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NEWS and COMMENT

Washington PerspectiveAll expenses paid, DoctorThe American Medical Association earlier this month

adopted a chastity code titled Guidelines for Gifts fromIndustry to Physicians. Prepared by the AMA’s Council onEthical and Judicial Affairs, the thrust of it is that ballpointpens and note pads are permissible but paid Caribbeanholidays are not, even when a drug seminar precedes thesnorkeling. Soon after the AMA acted, the PharmaceuticalManufacturers Association, representing the seducers,issued a Code of Pharmaceutical Marketing Practices thatembodied the AMA’s guidelines.By coincidence or not, these attestations of virtue were

proclaimed just a few days before Senator Edward Kennedychaired hearings on promotional practices in the

pharmaceutical industry. When the hearings were held, onDec 11-12, the two organisations could forthrightly assertthat they have proscribed seamy activities whose existencethey had long denied or minimised as inconsequential. Butthe hurriedly applied coat of rectitude did not cover oldblemishes.A Congressional hearing is usually a dramatisation of the

preconceptions of the committee majority. The measure ofsuccess is the attention of the news media. Mr Kennedy is apractised legislative dramatist, with a good sense of timingand unconcealed scorn for predatory practices in the healthindustry. With Congress in adjournment, Capitol Hill wasrelatively quiet. The first day of the hearings was taken up bypeople with sordid tales to tell, including a contrite formerdrug industry executive, several aggrieved physicians, and adisillusioned hospital pharmacist. The press was attentive.Representatives of the AMA and the PMA, testifying on thesecond day of the hearings, proclaimed a commitment topublic wellbeing, an uninteresting topic for journalists.Coverage was poor. Invitations to testify were declined byfour companies whose promotional techniques were

described by the first-day contingent: Abbott Laboratories,Ciba-Geigy, Wyeth-Ayerst, and Hoffmann-LaRoche.Their absence was duly noted by chairman Kennedy.Drawing on a survey of 16 major firms, Mr Kennedy

reported that their spending on gifts, holiday seminars,dubious honoraria, and other promotional activities totalled$165 million in 1988-a four-fold real increase in 15 years.Among the items cited by Mr Kennedy was a Wyeth-Ayerstscheme offering physicians "frequent flyer" points for eachprescription written for the firm’s drug ’Inderal LA’.

Following an investigation by the State of Massachusetts,the company paid a fme of$195 000 and discontinued what

the Senator referred to as the "frequent prescriber" plan. Itwas also brought out that a common quid pro quo for a drugsales pitch to a physician is a good dinner and a$100"honorarium" for listening.

Referring to the burgeoning of company-sponsoredsymposia, the Senator stated: "These gatherings wereoften held in plush resorts, with all expenses paid forboth physicians and spouses or guests. The locationsincluded resorts such as Palm Springs, Monte Carlo, andAcapulco... Often, the drug companies provided additionalentertainments such as cruises, sailing, or golf. In manycases, physicians were paid ’honoraria’ ranging as high as$1000 merely for being willing to attend." Witnessescorroborated the chairman’s report.

First came David C. Jones, former executive director ofpublic and professional affairs for Ciba-Geigy and, until1986, vice-president of public affairs for AbbottLaboratories. The industry once thought that drug demandwas inelastic, he said, but that changed in the early 1970swith the introduction of ’Tagamet’. "The drug produced awhirlwind of publicity and people were asking for it before itwas available. Drug companies saw instantly the potential tocreate new kinds of demand. They learned how to useeducation and publicity to get doctors interested in a drugand send consumers to their offices asking for it." Thetechniques described by Jones ranged from ghost-writtenarticles bearing the names of cooperative physicians tohighly imaginative entertainment.The latter was employed by Abbott Laboratories, Jones

testified, when it sought to enlarge the market for its

benzodiazepine tranquilliser ’Tranxene’ "for a new

indication for which it had no clinical basis at all". To

promote the drug, he said, Abbott "purchased a night at theopera for psychiatrists attending a meeting in New York.Singers performed a recital of the great neurotic episodesfrom opera. The programme described each condition,advertised our drug and conferred credits for medicaleducation on the doctors who attended this marvelous gala."A catalogue of promotional horror stories was delivered

by Dr Sidney M. Wolfe, director of the Public CitizenHealth Research Group, a Washington-based Naderaffiliate, which this year inaugurated the "Doctor BribingHot Line-202-872-0320, ask for Dr Wolfe". He relatedwhat he described as an episode reported to him by a Floridaphysician, who Dr Wolfe said was offered$1200 by a RocheLaboratories representative as a "grant-in-aid" for a

"clinical study" using ’Rocephin’, one of the company’sdrugs. Dr Wolfe testified, "The Florida doctor told me thatthis ’study’ would have taken about four minutes per patientto do beyond the usual care for the patient. For about 80

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minutes of work", Dr Wolfe stated, "he would get$1200, acompensation rate of$900 per hour".

"Given the cost of Rocephin", Dr Wolfe continued,"Roche can well afford to give a$1200 kickback to the manydoctors who have participated in this bribing scheme". Thecost of the drug for 20 patients for 10 days, he said, would be$11400.Another item brought up by Dr Wolfe was an offer by a

consortium of pharmaceutical firms to provide physicians’offices with a$35 000 computer system, at no charge. Inreturn, the physicians would be required to review andanswer questions about electronically delivered "clinicalinformation" and "promotional messages".Dr John C. Nelson, a Utah physician, told of a partner for

whom he covered during a Caribbean vacation. The partnerand wife "had stayed at a first-class hotel, eaten lavishly, hadgone snorkeling, and had a wonderful time. It was at thistime that I learned that all of the expenses had been paid byCiba-Geigy", manufacturer of a drug, ’Estraderm’, whichDr Neslon had prescribed a bit at the urgings of a companysalesman, though his partners had declined to use it. DrNelson said his holidaying partner later explained "that hehad continued to refuse to use the drug when one day hereceived an invitation to go on the trip. He also said that hehad been required to attend some lectures given by thecompany about the new product. He also admitted that hewas now convinced that he should use the new drug as thedrug of choice in all of his patients."Dr Nelson said the episode caused him to take a closer

look at the drug, which was more expensive than alternativesand, he concluded, of uncertain clinical advantage. "Puttingthose facts together with the high cost of the entertainmentcaused me to be concerned. Indeed, it appeared to me that adrug of questionable efficacy and great expense would nowbe used, perhaps to the detriment of patients, because of anexpensive incentive to a physician."Another witness, Arthur Zoloth, director of pharmacy at

a Seattle medical centre, told of being wooed bypharmaceutical firms with appointments to their "advisoryboards"-an honour he believed more attributable to his

purchasing authority than to "my intellect." He said heknew of "at least two teaching hospitals that have beenthreatened with the withdrawal of research support [byindustry] as a result of a pharmacist not supporting a givencompany’s product for formulary inclusion." Stating that "Ifind this pervasive presence of the drug companies in themedical system to be repugnant", Dr Zoloth said: "Thus,we see on one hand, physicians, making very nice incomes,accepting all sorts of largess from pharmaceuticalcompanies, including free trips, free educational courses,various handouts and gifts, and on the other hand manypatients struggling to afford essential medications whichfrequently cost over$100 a month apiece. In a sense, onecould say without hyperbole that the patient is paying notonly his doctor fees but in addition is paying for hisphysician’s continuing professional education as wellvarious assorted gifts. I find this ethically and professionallydistasteful."The guidelines adopted by the AMA (and endorsed by

the PMA) line up with the angels. They state that "Any giftsaccepted by physicians individually should primarily entail abenefit to patients and should not be of substantial value.Accordingly, textbooks, modest meals, and other gifts areappropriate if they serve a genuine educational function. Onthe other hand, cash payments serve only the physician’s

personal interest and therefore should not be accepted fromindustry."The principles are sound. But the rules, unaccompanied

by disclosure requirements or penalties, are merelyadvisory. Reform is left to the good faith of the industry andthe individual physician, perhaps reinforced by the risk ofhumiliation for violators. However, given the aggressivenessand ingenuinity of the industry, and the many physicianswho have long been on the take without embarrassment, theeffectiveness of mere guidelines is open to doubt.

Daniel S. GreenbergDaniel S. Greenberg

Round the World

Netherlands: The Amsterdam experiment

Though Holland is united politically, Amsterdam remainsvery different from the rest of the country-not least in itsattitude to marihuana. It is not much use shopping aroundthe villages or even the great port of Rotterdam; you mustfind your way to the coffee houses in the inner city capital,which overlaps with the red light district.Marihuana is not a legal substance in Amsterdam. The

police and politicians, however, have decided it’s a waste oftime prosecuting. The coffee shop managers have theblessing of authorities to allow trading in this but not in otherillegal drugs. The best guess is that cannabis use has notincreased substantially with the introduction of these

policies. Prevalence figures in the 10-18 year group for1988-89 was 2-7%. The highest rate of cannabis use was inthe 23-24 year group at 14.5%. Heroin use, however, hasprobably declined in recent years. Amsterdam is thought tohave about 7000 addicts, most of whom probably smokerather than inject the drug-prevalence in the 23-24 yeargroup 0-4%. Your friendly bus service visits the morepopular spots 5 days a week and dispenses methadone withminimum fuss. Urine is not requested and counselling notinsisted on. Condoms are distributed, and new syringes forold. For some reason the age of the average customer is

increasing. For those who wish to get more involved thereare methadone outlets around town that offer a greater rangeof services. Most opioid addicts are known to one or otherservice and are reasonably healthy. About one death a weekfrom heroin is the official figure. Junkie unions and healthauthorities take the view that heroin users should be kept insociety rather than drop out. The Ministry of Welfare,Health, and Cultural Affairs considers that in the genesis ofdrug abuse, poverty, racial divisions, and punitive laws areas important as pharmacological events. The HIV rateamong intravenous drug users has remained steady at about30% (1000). The police are not all trendies on bicycles-they have a special unit that uses undercover techniques,computers, and informers to try and bust the bigger dealers.The prison population, of whom about one-third are in fordrug-related crimes, is increasing modestly. Single cells arethe norm. It is possible to be arrested for simple possessionof heroin, but the risks, around Amsterdam at least, are low.On the other hand, there is general agreement that junkiesshould accept responsibility for offences against propertyand person.Whereas opioid use has possibly been contained in

Holland, cocaine and amphetamines seem to be gainingground. Many visitors, especially from Germany, have