Medication samples make it easier to treat patients with dry eye
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Ideas for this column come from all kinds of places.
This one actually came up while I was attending the 30th OSN New York meeting in midtown Manhattan. (Aside: Huge congrats to the OSN family and especially to Dr. Lindstrom on such a milestone.) While there, I had a number of sit-downs with both fellow physicians and colleagues from industry. One conversation stood out: How should we be thinking about samples?
It struck me that the answers to this question are largely generational, and even more so that they might illustrate the vast differences between the care experienced in academic centers vs. private practice. If you are younger than the age of, oh, 45 or so, you will have no idea what I am going to talk about. Likewise, if you practice in many an academic setting — the vaunted and venerable Anthracite Eye Center is a typical example — this entire discussion will be moot. In the spirit of the great Vince Lombardi who began a team meeting about returning to basics with, “Gentlemen, this is a football”:
A sample is a free version of a medication provided by a pharmaceutical company to be given to patients in a doctor’s office.
Really. Honestly and truly. Not only that, but up until 10 or so years ago, your office got samples for literally every medication you could possibly prescribe. There are three huge cabinets in the technicians’ area of our clinic that were busting at the seams with samples back in the day. Need an antibiotic for a corneal ulcer patient at 10 p.m. on a Sunday night? No problem. Which one would you like? Maybe that late-night patient has a corneal abrasion and is in terrible pain. Along with that antibiotic you could grab one of the three or four topical NSAIDs in the cabinet to make their night more comfortable. IOP rise the morning after cataract surgery in a squeamish patient you cannot burp? Pshaw, piece of cake! You could give them a sample of your favorite beta-blocker.
So, what happened to this little slice of nirvana? Well, like so many things that sit in the intersection between commerce and care in medicine, it is complicated. The most simple explanation is the bottom line: Samples cost somebody money, even if it is neither you nor your patient. As medications lose patent protection, manufacturers stop producing and providing samples. This becomes a particularly thorny issue when an entire class of medications is without a branded, patent-protected option. Think the aforementioned topical antibiotics and beta-blockers. Nobody provides samples for a medication that will be automatically filled with a generic product.
Reasonable people can disagree about the next reason samples have largely disappeared from our offices. There is a school of thought that the mere existence of samples gives the makers of the samples an irresistible power over the prescribing practices of any doctor who is within 100 yards of the sample closet. We are talking an effect that is two orders of magnitude greater than free penlights or a random tuna melt. Seriously, Svengali would blush. To avoid even the faintest taint of such an abhorrent situation, like so many St. Patricks running the snakes out of Ireland, institutions such as Anthracite Eye have banned all samples from its offices. No samples, no Svengali.
And, oh yeah, nothing to give to that poor patient in pain at 10 p.m. on a Sunday night.
To be at least a little bit fair, once upon a time, there was a definite quid pro quo in one lucrative area of eye care, postoperative antibiotic eye drops. Many practices (including SkyVision) accepted the “donation” of post-surgical kits containing anti-inflammatory eye drop samples in return for the understanding that surgeons would prescribe the antibiotic offering from that company. Never mind that at this time in the evolution of post-cataract care every patient received a branded antibiotic and that there was almost no price differential across the market segment. This arrangement was widely condemned as only slightly less horrible than the deal Robert Johnson cut at the crossroads with the devil in return for his otherworldly talent to play the blues. No more quid pro quo, no more kits and nothing to give to that patient ... you get the idea.
In reality, the availability of samples is a significant tool in the hands of physicians who need to prescribe branded, patent-protected medications. This is a dry eye column. In this therapeutic space, we prescribe multiple branded medications for which there is no generic alternative (not that the generics are always less expensive; see prednisolone). Not only that, we prescribe medications that may take a significant amount of time to show a clear effect, and during that time, there may be significant side effects experienced by the patient. Complicating matters even more, the fact that these are branded medications means that you and your staff nearly always face delaying tactics such as prior authorizations and step therapy rules, which can delay treatment that would be better initiated immediately.
This is where samples continue to shine (and where virtue signaling institutions that ban all samples are doing patients a disservice). A necessary medication with a complicated uptake (eg, immunomodulators) that requires adjuvant induction therapy (ditto) or is highly likely to suffer an insurance-driven step therapy delay (yep, here too) can be initiated with samples while all of that is being worked out. You can also get some sense of any side effects in play and address them before any medicine has been purchased. Absent samples, you are treading water and your patient is left hanging, their dry eye disease getting worse with every incomplete blink.
Listen, I am not a naive waif, blind to the possible influence of marketing efforts directed at me by pharmaceutical representatives bearing the gift of samples. Neither am I blind to the fact that samples are meant to facilitate the prescription of a medication that will be purchased, not as a 10 p.m. Sunday night failsafe. I know that it takes 2 years and many millions of dollars to produce a sample size that is different from the prescription size. I get all of that. What I want pharmaceutical companies (and large academic group administrators) to understand is that having a sample makes it easier for us to treat our patients.
Honest. It really is as simple as that.
- For more information:
- Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: dwhite@healio.com.
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