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Right Now | Vending Veritas

"Unsales" Pitches

November-December 2006

These days, prescription drug ads bombard the consumer at every turn. Even so, the $4 billion spent annually on direct-to-consumer advertisingenabled by federal legislation in 1997pales by comparison to what drug companies spend on marketing to doctors. According to the Amundsen Group, a pharmaceutical-industry consulting firm, drug manufacturers spend more than $12 billion a year on salespeoples salaries and benefits. That also includes managers salariesbut not the other costs associated with the sales pitches, such as drug samples and the free meals provided to doctors.

Its hard to compete with numbers like that, but physician Jerry Avorn is trying. A professor at Harvard Medical School, Avorn pioneered what he calls the unsales approach: offering doctors solid science to augment, and in some cases refute, what the drug salespeople present. Avorns Alosa Foundationnamed after a genus of fish that swim upstreamprepares literature and trains representatives to make unsales pitches. The drug industry calls their reps office visits detailing, so Avorn calls his reps visits academic detailing. He aims to bridge the gap between doctors and research scientists who seem, he says, to have a good handle on the evidence, but arent very good communicators.

Avorn heads the divisions of pharmaco-epidemiology and pharmaco-economics at Brigham and Womens Hospital and has written Powerful Medicines, a book about the high-stakes world of drug promotions. His unsales approach takes a page from the drug companies playbook: We go where [the doctors] are, he says. To increase academic detailings appeal, Avorn and his colleagues had the content certified for continuing-education credits through Harvard Medical School, so doctors who listen and pass a subsequent quiz can earn credit that counts in many states toward their license renewal.

Avorn emphasizes that the campaigns arent anti-pharmaceutical. The goal is not to get doctors to stop prescribing the drugs altogetherits to get them to prescribe a drug only when appropriate.

The approach appears to work. Doctors who received unsales visits and unadvertisements by mail reduced their prescriptions of targeted drugs by 14 percent. (All the brochures appear on the Internet at the Independent Drug Information Service, Our goal, Avorn says, is to make this as available as possible.) By weighing the cost of unsales literature and office visits against the cost of unnecessary prescriptions, Avorn has calculated that state governments or anyone else who uses the approach can save $2 for every $1 spent.

Among the myriad drugs featured in aggressive sales pitches, Avorn and his team look for drug classes that are overprescribed. They started with COX-2 inhibitorsnonsteroidal anti-inflammatory drugs prescribed to reduce pain and swelling. The class includes Celebrex and Vioxx. (The latter was withdrawn from the market in 2004 after it was linked to heart attacks and strokes.) The unsales literature boldly claims that COX-2 inhibitors are no more effective than plain old ibuprofen.

The second campaign focused on proton pump inhibitors, a class of drugs that treats heartburn and acid reflux by suppressing stomach-acid production. The class includes Nexium, the number-three prescription drug of 2005, with sales of $4.4 billion in the United States and $4.7 billion worldwide. The drugs can lead to hyper-production of acid if the patient stops taking them, the unsales brochure notes. In many cases, it says, garden-variety antacids or other over-the-counter remedies work just fine, as does the common-sense advice to lose weight and to refrain from eating large meals close to bedtime.

The latest target includes anti-platelet drugs, prescribed to prevent clotting in people at risk for heart attack and stroke. The class includes Plavixthe number-two drug worldwide last year, with $4.9 billion in sales. Studies have found that for some patients, aspirin works every bit as well as Plavix, which is more than 100 times as expensive. The unsales materials will help doctors decide which patients really need the brand-name drug.

Avorn first conceived of unsales when he was a medical resident in the 1970s. I noticed that doctors prescribing practices did not seem to match the science we were learning in the classroom, he remembers. He published his first paper on the approach in the New England Journal of Medicine in 1983. He says that in the Netherlands, Australia, and Canada, where healthcare systems are well integrated, government agencies have picked up the method, and believes the approach hasnt spread faster in the United States because no one is in charge. Its really no ones job to mind the store.

Yet there is evidence the unsales pitch is catching on. Kaiser Permanente, the California-based HMO giant, has incorporated unsales into its dealings with doctors in its network. Kentucky and Pennsylvania are trying the approach, hoping to trim spending on prescription drugs for the elderly and for current and retired state employees. Pennsylvania is spending $80,000 a month on academic detailing, but that amount equals less than a twentieth of 1 percent of the states annual drug cost, which tops $3 billion.

Americas healthcare landscape continues to change in the direction of making consumers more cost-sensitive. Sales volume for generic prescription drugs surpassed that for brand-name drugs for the first time last year, the trade magazine Pharm Exec reports. Avorn predicts that will be a boon for unsales. As drug prices continue to soar and patients pay more and more due to cost shifting, I think this is going to become more popular, just as hybrid cars and wind power become more popular the more expensive oil becomes, he says. And, he adds, We have an advantage that no drug company can have, which is, we can go to the doctors and say, Were not trying to sell you anything.

~Elizabeth Gudrais

Independent Drug Information website:

Jerry Avorn e-mail address: