Professionalism/Marketing of Pharmaceuticals
The pharmaceutical industry is a marketing giant. They spend twice as much money marketing their products than researching and developing them. The pharmaceutical industry has more motivation to sell their products than to innovate new treatments that improve quality of life.
Pharmaceuticals are marketed in a variety of ways intended to affect doctors, patients, and even children. Pharmaceutical companies create incentives for physicians to promote their brand-name drug and to give away free samples. When patients describe a vague set of recurring symptoms that are associated with a condition, they become convinced that they have a condition requiring the use of a particular drug. Tragically, children are often convinced in similar ways -- the TeenScreen program, for example, was funded by pharmaceutical companies to diagnose high school students with certain psychiatric conditions requiring the use of brand name drugs.
In this chapter, we will present the techniques used by pharmaceutical companies to promote and sell their products. We will also discuss the various consequences of these techniques and how they are ethically unsound.
The 1997 FDA guidelines that allowed drug companies to greatly expand the scope of their direct-to-consumer advertising required the companies to “present a fair balance between information about effectiveness and information about risk.” 
The FDA’s Division of Drug Marketing, Advertising, and Communications (DDMAC) oversee direct-to-consumer advertising, monitoring ads to make sure information is “truthful, balanced, and accurately communicated.” 
The FDA has been criticized by the Government Accountability Office (GAO) for its inability to ensure that all ads are reviewed adequately.
There are three types of direct-to-consumer advertising:
- Help seeking advertisements discuss a particular disease or health condition and advertises to the consumer to “ask your doctor” about the condition if you experience these symptoms. No particular product is mentioned within the advertisement. 
- Reminder advertisements calls attention a particular product, but it does not mention a particular health condition that the product treats. These advertisements target physicians that would recognize the product and be reminded. 
- Product claim advertisements include the product’s name and a therapeutic claim about the specific product. 
Product claim advertisements are the most common and most memorable ones in public media, coming in the form of commercials and magazine advertisements. They are also the only type of ads that the FDA directly regulates.
Common techniques used in pharmaceutical commercials include: peaceful happy people, pleasant music, calming animation and colors, “free sample”, etc. These techniques shroud the information or disclaimers presented about the product. These gimmicks are used to entice the consumer rather than educate them about the drug.
As hear in drug commercials and seen on magazine ads, it states “ask your doctor about . . .” This phrase of “ask your doctor about” a certain prescription drug turns normal people into their own doctors, self-prescribing their own medication, going to their physicians requesting a specific drug. As a result, physicians may feel pressured to sign patient prescription requests. Therefore, these physicians are no longer paid for their judgment, but rather their signature.
These commercials and advertisements may also turn “normal people into patients. The ordinary experiences of life become a diagnosis, which makes healthy people feel like they're sick.” quote from Dr. Lisa M. Schwartz of the Dartmouth Medical School.  These ads may magnify problems, implying that if you experience these symptoms, you might need medication. Therefore these direct-to-consumer prescription drug ads may also harm public health by advocating drug use as a primary response to medical conditions that can often be remedied in other ways such as diet, exercise, stress reduction, and other preventive measures.
A study from the University of Georgia, led by Dr. Wendy Macias, analyzed a week’s worth of direct-to-consumer commercials on broadcast and cable television. They found that the average 60 second commercial contained less than 8 seconds (13% of total ad time) of side effects disclaimer, while the average 30 second commercial contained less than 4.4 seconds (15% of total ad time) of disclaimers, and most of the 15 second commercial devoted no time at all to disclaimers. Almost all commercials disclosed side effect disclaimers in a voice over with 2.2% of commercials providing text form along with the voice over.  The rest of the commercial is filled with gimmicks that are used to entice consumers rather than educate them about the drug of the health condition.
Perception of Risk
The information and disclaimers provided during commercials is “often presented in a way that most people aren’t likely to comprehend or even pay attention to.” (quote from Dr. Wendy Macias, associate professor in the University of Georgia, Grady College of Journalism and Mass Communication).  Though the FDA is supposed to regulate and review these ads, some physicians ethically criticize these direct-to-consumer advertisements because the information provided obscures information about a drug’s risk, therefore reducing the perceived health risks associated with the drug. 
Another case where perception of risk is altered is in the advertising of withdrawal syndrome. Discontinuation syndrome is an alternative term for antidepressant withdrawal. It was renamed in 1996, from withdrawal to discontinuation syndrome after a symposium hosted the drug manufacturer Eli Lily. Common symptoms include headache, irritability, nausea, blurred vision, sexual dysfunction, brain zaps, and bone pain. These symptoms are common to all of SSRI antidepressants. This renaming of side effects to an unfamiliar name, such as renaming withdrawal to discontinuation syndrome, obscures the information about the drug's risk, therefore reducing the perceived risk associated with the drug.
Fava et al. concluded that 78% of patients who took the SSRI antidepressant Effexor would suffer discontinuation syndrome if they try to stop taking it.  When a patient wants to come off Effexor, his or her doctor typically recommends first switching to another anti-depressant with a lower probability of experiencing discontinuation syndrome. It may take months to complete draw down off an SSRI antidepressant. Some patients resume taking their antidepressants due to the severity of the discontinuation symptoms.
Health Care Costs
It is reported that every dollar spent on these pharmaceutical advertisements yields an additional 4.2 dollars in sales. The money spent on advertising prescription drugs is passed on to consumers by raising the price of these drugs. 
Reports of pharmaceutical company spending shows that twice as much money is spent on advertisement than research and development. The top 25 direct-to-consumer advertised prescription brands accounted for 62% of total direct-to-consumer ad spending in 2008.  Total pharmaceutical expenses rose from 11.4 billion in 1995 to 29.9 billion in 2006. 
Pharmaceutical companies are for-profit business entities whose purpose is to make money. These companies advertise prescription drugs to increase their profits, not necessarily to improve public health. The marketing tactics used in direct-to-consumer advertisements may manipulate, create false impressions, and otherwise mislead consumers instead of educating them about the drug. 
Brand Name vs. Generic Drugs
Physicians usually prefer cheaper generic drugs to more expensive name-brand ones, thereby limiting pharmaceutical companies’ ability to influence physicians through traditional marketing tools. In an attempt to regain control of the retail prescription drug market, companies shifted their focus in the late 1990s from direct-to-physician to direct-to-consumer advertising.  An ethical argument by critics is that these ads drive up health care costs by steering consumers to costly drugs they may not need when less expensive, generic drugs can often be just as effective. 
Benefits of Direct-to-Consumer Advertising
The results of FDA surveys showed that the proliferation of direct-to-consumer advertising has led many patients to become aware of newly available medical treatments for certain health conditions, motivating patients to ask better questions of the healthcare provider. Surveys established that a positive public health response to the advertising was that patients sought additional information about those health conditions for themselves or loved ones. 
In the pharmaceutical industry, the biggest profits are secured from monopolies on brand-name drugs protected by patents. Because of the monopoly on the drug, typical brand-name drugs can be marked up to $4.00 per dosage unit , therefore they are a large profit generator. When the patent expires, the monopoly no long exists and other pharmaceutical manufacturing companies can produce essentially the same drug and sell it at significantly lower price, therefore the brand-name drug loses 85% of the market share .
Therefore it is economically advantageous to create patents and monopolies on pharmaceuticals for the least cost. Patent extenders are drugs which are produced by slightly altering another drug whose patent recently expired. This is typically done by slightly changing the chemical compound of the previous patent expired drug to create a "new" drug for which a new patent can be obtained. These drugs are often marketed as breakthrough drugs with many advantages over the patent expired drug. However, these patent extenders are often similar or even identical to the drugs they replace. This behavior is highly unethical because, while the patient sees no additional benefit in a drug's effectiveness, they are paying a premium price for the new patented drug. As a result, pharmaceutical companies earn large profits without innovating a 'new' more beneficial drug.
There are a number of examples of patent extenders, two of which are presented below.
Pristiq is a classic example of the patent extender. In 2008, Effexor's patent expired. Faced with a loss of profit, Wyeth (now part of Pfizer) created Pristiq (desvenlafaxine), which is the active metabolite of Effexor (venalafaxine). Effxor and Pristiq are chemically very similar and when Effexor enters the body, the liver turns (metabolizes) it into Pristiq and then distributed via the bloodstream. That is, once these two drugs are metabolized within the body, they are chemically identical. Nonetheless, Pristiq is can be marked up to as high as $4.00 per unit, whereas the generic version can be priced as low as $0.25 per unit. Moreover, through the use of free samples and direct-to-consumer advertisements, patients are given Pristiq even though Effexor or other generic alternatives may be just as effective.
Another strategy used to create patent extenders is the creation of extended release drugs. Ritalin is a psychostimulant containing methylphenidate, while Concerta is simply a capsule form of the very same substance. Nevertheless, Concerta has been patented until 2018  and marketed to parents with children who have ADHD as a superior drug to Ritalin.
Pharmaceutical companies unethically market their drugs with the sole goal of maximizing profits. As business entities, success is measured by financial earnings and profits through pharmaceutical sales, rather than medical breakthroughs that improve overall quality of life. Thus, it is in each pharmaceutical company's interest for people to think they are ill. Pharmaceutical marketing, therefore, attempts to convince consumers that they have an illness and that a particular drug is the solution.
- University of Georgia (2008, January 4). Most TV prescription drug ads minimize risk information, study finds. Science Daily. Retrieved from http://www.sciencedaily.com/releases/2008/01/080103161527.htm.
- Huh, J., DeLorne, D. E., Reid, L. N., & An, S. (2010, March). Direct-to-consumer prescription drug advertising. Clinical and Health Affairs.
- Vogt, D. U. (2005, March 25). Direct-to-consumer advertising of prescription drugs. Congressional Research Service Report for Congress. CRS-1 – CRS-32.
- Rowe, J. (2006, Aug 21). Drug ads sell a problem, not a solution. The Christian Science Monitor. Retrieved from http://www.csmonitor.com/2006/0821/p09s01-coop.html.
- Rosenthal, M. B., Berndt, E. R., Donohue, J. M., Epstein, A. M., & Frank, R. G. (2003, June). Demand effects of recent changes in prescription drug promotion. The Henry J. Kaiser Family Foundation. 1-33.
- Fava M, Mulroy R, Alpert J, Nierenberg A, Rosenbaum J (1997). "Emergence of adverse events following discontinuation of treatment with extended-release venlafaxine". Am J Psychiatry 154 (12): 1760–2
- Gebhart, F. (2009, April 27). DTC ad spending decreased last year. Commercial Alert. Retrieved from http://www.commercialalert.org/news/archive/2009/04/dtc-ad-spending-decreased-last-year.
- Beasley, D. (2011, Mar 23). Branded drug prices soar as generic pressures rise. Reuters. Retrieved from http://www.reuters.com/article/2011/03/23/us-branded-drug-prices-idUSTRE72M57X20110323.
- Pearce III J. A. (2008, Apr 1). Retaining patent profits. Drug and Develop Magazine. Retrieved from http://www.dddmag.com/Article-Retaining-Patent-Profits.aspx.
- Generic Contra. (2011) eMedTV. Retrieved from http://adhd.emedtv.com/concerta/generic-concerta.html.