When a doctor prescribes a drug for some ailment, it’s natural for the patient to assume the physician thought through all the available drugs and chose one that would work the fastest with the least number of side effects and, if possible, not cost too much money.

In the U.S. today, that vision is nearly pure fantasy. In fact, big drug companies are spending billions of dollars trying to steer doctors towards their newest and most expensive drugs. With prescription drug costs now rising at three times the rate of inflation, it seems the companies are succeeding.

Standing in opposition is the group No Free Lunch. Now in it’s fifth year, the New York City-based group urges doctors and medical students to turn away drug company reps. The group’s website nofreelunch.org even has a pledge asking doctors to agree to turn away drug company marketing reps and even stop accepting the samples and freebies they bring with them.

I recently spoke with Dr. Edwin Montell, who signed the No Free Lunch pledge. A noted gastroenterologist who’s practiced in Hilo for the past 26 years, Montell is an outspoken critic of drug company marketing practices:

Maui Time: Why did you sign the No Free Lunch pledge?

Montell: This is a subject near and dear to my heart. Generally, escalating costs of medical care are important to everyone. One factor is clearly pharmaceutical costs: They’re up 20 percent a year. We need to look at how to restrain costs without depriving people of needed medication.

Something’s wrong with the way doctors are analyzing drugs. I’d like to see more thoughtful prescribing based on a scientific basis.

How does prescribing actually work?

Let me give you an example. There are a group of drugs that are very effective in treating acid reflux disease. One of those is Prilosec. A couple years ago, Prilosec was close to losing its patent protection [which would dramatically lower its cost]. The company that manufactures Prilosec then stopped promoting it and started promoting Nexium.

It even began billing it as “the other purple pill”—the first purple pill being Prilosec. They shifted 20 percent market share to Nexium, but Nexium has virtually no benefit over Prilosec. In fact, Prilosec is essentially Nexium.

There is no clinical benefit to this. But it’s promoted to doctors, who get lots of samples. Now they’re advertising Nexium as “the number one [protein pump inhibitor] PPI prescribed by gastroenterologists.” It’s a $4 pill, but customers can get the same drug for 70 cents at Costco.

I’ve read that the pharmaceutical industry spends something like $15 billion each year marketing directly to doctors.

Yes. Lipitor, made by Pfizer, has 65 reps in the state of Hawaii calling on doctors. Many doctors believe the pharmaceutical industry’s marketing habits have no effect on them, but most of them, interestingly enough, believe that it affects others.

I find it difficult to believe profit-making companies pour these kinds of dollars into marketing if there’s no impact. I do think we are blind to this. Part of it is we’re busy, pressed for time.

What have drug reps offered you?

They’ll say something like “Why don’t you come to San Francisco. You can bring the wife, go to the Giants game, get in a round of golf and we’ll pay for your air fare and then you can come to a meeting in the morning.”

These companies do beautiful work, they’re so good at what they’re doing. But I never took pens, pencils, books, trips. I never did anything that I would be embarrassed to let my patient know about.

And this is considered normal?

Up to 1991, 1992, there was no code of conduct for the pharmaceutical companies. They gave out golf trips, trips to other islands, tickets to sporting events, dinners, all in exchange for a one-hour talk.

But then the companies introduced a code of conduct. This produced a subtler shift—“come to San Francisco to consult for us. We’ll pay your expenses, pay you $2,000, but we want you to consult for us.”

What do you mean “consult?”

You end up spending a couple hours looking at marketing materials. That gives it legitimacy. Now they say they want you to participate in research—in Palm Springs.

I’ll tell you what is even more subtle: Most continuing medical education, which law and professionalism requires us to do, is drug-company sponsored. They will bring out great guests—really reputable speakers. But they already know what the people are going to say. They don’t bring out someone to talk about Prilosec—they bring out the guy who does Nexium. By shaping speakers, they shape the message.

It is brilliant! I really admire their cleverness—I wish I’d bought stock in them 20 years ago.

What about drug samples?

One major reason that doctors see reps is to obtain samples. This is a noble goal—they want to get drugs for people who can’t afford them.

I don’t take samples, but I’m not critical of why doctors take samples. The problem is that it promotes the use of the most expensive drugs. Sampling is a way of getting people hooked on high-priced, brand name drugs.

The problem isn’t the drug reps. They’re good people, but they’re sales people. My colleagues listen to these reps like they were medical professionals.

The drug reps go to sales meetings and the companies pump them full of so much information. I think they’re sincere in believing their drug is truly the best. But it’s the drug companies that I have issues with.

I feel bad that I won’t sit down and have coffee with the reps, but I’m afraid of getting influenced.