PUSHING PILLS

DEPRESSION isolates. Prozac can help," pronounces a three-page magazine
advertisement.

A few pages later there's another one tucked between an article on makeup
tips and a celebrity interview. You've grown up," it observes. "So should
your acne medicine. Differin adapalene gel."

Regular readers of almost any magazine, whether it be U.S. News & World
Report, Readers Digest or Cosmopolitan, undoubtedly have noticed a recent
surge of ads touting prescription drugs.

Mainstream newspapers and television also are increasingly showcasing drugs
that treat for everything from high cholesterol and nicotine addiction to
cancer or AIDS.

But despite the fact that these drugs must be prescribed by a doctor, ads
these days are targeting consumers directly. But why?

The reason, according to the phar-maceutical companies, is that ads aimed
at consumers are instrumental in helping to push over-the-counter drug
sales toward the $100 billion-per-year mark [Yes, that is a "b" in billion,
not an OCR error].

But some health professionals and consumer advocates say it may be
dan-gerous to convince patients through a combination of marketing-induced
emotionalism and often-overlooked fine print to demand drugs from their
doc-tors that may not be appropriate.

"To my mind, these ads subvert the doctor-patient relationship and foster
drug-seeking behavior," said Jon Zwelg, a doctor of internal medicine for
Kaiser Permanente in Redwood City. "It makes the doctor the barrier between
the patient and the drug brand the patient wants."

Pharmaceutical advertising in the United States is really a fairly recent
phenomenon.

Drug manufacturers started in the mid- 1980s by placing "reminder" ads in
magazines that would either mention the name of the drug without saying
what the treatment was for, or list symptoms of health problems and hint
there might be a treatment.

Then Pharmacia & Upjohn in the late 1980s began producing 30-minute
infomercials for its Rogaine hair-loss treatment, complete with full
discussions on significant side ef-fects and lengthy small-print warnings
that scrolled down the screen, Other drug companies soon followed suit.

The early print and broadcast approaches adhered to federal Food and Drug
Administration rules requiring drug advertisements to explain side effects
thoroughly if the ads mentioned both the product name and the ailment.

But under more relaxed FDA guidelines passed last year, companies need only
mention significant side effects and refer consumers to toll-free numbers
or Internet sites for details.

The result has been an un-precedented barrage of brand-name drug
advertising and mounting frustration for some health-care professionals who
say they're witnessing a rise in unneeded or misguided prescriptions.

"There's nothing educational about the advertising," said Larry D. Sasich,
a pharmacist and a research analyst with Washington, D.C,-based Public
Citizen, a consumer advocacy group founded by Ralph Nader. "Consumers don't
have access to objective information,."

Pharmaceutical companies, however, say their advertising really does do a
public service by bringing health information directly to consumers and
encouraging them to seek their doctors' advice.

Ads for Prilosec, a top-selling ulcer drug manufactured by As-tra-Merck in
Pennsylvania, include 60-second animated television spots quizzing
con-sumers on their heartburn. The object, said company spokesman Jim
Coyne, is to help people determine whether their heartburn really might be
a symptom of something more serious.

"We're not trying to make a diagnosis or evaluate people's problems over
the air," Coyne said. "The Idea is to encourage people to think about their
symptoms and to talk to their physician."

For Michigan-based Pharmacia & Upjohn - which manufactures treatments for
sensitive or embarrassing ailments such as impotence, incontinence and hair
loss - the ads serve to remind consumers that a medical treatment is
available, said spokesman Tom Vance.

Another Impotence drug manufacturer, Vivus Inc. of Mountain View, launched
a major television and print ad campaign this weekend during the AT&T
Pebble Beach National Pro-Am tournament. Its promotions for the drug MUSE
are an attempt to fill waiting rooms with men who might not otherwise have
been aware they have a treatable physical problem.

"Our main challenge with the ad campaign is to debunk the myth that
impotence is a psychological condition," said Ju-han Gangolli, vice
president of sales and marketing at Vivus.

But while education is one goal of the ads, increasing sale is the ultimate
goal.

Drug makers spent $277 million on television advertising alone in the first
nine months of 1997, 52 percent more than they spent during the same nod in
1996, according to Nielson Media Research.

"One of the big issues all drug companies have is to locate enough
patients," admltted Ed Jacobs, senior vice president of commercial
operations for Sequls Pharmaceuticals, Menlo Park. "They feel these
campaigns can focus on consumers who will take the names of those drugs to
their doctors and trigger some sort of response."

Additionally, pharmaceutical companies say direct-to-consumer advertising
has the potential to impact health maintenance organizations' for-mularies,
which are the limited lists of drugs each managed-care group has approved
for prescription based on price. and effectiveness.

Oakland-based Kaiser Permanente accounts for about 2 percent of all
pharmaceutical purchases in the United States, said David Campen, chairman
of Kaiser's formulary committee.

But the HMO's formulary includes only about 750 or 800 approved drugs,
effectively shutting out thousands of similar drugs manufactured by other
pharmaceutical companies.

It's in those companies' best interest, then, to try to convince massive
HMOs such as Kaiser to replace the drugs in their formularies with their
own versions - a maneuver that could mean millions more dollars in sales.
And it certainly helps to have legions of consumers asking for a specific
drug by name.

"In some situations, the industry spends an amount in advertising similar
to what they've spent in research," Campen said. "Stop and think about
that; it's a huge amount. But there's no doubt it works."

Most Bay Area doctors can cite anecdote after anecdote of patients trouping
into their offices and demanding a drug they've seen while watching
"Chicago Hope" or "20/20."

"It happens all the time," said Campen, who nevertheless said Kaiser
doesn't change its formulary based on patient demand or advertising.
Nationwide, nine out of 10 physicians surveyed In 1997 by industry
researcher IMS America said they've gotten more brand-name drug requests
from patients over the last year, even In cases where no drug treatment is
needed.

But though doctors admit they have the final say in whether a patient
receives a prescription, many managed-care physicians say that the patient
pressure puts them in an awk-ward position.

On one hand, they're guided by their organizations' formularies.

But on the other hand, they're also overseen by powerful HMOs reluctant to
anger their members - and which often give them leeway to prescribe drugs
not on the formularies, even if insurance doesn't cover the treatments.

So unless a drug will have significantly adverse effects or doctors can
successfully defend their own preferences, pushy patients usually will walk
away with what they came in for.

A physician's prescribing behavior, too, can be influenced by the
advertising, Sasich of Public Citizen said.

But going along with advertising-driven demand can be dangerous,
uneconomical or both, he said. Advertised products likely aren't always the
most cost-effective or best treatments available. Sasich described a
favorite example: G.D. Searle manufactures and aggressively advertises a
high blood pressure drug named Covera-HS, which retails for about $60 for a
month's supply.

But many doctors prefer similar drugs by other manufacturers, some of which
not only sell for about $3.95 for a month's supply, but which have been
proven to also reduce the risk of heart attack and stroke - a claim Covera
can't share.

It's not hard to guess which drug advertising-driven consumers request by name.

"In the face of science and in the face of national health recommendations,
doctors are being asked to prescribe this other drug," Sasich said. "That's
what happens when consumers don't have enough information to make an
informed decision."

The Information actually available - drug package inserts meant for
physicians' use or the fine-print, page-long masterpieces featured in print
ads - are written in a regulatory language that is nearly incomprehensible
to those without an extensive education in health care.

Sasich and others are working to change FDA guide-lines so that drug
manufacturers must provide consumers with plain-English translations of the
package inserts when they're given their prescriptions.

Pharmaceutical companies long have argued that doing so would be
tooexpensive. or would scare patients into not taking their medicine.

But one class of pharmaceu-ticals already does provide consumer-friendly
package-insert translations: women's health drugs such as estrogen
replacement therapy and hormone replacement therapy.

The National Women's Health Network was instrumental 25 years ago in
convincing the FDA that scientifically balanced information was needed,
said Lisa Cox, the organization's program and policy director.

"Consumers shouldn't be put into the position that they should have to beg
for balanced drug information. We feel it should be very available," Cox
said. "We're very supportive that the rest of the industry should have to
comply to the same standards we've achieved."

But Sasich says he doubts that will happen anytime soon.

Pharmaceutical companies have spent millions lobbying Congress to make and
keep advertising rules as loose as they are now.

The FDA Modernization Act of 1997, in which the more relaxed
drug-advertising guide-lines were included, was an industry-sponsored bill
phar-maceutical lobbyists pushed through with the help of more than $30
million in contributions to the Senate and House of Representatives,
according to Public Citizen.

The result: Consumers increasingly need to get involved in their own care,
advocates say.

The best thing patients can do for themselves is to encourage an open
consultation with their doctor on treatment options, Zweig at Kaiser said.

Consumers also should read and attempt to understand the package inserts
included with their prescriptions, then invest In a Physicians' Desk
Reference and continue to educate themselves on their own treatinents.

"Consumers need to get information anywhere they can if they're going to
take charge of their own care," said Jamie Court, director of the Santa
Monica-based consumer group Consumers for Quality Care. "They shouldn't
demand a pre-scription without the facts, but unfortunately that happens
far too frequently."

Sidebar: Big Budgets (in millions $) in year: 1997

Pharmacia & Upjohn 125

Schering-Plough Corp. 145

Glaxo 90

year: 1996

SmithKline 70

Warner-Lambert Co. 140

Johnson & Jonhson 214