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The boxes contain thousands of doses worth of now-expired free samples of name-brand prescription drugs — everything from antidepressants to antibiotics. The women lament that the samples are out of date, can't be used in the U.S. and will have to be shipped to aid programs abroad. The clinic often relies on trial medicines to treat its patients, most of them low-income, uninsured Latino immigrants. They also rely on drug company sales representatives to come by and replenish the medicine cabinet.
La Clinica's executive director, Dr. David Campbell, suspects that the sales visits are infrequent because the majority of his patients can't afford prescription drugs. "The goal in the industry is that samples are a hook," says Campbell. "Because of that, our access to samples is somewhat limited. This is a marketing tool. We don't have drug reps coming into La Clinica because we're not going go and give a patient four days worth and then write a script for this medication."
The use of free samples is widespread. A survey published last spring in the New England Journal of Medicine found that 78 percent of doctors throughout the county accepted them in the past year. Often the complimentary medicine goes toward treating the indigent. In some cases treatment centers like La Clinica depend heavily on the samples as a source of name-brand drugs, giving patients monthlong doses of medication that pharmaceutical companies intended to be used for just a few days.
"The percentage of insured patients at our clinic is very small, less than 5 percent," says Campbell. "Without free samples, I think a lot of my patients would simply not be able to afford to get medicine they need."
"We provide samples to doctors for the purpose of starting patients to see if it's the right treatment," responds Laura Woodin, a spokeswoman for AstraZeneca pharmaceuticals. "We have patient-assistance programs to get longer term access to drugs."
As Woodin points out, the pharmaceutical industry has many programs that furnish free drugs to the needy, most notably the Partnership for Prescription Assistance, a Web site that provides access to the aid programs of 175 different companies. AstraZeneca and Pfizer also offer plans that allow participating pharmacies to distribute drugs to disadvantaged patients for free and get reimbursed at the end of the month. The problem, many healthcare providers complain, is that the programs require a mountain of paperwork and take too long to get the medications into patients' hands.
"Sometimes I get the impression they want to be able to say they have a program but don't want to give away too much medicine," says Barry Wilson, chief pharmacy officer at Family Care Health Centers, a trio of clinics in St. Louis that serves low-income patients. "The Pfizer program took us two years to get on it. It was driving me crazy."
Clinics frequently turn to samples when faced with such bureaucratic obstacles.
"It's a common practice," says Dr. James Crane, who oversees the faculty-run treatment center at Washington University, which uses the promotional drugs it receives almost exclusively for treating the poor. "But we only use them for a few days to a few weeks, long enough to see if the patients respond. We just want to make sure they have the medicine they need until we find sustainable resources."
Sometimes, though, samples are the only option. Before Campbell began running La Clinica eighteen months ago, it relied almost exclusively on them. The clinic has since joined a program called Allscripts, which allows Campbell to stock his pantry-sized pharmacy with low-cost generic medicine, and many patients are now referred to Target and Wal-Mart, which offer hundreds of prescriptions for $4 each.
However, La Clinica, which treats anywhere from 30 to 50 patients a day, for everything from gynecology to dental work, still counts on the trial drugs for many essential medicines that don't have generic alternatives, mainly antibiotics and cholesterol medications. The handouts can often be hard to come by, particularly since pharmaceutical companies have began turning to promotional coupons instead of actual medicine.
"Some of them will be a gift card type thing, where you can use it for a week's worth of meds, but some you have to go through a long application for. It kind of ticks me off because we're doing all the work for them," says Wilson, who has subscribed to a Web site, www.rxassist.org, which connects doctors who aren't going to use their free samples with clinics who need them.
"We started seeing [coupons] about a year ago and it's really started to pick up momentum," Campbell says. "But if someone has no insurance and Lipitor (a cholesterol medicine) is $100 bucks a month, $20 bucks as a discount doesn't help much."
Woodin, the AstraZeneca spokeswoman, says that the vouchers "free up space in the doctor's office."
The feast-or-famine nature of free sample availability can have unfortunate side effects. Campbell tells how they've had to prescribe a more potent than necessary antibiotic sample because it was the only thing available at the time. Says Amanda Maust, La Clinica's manager: "A lot of the time, samples are great as something to start patients off, but there isn't any left when they come back."
The fact that La Clinica prescribes samples for long periods of time occasionally makes for a peculiar scene. Because the pills are packaged individually in bulky cardboard or plastic, patients are sometimes forced to carry medicine that would normally fit in a small pill bottle out by the armful.
Campbell believes the people he and his staff treat, almost all of whom are undocumented immigrants, wouldn't be forced to go to such lengths if the pharmaceutical industry realized the economic benefits of providing samples to doctors at low-income clinics.
"Even though we're talking boxes of samples to give someone a month's supply, we're seeing first hand the therapeutic effectiveness of it," he says. "I don't know if they realize that because of that we're more likely to prescribe it in our private practices to patients with insurance."