Nov-Dec 2006 Table of Contents

LETTERS

Fam Pract Manag. 2006 Nov-Dec;13(10):16-21.

Closing the sample closet



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I would like to suggest an alternative to the strategies for “Taming the Sample Closet” described in Dr. Mitchell Cohen's article [October 2006]: Close the sample closet. As Dr. Cohen notes, a sample closet requires a lot of work. Does this time and effort achieve a great benefit?

No evidence shows that patients benefit from the use of samples. In fact, access to a sample closet leads to non-rational prescribing1,2 and may lead to worse outcomes in our underserved patients.3 Additionally, while samples might provide short-term cost savings for patients, the new, heavily marketed drugs in the sample closet will likely cost patients more over time than would rational drug choices. As Dr. Cohen notes, drug samples are also misused and often taken home by family members or office staff.4

The sample closet's primary beneficiary is the pharmaceutical industry. Samples are an important tool for marketing new medicines. Why else would the industry distribute $15.9 billion worth of samples annually?5 These poorly policed dispensaries could fittingly be renamed “marketing closets.”

For these reasons, we closed the sample closet in our family medicine center one year ago. Our decision was not without controversy, but ultimately, few providers or patients have missed it.

Our doctors in training are leading the way on this issue. At the 2006 National Conference of Family Medicine Residents and Students, both students and residents adopted resolutions encouraging the AAFP to investigate and support alternatives to the use of industry-sponsored “free” samples. The Puget Sound Health Alliance, an influential nonprofit organization working to improve health care quality, has also suggested ending the practice of sample use.

So what are the alternatives to the traditional industry-sponsored sample closet? A physician and pharmacy-supported, low-cost sample formulary has been suggested in Family Practice Management.6 Additionally, industry-supported, reduced-cost drug programs and national reduced-cost generic drug programs can be accessed at http://www.needymeds.com.

It's time to close the closets. We owe it to our patients to base our prescribing choices solely on the best available evidence.

1. Chew LD, O'Young TS, Hazlet TK, Bradley KA, Maynard C, Lessler DS. A physician survey of the effect of drug sample availability on physicians' behavior. J Gen Intern Med. 2000;15:478–483.

2. Adair RF, Holmgren LR. Do drug samples influence resident prescribing behavior? A randomized trial. Am J Med. 2005;118:881–884.

3. Zweifler J, Hughes S, Schafer S, Garcia B, Grasser A, Salazar L. Are sample medicines hurting the uninsured? J Am Board Fam Pract. 2002;15:361–366.

4. Westfall JM, McCabe J, Nicholas RA. Personal use of drug samples by physicians and office staff. JAMA. 1997;278:141–143.

5. IMS Health Inc. Total U.S. value of free product samples, 2004. Available at: http://www.imshealth.com. Accessed Oct. 19, 2006.

6. Erickson SH, Cullison S. Closing the sample closet. Fam Pract Manag. October1995:43–47.

The best way to tame the sample closet is to eliminate it. I stopped seeing drug reps and wrangling with the sample closet last year and have never looked back. The amount of money patients saved because of samples is offset by the loss in physician productivity in procuring the samples and fiddling with the cabinet. A generic prescription is usually a better choice for most patients anyway.

Dr. Mitchell Cohen outlines many problems associated with maintaining a sample closet in his article. I would like to suggest an even simpler alternative to his recommendations: Get rid of the sample closet altogether. This is not only the most practical approach, but it is also the most ethical, as it ensures that the medications we prescribe are the best treatment for the problem at hand and not just the latest, and usually more expensive, drug available.

Physicians who are skeptical about the physician-drug rep relationship may use samples as a reason to maintain the relationship, arguing that samples provide prescription medications to indigent patients who can't afford to pay for them. There are two problems with this reasoning. First, samples are not often reserved for indigent populations, negating the utility, if not the honesty, of that argument. Second, the cost of drugs is high partly because of the amount of money the pharmaceutical industry spends marketing to physicians, sampling included.

Thousands of physicians across the country do not accept or distribute samples and provide high-quality, evidence-based care. Many of them have patient populations consisting entirely of lower-income and indigent populations.

The American Medical Student Association (AMSA) asks physicians to refrain from accepting gifts or samples from drug reps as part of its Pharm Free Campaign. I am a member of AMSA and coordinator of the Pharm Free Campaign. There is no such thing as a free sample, just as there is no such thing as a free lunch. Our patients pay for both.

Dr. Cohen's article about pharmaceutical samples prompted me to question “How much time will you and your staff invest in following his recommendations?” I tamed my sample closet by getting rid of it four years ago. This move saves me at least two hours a week, and my staff saves time as well. Because of my tendency to prescribe generic drugs, we don't have to manage many formulary-related requests, and we spend much less time responding to requests for “free” medications. I don't talk with drug reps much anymore, so I stay up-to-date on new medications by subscribing to an unbiased newsletter.

Author's response:

Eliminating the sample closet is an entirely reasonable option that many physicians may choose. Conversely, because of current practice patterns, many reasonable physicians employ the option of providing medication samples for patients. The intended take-home message from my article is that if a physician does choose the latter, it should be done in a conscientious manner with patient safety in mind. The question of whether drug samples have a role in medicine is an interesting and important topic for debate, but it was beyond the scope of the article.

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