The true cost of “free” samples

When pharmaceutical sales reps visit doctors, they don’t come empty-handed. Most often they will bring food, small gifts like pens or mugs, and/or drug samples. Many physicians see drug samples as a benefit, because they can give pills to patients who may not be able to afford the medication otherwise.

But are “free” drug samples really free? While an individual drug sample may be free, what happens when the patient needs a continued subscription of the drug? The patient (or their insurer) will end up having to pay more for the expensive branded drug than they would have paid if a generic drug had been prescribed in the first place.

Even worse, drug samples may have a cost to patient health; research shows that doctors are more likely to prescribe drugs given as samples, even if that drug is not their first choice for the patient. One study found that uninsured patients with high blood pressure treated with “free” drug samples ended up with higher blood pressure compared to patients treated by the physicians’ free choice of drugs.

Given the effects of drug rep visits on physician prescribing decisions and health care costs, it is valuable to know how prevalent drug rep visits are, and which types of physician practices receive the most visits.

A recent study in JAMA Internal Medicine provides illuminating survey results on the frequency of drug rep visits for primary care physicians. Researcher Ashleigh C. King at the Dartmouth Institute and colleagues found that out of 2190 physician practices, nearly half reported that they had visits from a drug rep every week. About 60% reported that their practice had a “sample closet”- a designated area to store free samples.

Larger physician practices and those with an academic affiliation were less likely to report weekly drug rep visits, compared to smaller, non-academic affiliated practices. It seems that the policies undertaken by academic medical centers to restrict drug rep visits are working, although about one third of academic-affiliated practices still reported weekly drug rep visits.

Nearly half of primary care practices reported that they had a drug rep visit every week.

This study from King et al. shows that drug rep visits and free samples are alarmingly common. The normalization of drug rep visits may also justify the practice to physicians–doctors may think, “Everyone else is doing it, so why can’t we?”

What can we do to reduce reliance on drug samples? The most obvious solution is for clinicians or institutions to limit drug rep visits at their practice. Clinicians and institutions can adopt pharma-free policies for their own practices and refuse to accept food, gifts, or samples from drug reps. These clinicians should display their pharma-free status proudly, and invite conversations with other clinicians and patients about why they made this decision.

Another solution would be for government agencies to more strictly regulate the dispensing of drug samples. Current regulations make it easy for prescribers to accept drug samples because the requirements for storing and dispensing samples are lax. The sample closets where clinics keep their samples can become a disorganized heap of pill bottles that stay in the closet far past their expiration dates. If clinicians had to comply with safe drug storage practices for drug samples and knew the rules would be enforced, they might reconsider whether accepting free samples was worth it for their practices and their patients.