Thomas Reardon, MD, while chairman of the American Medical Association’s Board of Trustees, said that thanks to the Internet and trends in advertising, “patients are better equipped to take part in their care than ever before.” David Nash, MD, has edited a text regarding how to connect with the “new healthcare consumer.” Not only do healthcare consumers, formerly known as patients and unfortunately referred to of late as clients, expect more of their clinician, but they expect more of themselves as well. They enter the office asking for a specific treatment or procedure, or asking detailed questions about pharmacotherapy that would be entirely reasonable at a medical education seminar. They pursue the scientific literature with greater vigor than, in many cases, their doctor, often bringing clippings with them to their appointments.

Since direct-to-consumer (DTC) advertising was initiated in the United States, another source of information has become readily available for our patients. Obviously biased by nature, these advertisements have been presented on television and radio, in magazines, and on the Internet. There are three permissible types of DTC advertising:

1. Help Seeking: Within this advertisement, a disease or condition is mentioned, but no branding is provided. The corporate name may be shared. So, for example, Lilly® may recommend that patients see their physician if they are experiencing misshapen cuticles so that they may obtain a new unnamed treatment.

2. Reminder: This advertisement can present a brand, but no mention of the disease. The initial launch of Levitra®, a competitor of Viagra®, was presented through the metaphor of a middle-aged man having difficulty getting a football through a tire swing. There was no statement as to what Levitra did other than an implication that the man’s aim and stamina would improve.

3. Product Claim: This is the full ad that we often see for Zoloft® (the little animated “dot”) or Paxil CR® on television. The brand, its intended use, significant side effects, and a fair balance of risk/benefit all must be presented.

One company cleverly discovered and took advantage of a loophole by presenting a help-seeking ad followed by a reminder ad without having to present the side effects or risk/balance discussion so long as the two ads were separated by another advertisement. After the company was spanked, it promised never to do it again; since that time, companies have been reasonable in following the intent of the differing ad approaches.
Two drugs commonly prescribed to patients with substance use disorders are ReVia® and Antabuse®. The medications have not been promoted on television, but there are Web sites available for both. Typically, brand-name drugs have their own Web sites. Getting to the Paxil Web site requires nothing more than typing “Paxil” into the URL entry area of your Web browser.

I typed Antabuse into my browser and was immediately taken to www.antabuse.com. This is actually the home page for Odyssey Pharmaceuticals, the manufacturer of the Antabuse brand of disulfiram. There is very little information about the drug available here, but the paragraph about the drug presents the important highlights — Antabuse is an aid to management of certain patients and must be used as part of an integrated program that includes medical and psychological counseling. No detailed information is available. An attempt to go to disulfiram.com resulted in being taken to Canadapharmacy.com instead. Multiple sites have information regarding disulfiram. A full drug monograph is presented at www.mentalhealth.com/drug/p30-a02.html. The monograph presents details regarding the metabolic process used by the drug. Clinicians should obviously be aware that patients may read such a monograph, being as readily available as it is, and may be confused or have misunderstandings as a result.

There is no named ReVia site. A Google™ search for ReVia revealed several opportunities to purchase the medication. The University of Pennsylvania Health System has an Internet Alcohol Recovery Center that presents a flow sheet for the initiation of ReVia as well as a FAQ (a Web page outlining frequently asked questions) for the medication, explanation of pain management issues, and letters from patients taking naltrexone. The site is very nicely divided between consumer and professional areas and is available at www.uphs.upenn.edu/recovery/. Many online medication sites have such divisions, but many consumers immediately gravitate to the professional portion of the site, feeling that this is where the “good stuff” is. Patients have mentioned to me that they feel the professional part of such sites is where information is placed that the manufacturer wishes to hide from the consumer, or that information in the consumer area is written for a fourth-grade equivalency reader.

Generic versions of both medications are available, perhaps leaving the manufacturers of the brand with little incentive to promote the branded version of the medication. Unfortunately, this leaves the consumer searching for information, perhaps finding something of value, like the Penn site, or perhaps finding something inaccurate. One site I looked at stated that ReVia and Antabuse should not be taken concurrently as they both can cause hepatic damage. ReVia and Antabuse are often prescribed concurrently, and while liver function should be monitored with such a regimen, it would be unfortunate if a patient were to stop prescribed medication or lose faith in his or her clinician as a result of such a Web site. The advantage of having pharmco-sponsored advertising is that the bias is always clear. Consumers and patients alike are familiar with advertising and recognize it as being a one-sided representation of a product. In the absence of such information, consumers are placed into a state of confusion caused by not knowing, or by inaccurately guessing, the bias of a particular Web site.

What do you think? Would you rather see more or less information from pharmaceutical manufacturers directed to consumers? Are you annoyed, or gratified, by having your patients come to you with information they’ve obtained online or from DTC advertising regarding their treatment? Does it show that they’re second-guessing you? Or does it mean they simply want an active role in their treatment?

Stuart Gitlow, MD, MPH, is the author of Substance Use Disorders: A Practical Guide, from Lippincott Williams & Wilkins. He spoke at the Psychiatric Congress in Orlando in November 2003 on e-mail and the psychiatric patient.

This article is published in Counselor,The Magazine for Addiction Professionals, February 2004, v.5, n.1, pp. 68-69.

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