d like to provide a few of my thoughts as a medical student with interested in pharma policy (there is I believe an extended debate related to pharmaceutical industry practices from Dr. Rikita Goel’s post as well).

      I personally do not believe that there is anything wrong with healthcare providers being challenged about medical knowledge, whether coming from our colleagues, allied health professionals, patients or pharma reps. In fact, I believe pharma-MD relationships in developing new therapeutic products is a great idea. However, it is rare that reps would visit the physician’s office after a new drug has been approved with only journal articles in hand. There is nothing that challenges medical knowledge nor benefiting patient care from rep visits that involve fancy dinners, thoughtfully selected gifts and free samples.

      Many say that free samples are the only way to provide care for those without the ability to pay for medications. However, I contend that free samples take away the political will to make the difficult policy decisions necessary to ensure that those living at the margins of our society have the same access to medications as the most affluent. Rather than relying on the status quo of free samples, perhaps it is time to push for universal pharmacare that would ensure coverage for every Canadian.

      There are many health and economic rationales for this, which are nicely summarized by the Pharmacare 2020 website: http://pharmacare2020.ca/

      Looking forward to your thoughts.

      • Gerald I. Goldlist, MD

        %featured%It is fine to talk of pressuring government to bring in Pharmacare in the future but in practice we have to deal with our patients sitting in front of us right now. Imposing your personal ideology and refusing to keep samples in your office does some poor patients a disservice.%featured%

        • Jeremy Petch

          I think this marks the first time Gerald I. Goldlist and I have ever agreed on anything.

          Personally, I think we absolutely must work towards universal pharmacare, and it’s certainly true that universal pharmacare would eliminate the need to use samples to cover patients who cannot currently afford medications. However, pushing for universal coverage does not absolve clinicians of their ethical duty of care for the patients in front of them.

          • Yan Xu

            Hi Jeremy and Dr. Goldlist,

            Thank you for your thoughts – one of the reasons I enjoy the discussions on Healthy Debate is the breadth of perspectives and how they inform/challenge the way I think.

            Jeremy – I agree with you that the lack of pharmacare should not lead to physicians not trying their very best under the policy circumstances that we currently find ourselves in today. What this means for me, though, is that we need to carefully balance the risks and benefit of providing a free sample for a patient through free samples. As Dr. Persaud mentioned, providing temporary therapy may be of marginal benefit in many circumstances and can have important risks when a medication is abruptly stopped.

            In many circumstances, this balancing of risks and benefits would suggest a patient should not receive treatment with free samples, while we would suggest the same treatment in the same patient patient if s/he had coverage.

            It is uncertain how often one considers these additional factors when they hand out free samples, and how often free samples can mask other avenues for medication coverage that a patient is eligible for (i.e., Ontario Works, Ontario Disability Support Program) but involves more paperwork.

        • Dr. Suleymane

          I agree with you wholeheartedly.

          The pharmaceutical companies have us in handcuffs. Patients need certain medications to be well, and sometimes those medications are unaffordable. The pharm companies give them to us so that we can give them to the patients, as that would be the only way the patients could access them.

          The problem is not with pharmaceutical free samples. The real problem is with governments not appropriately funding necessary medications (only those that are used by most of their boomer voting base)

    • Nav Persaud

      The medications that pharmaceutical companies produce can save lives. But there is no evidence that marketing improves care and it is very hard to imagine how it would. Patients pay for the marketing of medications and what do they get in return?

      • Jeremy Petch

        Are you implying evidence of absence or absence of evidence? Seems like the latter, which isn’t a particularly persuasive argument.

        And if you extend “marketing” to include samples, which I assume you are, there’s plenty of anecdotal evidence from clinicians that samples can be used to improve patient care, such as using samples to bridge patients who are waiting for coverage, or who only need medications for a limited period of time (such as docs who get samples of prenatal vitamins to give to their low-income pregnant patients). Seems to me that’s improving patient care.

        • Nav Persaud

          Yes some patients benefit from samples. When I distributed samples to patients I justified the practice by thinking primarily or maybe even exclusively about these patients. It is tempting to contemplate anecdotes about patients who benefited from samples, pat yourself on the back and then stop thinking.

          If you do that, you can ignore the lack of evidence for any benefit. Usually when we consider providing an intervention to patients we require some evidence that it makes people better and not worse. Is there evidence that giving someone a one month supply of an antihypertensive medication is helpful? I don’t think so. But I used to feel very good about doing it.

          • Gerald I. Goldlist

            “Yes some patients benefit from samples.” So do you agree that we should not stop giving out all samples?

            “I justified the practice by thinking primarily or maybe even exclusively about these patients.” Ethically your first duty should be to the patient in front of you. That is my opinion anyway. If your primary duty is to some ideology then it is only fair that you tell the patient that your duty is primarily to your ideological goal and that if the patient prefers to have a doctor whose primary duty is to the individual patient then you should direct them there. Sort of like when a doctor who does not believe in abortions is obligated to refer them elsewhere.

            “It is tempting to contemplate anecdotes about patients who benefited from samples, pat yourself on the back and then stop thinking.” The fact that you might stop thinking is more a statement about how you think than about the samples themselves. Sorry if I have insulted you but you have implied that those of us who do find samples useful and use them appropriately are doing something morally inferior.

            If you do that, you can ignore the lack of evidence for any benefit. Usually when we consider providing an intervention to patients we require some evidence that it makes people better and not worse. Is there evidence that giving someone a one month supply of an antihypertensive medication is helpful? I don’t think so. But I used to feel very good about doing it.

            • Gerald I. Goldlist

              Sorry but I forget to put the last bit in quotations and reply.

              “Is there evidence that giving someone a one month supply of an antihypertensive medication is helpful?” It is not the 1 month sample that is the reason you should prescribe the medication but the evidence that the doctor has examined and thought about that determines if a medication should be used.

              “But I used to feel very good about doing it.” I don’t see how feeling good about something should mean that you shouldn’t do it. I feel good about putting a cycloplegic into the eye of a patient with iritis and then asking the patient 10 minutes later if they are feeling less discomfort. It feels very good to relieve pain. It also feels good when a patient who can’t afford a medication says thank you.

              It is not

  3. Erik Venos

    Interesting discussion. The best review that I found aggregating the various methods of studies (trials, surveys, etc.) performed on the topic concluded:

    “These studies overall support a consistent effect of drug samples in driving prescribing practices. Drug samples provided to physicians by detailers lead physicians to prescribe drugs that differed from what otherwise would be their preferred drug choice, including more expensive, second-line drugs.”

    The paper is downloadable from http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2121535.

    • Gerald I. Goldlist, MD

      It should be the knowledge and integrity of the individual doctor that drives his treatment.

    • Gerald I. Goldlist

      If a doctor prescibes inferior drugs because of samples that reflects on the quality of the doctor’s thinking, care and ethics more than on the samples themselves.

      • Erik Venos

        Hello Gerald,

        The part I quoted was from the paper itself; it was not in the abstract.

  4. David Walker

    %featured%It is a sad commentary that poor and marginalized patients in Canada’s vaunted and well loved “comprehensive”, “publically funded’ and “accessible” health care system depend on physicians handing them drug samples the doc probably would not have chosen and which may not be best indicated.%featured% I have great regard for the remarkable strides made by pharmaceutical companies in developing effective drugs for our patients but suggesting that we, as physicians, are not influenced profoundly by various marketing tools is naive. I recall that a few years ago The Economist published a list of the top ten drugs sold by volume in the developed world. Next to it were the top ten drugs in the same marketplace listed by promotional dollars spent. The lists were identical. Must run….there is a doctor’s dinner at the restaurant tonight; guess who is paying.

  5. Elizabeth Doyle

    Nav, I appreciate your concern over branding and indirect endorsements that come with offering drug samples to patients. However, I don’t think that your proposed solution actually addresses the problem you highlight. As an ethicist, I’m also deeply troubled by the fact that you’ve offered psychological generalizations about brand power, YAZ, and antidepressants cycling as the reasons why you’ve chosen to no longer be receptive to receiving and offering ALL drug samples.

    It’s perfectly consistent to offer samples to your patients, while, at the same time, communicating your misgivings and concerns to both students and patients alike. Instead of looking at receiving pharmacy samples as “I don’t want to be part of this system that furthers a corporate agenda, therefore I’ll throw out perfectly good samples full stop,” I think that the more considered, responsible approach is to recognize that – whether receiver or reactionary – you’re part of the system and are bound to have patients who can’t afford the medication they need. You COULD provide them with it, while also educating and counseling them about branding, cycling, and the class-action lawsuit against YAZ. I see this as a way to address your own misgivings, mentor your students, while not letting your patients go without.

    • Nav Persaud

      Thanks Elizabeth for the thoughful comment. Perhaps my piece was unclear: The reason I have stopped distributing samples is because I think the practice of distributing samples to patients is, overall, harmful to patients. I still happily prescribe the medications that help pharmaceutical companies turn a profit because doing so helps patients. If I thought distributing samples was good for my patients I would keep doing do so regardless of the effect on pharmaceutical companies.

      My only reason for delving into the fact that samples are a marketing tool is to make the point that patients are needlessly paying more for medications because clinicians continue to distribute samples. But ultimately even this argument is not about pharmaceutical companies, but rather about saving the money of patients. This includes the “working poor” who do not have access to either public or private health insurance for medications and who either barely manage to pay for medications or go without.

      • Gerald I. Goldlist

        In my practice the “working poor” are helped the most by samples, specifically, those that are not covered by government plans nor do they have private plans.

  6. Linda Wilhelm

    I am merely a patient who has lived with Rheumatoid Arthritis for over thirty years but lately I have been wondering why the samples are even being distributed to physicians? For every other medication we take our doctor must write out a prescription which we then take to our pharmacy. Besides the fact that they have all medications secured behind their counter this also serves as an extra safety step for patients. Since the pharmacy has all the patients medication records in their system they can quickly pick up contraindications and this latest “sample” prescription would now be an ‘official” part of the file.

    • Nav Persaud

      Great Point. Sample distribution circumvents the usual checks done by pharmacists which are in place to protect patients. If anyone was going to distribute samples – and I don’t think anyone should – pharmacists would be best placed to do so.

  7. Barb Shea

    Another issue with sampling is the sampled drug may not be covered by the patient’s drug plan while a suitable alternative is covered. If the patient finds the sample to be effective and drug therapy is to be extended beyond the sample one scenario sees the pharmacist calling to suggest a change. The patient may feel they are being given something less effective or “cheaper”. I have seen this in my days of a practising pharmacist and it makes the patient question if they are receiving the best option (e.g. in the case of antidepressants). The patient and health team will then take time to sort things out. When I was Executive Director of the Saskatchewan Prescription Drug Plan, we sponsored a pilot project where samples of a number of generic drugs were made available in a medical practice. These were drugs that had been approved for coverage and if the prescription was found to be effective, the patient was assured the drug would be a benefit. This sort of system could be set up through pharmacies. If both brand and generic samples were available the pharmacist could provide advice supporting the best option. There are a whole set of economic factors in changing the system. No one said it would be easy but with some ingenuity it’s possible to do things differently and improve a longstanding way of doing things.

    • Nav Persaud

      Great point. I hope the pilot program in Saskatchewan grew into something larger.

    • Gerald I. Goldlist

      When a patient is given a sample by a physician it is the physician’s responsibility to check if the drug is appropriate.

      The fact that generic drugs were made available by Saskatchewan Prescription Drug Plan does not make them available in other provinces. To speak of a possible future utopia does not help the patients that a physician is dealing with right now in a non-utopian situation. Samples can be very useful today. They may not be necessary in Utopia.

  8. Gerald I. Goldlist

    The fact that some patients go without medications that they cannot afford or won’t use for other reasons does not at all negate the usefulness of samples. Some of the patients who cannot afford medication can be helped to tide them over. In fact, some poor patients may not have to spend any money at all when they are given a week course of antibiotic samples by their physician.

    It is also helpful for a patient to get a couple of doses of antibiotic into them even before they get to a pharmacy.

  9. Gerald I. Goldlist

    In his conclusion Dr. Persaud states: “For these reasons my practice recently decided to stop distributing samples…” and links to the following article.

    patientshttp://www.plosmedicine.org/article/info:doi%2F10.1371%2Fjournal.pmed.1000074
    “No More Free Drug Samples?”

    I have read the article carefully and would like to share my thoughts about it as it seems pertinent to the discussion here on Healthy Debate.

    In this article the authors “argue that ‘sampling’ is not effective in improving drug access for the indigent, does not promote rational drug use, and raises the cost of care.”

    They imply that since some of the samples go to higher income patients, physicians for personal use or to the drug representatives themselves that there is something wrong with giving samples to PATIENTS. I don’t see how one follows from the other.

    They say that “IF distribution is inadequately documented in patients’ records, some people who receive samples in doctors offices may not be notified or told to discontinue the medication in the event of a product recall or the emergence of new drug complications.” This seems implausible for prescription drugs as the prescriptions have to be renewed at the pharmacy and by the physician. Both of these have an opportunity to intervene if there is a future problem with the drugs.

    They go on to say that “Physicians who offer samples of patients and fail to supply appropriate cautions and warnings about the use of these drugs may be subject to liability, along with the company that promoted the drug.” Of course the doctor is liable for all treatments he prescribes whether they are sample related or otherwise. This is not an argument against sampling but an argument for doctors taking their responsibilities seriously. Samples are part of marketing but that does not obviate the doctor’s responsibility when using them.

    There are alternatives to sampling as many European countries provide universal health coverage, including drugs. Unfortunately at this point in time we in Canada do not have universal health coverage. In this situation samples are helpful.

    The final statement in the article is:

    “The tradition of physicians dispensing samples has many serious disadvantages and is an anachronistic as bloodletting and high colonic irrigations.” That is a ridiculous metaphor.

    • Nav Persaud

      I think we agree that some patients can benefit from samples. I also agree that the fact that samples are disproportionately given to patients with higher incomes is not in itself a reason to stop giving them to patients with lower incomes.

      Clinicians might overestimate how beneficial samples are for patients. There is a long tradition of distributing samples and clinicians tend to feel good about having done this. It is tempting to assume that a patient benefits from getting a month’s worth of samples of a medication (e.g. antihypertensive) even if there is no evidence or good reason to believe that taking this medication for one month makes a difference.

      Clinicians have to decide between either stocking samples in their office or not. This is where we seem to differ. On balance, I think the drawbacks of samples – including the association with poor prescribing, the added marketing costs paid by patients, the effect on trainees, the lack of usual pharmacist involvement, the unnecessary presence of pharmaceutical company representatives in clinics, their inappropriate personal use by clinicians, etc – outweigh any benefits of sample distribution.

  10. Denis Morrice

    Great article. Question: if you don’t meet with Drug reps anymore what avenues do you use to stay on top of new medication developments?

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