On 17 January, a series of papers on money and influence unlocked the Pandora’s box of the pharmaceutical industry's influence on medicine and healthcare. It has always been known that the pharmaceutical industry exerted influence on doctors to prescribe more brand-name drugs and the FDA to accelerate their drug approvals - usually through financial relationships.

However the recent studies showed that they even influence those who write guidelines that outline doctors' practices, patient advocacy organisations, letter writers to the Centres for Disease Control and Prevention, and even oncologists on Twitter.

"The very way we all think about disease - and the best ways to research, define, prevent, and treat it - is being subtly distorted because so many of the ostensibly independent players, including patient advocacy groups, are largely singing tunes acceptable to companies seeking to maximise markets for drugs and devices," researchers Ray Moynihan and Lisa Bero wrote in an accompanying commentary.

Guideline writers have financial relationships with drug makers

In February 2016, the CDC issued guidelines regarding the limitations of drug prescriptions for chronic pain. More than 150 organisations formally submitted comments after the issuance and 80% were supportive. However, some recommended changes and it was found that opioid manufacturers have been funding these organisations.

Among the 45 groups that received money from opioid makers, the level of support was only 62% and none disclosed their funding sources in their comments. The CDC did not ask or require them to do so either.

“More people are dying than ever before from these products and it’s important to know how the market is shaped by the spending of drug companies,” said G. Caleb Alexander, co-director of the Centre for Drug Safety and Effectiveness at Johns Hopkins University.

The papers also exposed two committees that developed guidelines for the management of high cholesterol and hepatitis C, for not fully complying with standards set by the Institute of Medicine in 2011 to limit the number of industry-funded panellists. The standards required that less than half of the guideline writers can have commercial ties and that all chairs and co-chairs should have no conflicts.

But in both cases, at least one chairperson received money from industry and, in the case of the hepatitis C guidelines, the majority of panellists received funding.

The authors also noted that when separate committees without commercial conflicts wrote the guidelines, the recommendations were more conservative and recommended cheaper first line treatments.

Two-thirds of patient advocacy organisations received industry funding

One of the papers showed that two-thirds of patient advocacy organisations admitted to receiving industry funding in the last year. The money represented a small share of their budget, for the majority, but for 12%, they received more than half of their money from the industry.

Most of the organisations reported having a conflict-of-interest policy, but a smaller percentage said that their groups had policies for public disclosure of those relationships. Fewer than 8% of respondents said their group "perceived pressure to conform its positions to the interests of corporate donors or partners” and nearly 14% cited concerns of conflicts of interests therefore declining contributions.

The question of whether these advocacy groups actually serve the interests of their constituencies was posed by the authors who suggested greater transparency of funding sources by the groups.

Moynihan and Bero also suggested that the groups could decrease their industry sponsorship and ultimately disentangle themselves from the industry, therefore gaining authority despite losing resources. This would mean a healthier patient voice in medical research, education, policy and practice.

PRMA quick to defend relationships

Nearly 80% of US haematologist-oncologists who use Twitter were found to have financial conflicts of interest. This raises concern as a preliminary analysis of tweets by these doctors, showed that "a sizeable percentage are tweeting about drugs that they have specific ties to," said oncologist Vinay Prasad, one of the authors of the study.

"Not a single one has disclosed so far, but we'll find out."

The authors called for the disclosure of industry funding in the biographies of these physicians active on Twitter.

The pharmaceutical industry trade group was quick to defend the relationships between the Big Pharma and other organisations.

"Industry engages with stakeholders across the healthcare system to hear their perspectives and priorities," said the statement by the Pharmaceutical Research and Manufacturers of America. "We work with many organisations with which we have disagreements on public policy issues, including on prescription medicine costs, but believe engagement and dialogue are critical."

It also says that it has heard from many patients who are concerned about the growing out-of-pocket cost burden when accessing healthcare services and treatments and highlights the consensus by the patient community that there is a need for the development of cures for a significant number of diseases. MIMS

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