Patient requests for specific drugs have major impact on prescribing

Patient requests for specific medications—including requests for brand-name drugs spurred by direct-to-consumer (DTC) advertising—have a substantial impact on doctors' prescribing decisions, suggests a study in the April issue of Medical Care.

"A patient request for a specific medication dramatically increases the rate at which physician s prescribe that medication," according to the new research led by John B. McKinlay, PhD, of New England Research Institutes, Watertown, Mass. They add, "These results highlight potential negative impacts of DTC advertising and other forms of activation in medication requests."

How Do Doctors Respond When Patients Request Specific Drugs?

The researchers designed an experimental study to evaluate the effects of "activated" patient requests for specific medications. They made videos in which professional actors portrayed patients with two common, painful conditions: sciatica causing back and leg pain or osteoatrthritis causing knee pain.

Half of the "patients" with sciatica specifically requested oxycodone, a strong narcotic painkiller; while half of the patients with knee arthritis requested the prescription drug Celebrex. The other half of patients requested "just something to make it better."

The patients requesting oxycodone said they had tried their spouse's leftover medication; those requesting Celebrex said they saw it advertised, and that a co-worker took it and said it really helped. The video scenarios were randomly shown to 192 primary care physicians, who were then asked a series of questions about diagnosis and management, including what treatment they would recommend.

The results suggested that "activated" patient requests for drugs had a strong effect on recommended treatments. About 20 percent of sciatica patients requesting oxycodone would receive it, compared to one percent of those making no specific request. Strong such as oxycodone are generally not recommended for sciatica, particularly for a newly presenting case, such as was in these cases.

About half of knee arthritis patients requesting Celebrex would receive that drug, compared to one-fourth of those requesting no specific medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as Celebrex are recommended for treatment of . However, the brand-name drug Celebrex is a "selective" NSAID that is much more expensive than other options, with no additional benefit. The gender, race/ethnicity or socioeconomic status of the patient had no effect on the inclination to grant a patients' request.

Results Raise Questions about Impact of DTC Advertising

Even if they didn't receive the specific drug they requested, treatment patterns differed for patients who made active requests. "Patients requesting oxycodone were more likely to receive a strong narcotic and less likely to receive a weak narcotic," according to Dr McKinlay and colleagues. "Patients requesting Celebrex were much less likely to receive a non-selective NSAID."

The findings add to concerns over the potential safety and economic impact of prescription drug requests driven by DTC advertising. The United States is one of only two countries that permit DTC advertising—familiar to television viewers as "Ask Your Doctor" ads—for prescription drugs.

There is continued debate over the impact of DTC advertising. "Supporters defend the practice as a way to empower consumers, while opponents argue that commercially motivated messages leads to inappropriate patient requests for medication," comments Dr G. Caleb Alexander, Deputy Editor of Medical Care. "In order to resolve this debate, more research is needed to determine the effects of DTC advertising on patient and physician behavior, especially how it affects prescribing decisions and health outcomes."

The new report is one of the few rigorous experimental studies to evaluate the impact of DTC advertising. Since DTC advertising is exclusively used for expensive medications, patient requests for specific medications "activated" by ads are likely to increase medication costs.

In addition, some activated requests may sometimes lead to suboptimal care—for example, receiving oxycodone for sciatica or Celebrex for arthritis might have more side effects, compared to alternative medications. "The results highlight the ongoing need for improving strategies for patient-physician communication," Dr McKinlay and coauthors conclude.

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