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Use of Trade Names of Drugs and the Scientific Content of Medical Congresses

National Cancer Institute, Milan, Italy
University of Texas M.D. Anderson Cancer Center, Houston, TX

To the Editor:Pain occurs in more than 80% of cancer patients before death.¹ The increasing number of cancer deaths around the world means that the global burden of cancer pain will increase in the future.^2-4 Opioid analgesics are considered the mainstay in the management of pain for these patients.^1,5

The World Pain Congress of the International Association for the Study of Pain takes place every 3 years and is the most important educational forum for the dissemination of knowledge about pain treatment. During the last meeting in Vienna, Austria, in August 1999, we observed a dramatic increase in the use of trade names of opioid drugs in the different poster and slide presentations as well as in the abstract book of the congress.⁶ After having reviewed the last three International Association for the Study of Pain congresses abstract books,^6-8 we found that the use of trade names of opioid analgesics has significantly increased from 1993 to 1999 (P = .007). The use of trade names was significantly higher in papers sponsored by the pharmaceutical industry when compared with those for which the authors had no industry affiliation (P < .001).⁹ In abstracts reporting on the more expensive, patented, controlled-release (CR) opioids (CR oxycodone, CR morphine, CR hydromorphone, or transdermal fentanyl), the frequency of trade name use was significantly higher when compared with the cheaper, nonpatented, immediate-release opioids (tramadol, morphine, hydromorphone, methadone, codeine, levorphanol, and any other opioid preparation) (P < .001).⁹

In 58 (53%) of 109 abstracts using CR opioids, the authors identified an industry affiliation, as compared with 47 (18%) of 257 abstracts in which CR opioids were not used (P < .001). The trade name was used (mean ± SD) 4.6 ± 4.2 times in abstracts reporting on CR opioids versus 2.2 ± 2.3 times in abstracts of all other opioids (P < .001).

Our findings suggest that the use of trade names has become the norm rather than the exception in articles reporting on the more expensive patented opioid drugs, such as CR opioids, and in studies for which there is pharmaceutical industry participation. These findings raise a number of questions: Why are authors using trade names more frequently and why is this use more frequently related to more expensive patented opioid drugs? Is it essential, from the scientific and educational perspectives, to use the trade name? Is it ethical to use the trade name if it is not essential? Why do the academic physicians who participate in this research agree to the use of the trade name?

It is well known that the pharmaceutical industry is highly lucrative. Pharmaceutical companies in promotion and marketing¹⁰ spend more than 11 billion United States dollars each year.

The numbers of symposiums sponsored by the pharmaceutical industry have increased from 7,500 in 1974 to 34,688 in 1988.¹¹ Industry-sponsored activities can provide health care professionals with excellent opportunities for educational and scientific exchange. However, those same activities may also be used for the illegal promotion of the sponsors’ products.¹² It is notable that pharmaceutical-sponsored studies or meta-analyses are significantly more likely to find outcomes favorable to the sponsor’s treatment,^13-15 such as in the case of rheumatic disease or stroke research.^16,17 In addition, the trade name itself sometimes portrays the drug as having an effect different to the one demonstrated in clinical research.¹⁷

The duty to maintain ethical standards in national and international journals and scientific meetings does not reside ultimately with the pharmaceutical industry, but rather on the leadership of the scientific organizations, the authors of the submitted abstracts and articles, and ultimately on all the readers and participants of the events.^18,19 An ethical medical congress is one in which the scientific content of the meeting is most likely to help patients.

New patented drugs are of higher interest because of their novelty. In addition, industry-funded studies can afford impeccable methodology and large patient numbers, and in many cases, they may be selected for presentation with a higher priority for these very reasons. This may lead to inappropriate emphasis on drugs that may not necessarily be much better. Of even greater concern would be the neglect of other relevant clinical studies due to lack of space. The use of methodology as the gold standard can produce a bias toward studies that cost more (ie, industry-sponsored studies). When scientific committees select papers for presentations at annual meetings, they should look not only at the methodology but also at papers that may have impact on common important areas of patient care. Space allocation based on simple methodologic review will not address this problem. There needs to be a balance of content at meetings.

Another ethical issue is that the presence of some trade names may start the slippery slope consisting of studies being conducted and reported to raise the visibility of the trade name rather then for scientific purposes. When one manufacturer uses a trade name, this generates pressure on the other manufacturers to do the same thing. Some of the findings by our group suggest that this trend has already started; in some of the studies authored by members of the pharmaceutical industry, there were reports of pooled data from a number of studies that did not allow the reader to determine whether this was new or recycled information.⁶

In selecting abstracts for presentation in the scientific sessions, the program committee’s prime responsibility is to maintain the scientific integrity of the program. Because participants pay a significant amount of money to register and travel to these meetings, they should be able to receive the most accurate and unbiased information possible, free of the pressure of advertisements. One concern is the possibility that they will receive incorrect information because of the strong pharmaceutically sponsored content. They may also be exposed to unnecessary advertisements and be influenced to prescribe more expensive drugs. Medical journal readers or congress participants should demand that their publications and congresses eliminate unnecessary advertising material.

Our findings raise the concern that, in some cases, the abstract book and poster and slide sessions may be seen as a useful tool for promoting the trade names of patented and more expensive opioids by pharmaceutical companies.⁹ It has generally been assumed that the original paper sessions presented as slides or posters had a strictly scientific purpose.

We would like to recommend some simple measures to prevent the escalating use of trade names:

1. The use of trade names of drugs should not be allowed in the title or text of abstracts and should not be allowed in any scientific presentations during scientific meetings as well as during teaching sessions or continuing medical education programs, even if a pharmaceutical company sponsors them. When it is necessary to identify the source of the drug, it is enough to provide the name of the drug with the pharmaceutical manufacturer in brackets. Interested clinicians and researchers can then easily obtain the trade name.

2. Pharmaceutical affiliation of the authors or sponsorship for the study or lecture should be mandatory in all submitted abstracts, in continuing medical education programs, as well as in grand round meetings. This will allow the readers and the audience to interpret the reported results within the context of the potential bias.

3. There should be a balance between pharmaceutically sponsored and nonpharmaceutically sponsored scientific research in every meeting and educational program to avoid projecting false-positive information about the effectiveness of certain drugs or interventions that are likely to be more costly.

These measures should be implemented as soon as possible in all scientific meetings and educational programs. At a time when there is limited funding for clinical research and continuing educational programs, other than that provided by industry,¹⁷ these changes will ultimately be favorable to patients, participants at medical congresses, researchers, and the pharmaceutical industry itself.

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3. Whelan SL, Parkin DM, Masuyer E, et al (eds): Patterns of Cancer in Five Continents. New York, NY, Oxford University Press, 1990

4. Miller HA, Ries LAG, Hankey HF, et al (eds): SEER Cancer Statistics Review: 1973-1990. Bethesda, MD, National Cancer Institute, 1993

5. World Health Organization: Cancer Pain Relief. Geneva, Switzerland, World Health Organization, 1986

6. International Association for the Study of Pain: Abstracts: 9th World Congress on Pain. Seattle, WA, IASP Press, 1999

7. International Association for the Study of Pain: Abstracts: 7th World Congress on Pain. Seattle, WA, IASP Press, 1993

8. International Association for the Study of Pain: Abstracts: 8th World Congress on Pain. Seattle, WA, IASP Press, 1996

9. Bruera E, Ripamonti C, Beattie-Palmer L: Use of trade names of drugs in abstracts from congresses. N Engl J Med 343: 818, 2000[Free Full Text]

10. Wolfe SM: Why do American drug companies spend more than $12 billion a year pushing drugs? J Gent Intern Med 11: 637-639, 1996

11. Kessler DA: Drug promotion and scientific exchange. N Engl J Med 325: 201-203, 1991[Medline]

12. Bero LA, Galbraith A, Rennie D: The publication of sponsored symposiums in medical journals. N Engl J Med 327: 1135-1140, 1992[Abstract]

13. Cho MK, Bero LA: The quality of drug studies published in symposium proceedings. Ann Intern Med 124: 485-489, 1996[Abstract/Free Full Text]

14. Stelfox HT, Chua G, O’Rourke K, et al: Conflict of interest in the debate over calcium-channel antagonists. N Engl J Med 338: 101-106, 1998[Abstract/Free Full Text]

15. Dieppe P, Chard I, Tallon D, et al: Funding clinical research. Lancet 353: 1626, 1999

16. Liebeskind DS, Kidwell CS, Saver JI: Empiric evidence of publication bias affecting acute stroke clinical trials. Stroke 30: 268, 1999

17. Rochon P, Gurwitz JH, Simms RW, et al: A study of manufacturer-supported trials of nonsteroidal anti-inflammatory drugs in the treatment of arthritis. Arch Intern Med 154: 157-163, 1994[Abstract/Free Full Text]

18. Rennie D: Editors and advertisements: What responsibility do editors have for the advertisements in their journals? JAMA 265: 2394-2396, 1991[Abstract/Free Full Text]

19. Kessler DA, Pines WL: The federal regulation of prescription drug advertising and promotion. JAMA 264: 2409-2415, 1990[Abstract/Free Full Text]

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