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.