For some physicians, the drug samples closet may look like Santa’s workshop: a collection of meds for every ailment—antibiotics for upper respiratory tract infections, proton-pump inhibitors for heart burn, antihistamines and corticosteroids for allergies, and muscle relaxants galore.
But free samples are ethically tricky, and every withdrawal from the samples closet should be treated more like a bank transaction than a trip to the buffet.
For or against?
Some physicians argue for the acceptance and distribution of drug samples while others are detractors of the practice. Despite their often humanitarian purpose of providing access to patients in need, drug samples—like pens, notepads, textbooks, and free lunches—are gifts.
Stakeholders who support the gifting of drug samples argue that it does the following:
- Serves as substitutes for more expensive medications
- Lowers the costs of drugs to the patient
- Allows patients to try new medications without committing
- Allows physicians to discuss the medications with patients vs having pharmacists do the job
- Increases adherence by allowing for quick initiation of therapy
Those against the practice argue the following about drug samples:
- It can lead to drug misuse and diversion
- Expired samples can be given to patients in error due to oversight
- Samples may influence physicians to prescribe higher-cost, brand-name products
- Supply of samples can be inconsistent
- No pharmacist is on hand to advise patients
Drug companies have their own take on samples. They claim that samples provide physicians with access to new treatment alternatives. Samples also help patients who cannot afford them.
Drug samples for personal or family use
Samples not only flow to patients, but also to physicians and their family members. For this reason, countless physicians have raided their own stash of samples for personal use.
Here is what the American Medical Association has to say about the personal use of samples:
“The use of drug samples for personal or family use is permissible as long as these practices do not interfere with patient access to drug samples. It would not be acceptable for non-retired physicians to request free pharmaceuticals for personal use or use by family members.”
According to the American Association of Medical Colleges (AAMC), physicians at academic institutions cannot accept gifts from pharmaceutical companies, which includes drug samples for personal or family use.
If an academic does choose to allow drug samples in the system, the drug samples are to be rigorously accounted for. According to the AAMC:
“The distribution of medications in academic medical centers, including samples (if permitted), should be centrally managed in a manner that ensures timely patient access to optimal therapeutics throughout the health care system.
If central management is not thought to be feasible, or would interfere with patient access to optimal therapeutics, the academic medical center should carefully consider whether or not there are alternative ways to manage pharmaceutical sample distribution that do not carry the risks to professionalism with which current practices are associated.”
Policy at individual institutions that allow drug samples for patient distribution is careful to explicitly prohibit the personal and family use of drug samples in policy statements.
Here is policy from Boston University Medical School, for reference:
“Clinicians may accept free drug samples from industry for distribution to patients. Although distribution of free samples to patients is not prohibited, all distribution of free samples to patients must be administered by the BMC pharmacy. 2. Free drug samples may never be sold. 3. Free drug samples may not be used by clinicians for themselves, clinical staff, or family members.”
Another large medical institution, Mount Sinai School of Medicine, also has very clear guidelines on the issue:
“Physicians and staff may not accept pharmaceutical samples for their own personal use or for distribution to patients or family members. Distributing sample drugs would place physicians in a drug dispensing role, subject to applicable laws and regulations.”
As does the University of California, Los Angeles David Geffen School of Medicine:
“UCLA faculty, staff, and trainees should utilize pharmaceutical or device samples (i.e., glucose meters) only within policies established by the Medical Enterprise (i.e., logging in of samples), and when these samples clearly enhance patient care. Samples should not be used simply as a convenience or because of the encouragement of industry representatives. Samples should not be solicited or obtained by faculty, staff or trainees for personal use or for use by family members.”
Because of concerns over conflicts of interest and gift exchange, sentiments regarding the issue of free drug samples among professional associations appear tepid.
“To the extent that you have them [drug samples], people are mostly trying to use them for patients who can’t afford their medications,” Richard J. Baron, MD, president and chief executive officer, American Board of Internal Medicine (ABIM) and the ABIM Foundation in an exclusive interview with MDLinx. “I am aware of clinical physicians and physician administrators who use their relationship with drug reps to get personal supplies of expensive medications. And I think that is reprehensible…People who do favors expect favors in return…That’s going to change how you feel about the person who gifted.”
Free samples and physician prescribing habits
It turns out that not much is known about the effect of drug samples on prescribing behavior. This lack of data is especially true for small or rural practices.
Researchers of one study tested the effect of a policy banning prescription drug samples and industry interaction on prescribing patterns in a rural family practice clinic in central Oregon.
They found that, when samples were prohibited from the clinic, the use of promoted agents dropped by 1.43% whereas the prescription of non-promoted agents increased by 3.04%. A more substantial reduction in the number of promoted prescriptions written was observed for drugs targeting respiratory disease (11.34%), cholesterol-lowering drugs (9.98%), and antidepressants (11.34%).
Other results of banning samples in the clinic included a drop in the mean cost per prescription for lipid-lowering drugs of $0.70 per prescription per month. Mean prescription drug costs, however, went up by $5.18 immediately after policy implementation.
“Restrictions on industry detailing and samples in a family practice clinic had modest and variable effects on reducing branded and promoted drug prescribing,” wrote the researchers.
They added: “Clinics considering similar restrictions should evaluate both the positive and negative roles samples and industry representatives play on patient care.”
Here are some other interesting tidbits from the literature:
- Findings on which income levels are most likely to receive drug samples are mixed (Medicare recipients vs insured vs higher-income patients).
- Some researchers have shown that samples lead to increased out-of-pocket and total drug costs.
- Patients who receive samples are less likely to continue with treatment, according to some studies.
If you choose to take drug samples from drug companies, it’s important to keep your samples closet orderly and accountable to avoid skullduggery. First, learn all your state rules governing drug samples. Some states like New Mexico regulate the distribution of drug samples, but many don’t. Second, check the expiration dates on all medications, and dispose of expired drugs. Third, organize medication samples; one easy way to categorize medications is by medical condition. Fourth, lock up the samples at night. Finally, electronically keep track of how samples are distributed.