Medicine and the pharmaceutical industry.

One privilege of working in the health service today is the enormous range of effective therapies available to us. Advances in surgical techniques, tools, and materials have been more than matched by the vast number of pharmaceutical products addressing an ever wider range of conditions. Even for conditions where treatments have been available for many years, newer agents may be more potent, have less adverse or unwanted effects, and be easier to take than their predecessors. This is a huge contribution by the pharmaceutical industry. The other side of the coin, and of course there always is one, is the concern, voiced by several commentators, that the priorities of drug companies may not coincide with the health needs of the population.1,2 Despite ever-increasing resources, the number of innovative products introduced each year is falling.1 Equally importantly, most of the money spent annually on medical research is devoted to the eventual development of new pharmaceutical products or testing the effects of those currently the subject of sales drives. All other forms of research, including studies using drugs no longer under patent, risk being starved of funds, not to mention top calibre researchers. In the field of disability we are well aware of ‘Cinderella’ specialities that are under-researched because there is no easily available funding. The other major concern is the marketing process. We understand that to bring a drug successfully to market costs many millions of dollars, partly due to the regulatory hurdles set up to protect patients. This expenditure needs to be recouped, which means that the resulting products have to be sold. Apparently, the expenditure on marketing may be about twice that spent on research and development.1 As most drugs have to be prescribed, doctors are an important focus of this huge budget. Lurid stories appear regularly in the lay press about generous hospitality offered to doctors by pharmaceutical companies on dubious grounds. At first it all seems a little over-hyped, as most of us consider ourselves fairly independent minded, reasonably incorruptible, and would not participate in such events – would we? However, there are more subtle ways of potential compromise. In the UK, I attend clinical and educational meetings which only occur through industry support. This year the regulations governing this form of sponsorship have been tightened.3 Last year I accepted an invitation from a distinguished colleague to lecture on how to tailor treatment to the patient at a sponsored academic meeting outside the UK. The next series of contacts was from a separate company who started to discuss organizational details, but later tried to arrange a meeting with a representative of the sponsoring company to discuss the event, and then offered slides to help with the lecture. By this stage the lecture had been restricted to the adverse effects of drug therapy. Interestingly, the slides highlighted unwanted effects of rival products but did not mention any adverse effects from the drug made by the sponsoring company. Finally, a contract arrived which specified that all material provided for the meeting was confidential, became the property of the sponsoring company, and could be adapted and promulgated as they wished. It also specified ‘working with the company or its representatives providing input on the development and preparation of meeting materials’. After I explained that it was unusual to sign a contract to lecture at an academic meeting, this was omitted. The meeting was in a plush hotel and the delegates were an invited audience. The rest of the faculty were highly respected colleagues, well known in the field. The generous honorarium has made my university research fund much healthier. But was it an academic meeting or a promotional event? Two years ago the National Institute of Clinical Excellence in the UK drew up guidelines for epilepsy management. During this process it asked for the names of experts who could advise it and who were independent of the pharmaceutical industry. It was surprising how many of those considered had some sort of link with one or more companies, for example, by membership of an advisory panel. And, if attendance at subsidized conferences and meetings was included no one was completely independent. The data on which these guidelines are based is also variable. There is concern that some trials demonstrating efficacy may be massaged by selective publishing or by statistical manipulation.2,4,5 Consensus papers have been offered to us on the use of a particular therapy that arise from a meeting of distinguished colleagues sponsored by one of the companies concerned. In a recent case we found that those attending the meeting had received a generous honorarium which had not been declared, despite the major conflict of interest. Journal editors can also be influenced through pressure on advertising budgets. In that respect DMCN’s independence is a strength. Most companies and doctors act honourably. However, it is worrying that respected members of the medical profession, including ‘opinion formers’, can appear to be endorsing a product and receiving payment to do so. Pharmaceutical companies have their job to do and we have ours, but it is in both our interests that when supping together, each party uses a suitably long spoon.