The Medicines Repurposing Program - a critical perspective

The Medicines Repurposing Program was launched on 1 March 2024. It provides a pathway for registering and subsidising off-label medicines of significant public health benefit but which sponsors have no financial incentive to pursue. This article provides a short overview and critical analysis of the program. One concern that emerges is that commercial sponsors still retain de facto veto power over which off-label uses are prioritised and so have the capacity to sway the process. Simple suggestions are proposed to help mitigate this risk.

Cost-Related Non-Adherence to Prescribed Medicines: What Are Physicians' Moral Duties?

As the price of pharmaceuticals and biologicals rises so does the number of patients who cannot afford them. In this article, we argue that physicians have a moral duty to help patients access affordable medicines. We offer three grounds to support our argument: (i) the aim of prescribing is to improve health and well-being which can only be realized with secure access to treatment; (ii) there is no morally significant difference between medicines being unavailable and medicines being unaffordable, so the steps physicians are willing to take in the first case should extend to the second; and (iii) as the primary stakeholder with a duty to put the individual patient's interests first, the medical professional has a duty to address cost-barriers to patient care. In articulating this duty, we take account of important epistemic and control conditions that must be met for the attribution of this duty to be justified.

The increasing costs of medicines and their implications for patients, physicians and the health system

Most new medicines entering the market are high-cost speciality drugs. These drugs can cost tens to hundreds of thousands of dollars per course of treatment and in some cases millions of dollars per dose. Approximately half of all spending on medicines is projected to target only 2-3% of patients, raising important questions about resource allocation. While there is no doubt that breakthrough innovations have transformed clinical care in some disciplines, it is also true that cost is becoming one of the primary barriers to treatment access and that many new medicines do not provide value commensurate with their prices. This article examines pricing trends, the reasons for high prices and their implications for access and clinical practice.

The incidence of personal importation of prescription medicines among Australians 45 and older: a cross-sectional survey

Objective This study is the first to investigate the incidence of personal importation of prescription medicines among Australians aged 45 years or older, and the reasons driving this behaviour. Methods An online survey was distributed to Australians, aged 45 years or older, who were taking prescription medicines. Recruitment was conducted via Qualtrics. The survey was completed by 1180 respondents. Results In our sample, 1.8% of respondents had imported prescription medicines in the previous 12 months, 21.9% had not taken, or had delayed taking, a prescribed medicine due to cost, 21.9% described medicines as unaffordable/very unaffordable, and 17.7% took some budgetary measure to pay for their medicines. The most significant predictors (P  < 0.001) of importation were doctors raising it as an option (1.0% vs 42.9%), awareness of the Personal Importation Scheme (0.8% vs 22.6%), believing that importing was safe (1.6% vs 20.9%), paying more than the maximum PBS co-payment for any individual medicine (0.4% vs 8.1%), higher monthly spend on medicines (1.0% vs 6%), and delaying or not taking a medicine due to cost (0.9% vs 5.0%). Almost half (44.4%) would consider importing medicines to save money. Conclusions Potentially hundreds of thousands of Australians are importing prescription medicines from abroad, and many Australians indicate they are willing to import medicines to save money.

Clinicians' Perspective on Implementing Virtual Hospital Care for Low Back Pain: Qualitative Study

BACKGROUND

Alternate "hospital avoidance" models of care are required to manage the increasing demand for acute inpatient beds. There is currently a knowledge gap regarding the perspectives of hospital clinicians on barriers and facilitators to a transition to virtual care for low back pain. We plan to implement a virtual hospital model of care called "Back@Home" and use qualitative interviews with stakeholders to develop and refine the model.

OBJECTIVE

We aim to explore clinicians' perspectives on a virtual hospital model of care for back pain (Back@Home) and identify barriers to and enablers of successful implementation of this model of care.

METHODS

We conducted semistructured interviews with 19 purposively sampled clinicians involved in the delivery of acute back pain care at 3 metropolitan hospitals. Interview data were analyzed using the Theoretical Domains Framework.

RESULTS

A total of 10 Theoretical Domains Framework domains were identified as important in understanding barriers and enablers to implementing virtual hospital care for musculoskeletal back pain. Key barriers to virtual hospital care included patient access to videoconferencing and reliable internet, language barriers, and difficulty building rapport. Barriers to avoiding admission included patient expectations, social isolation, comorbidities, and medicolegal concerns. Conversely, enablers of implementing a virtual hospital model of care included increased health care resource efficiency, clinician familiarity with telehealth, as well as a perceived reduction in overmedicalization and infection risk.

CONCLUSIONS

The successful implementation of Back@Home relies on key stakeholder buy-in. Addressing barriers to implementation and building on enablers is crucial to clinicians' adoption of this model of care. Based on clinicians' input, the Back@Home model of care will incorporate the loan of internet-enabled devices, health care interpreters, and written resources translated into community languages to facilitate more equitable access to care for marginalized groups.

How therapeutic advances have transformed the medical landscape: a primer for clinicians

Novel medicines are entering the market rapidly and are increasingly being used alone or in combination to treat illnesses of every sort. While transforming the lives of many patients, these new therapies have also forced us to reconsider the way we evaluate, use and fund medicines. This article offers a primer to help practitioners understand how the therapeutic landscape is changing and how this might impact the evidence generation, access to interventions, patient experience and quality of care.

'First ensure no regret': a decision-theoretic approach to informed consent in clinical practice

Decision theorists recognise that information is valuable only insofar as it has the potential to change a decision. This means that since acquiring more information is time-consuming and sometimes expensive, judgements need to be made about what information is most valuable to acquire, and whether it is worth acquiring at all. In this article I apply this idea to informed consent and argue that the most valuable information relates not to what the best treatment option may be but to possible futures a patient may regret. I conclude by proposing a regret-minimisation framework for informed consent that I contend better captures the true nature of shared decision making than existing formulations.

Physicians' legal duty to disclose more cost-effective treatment options: an examination of Australian civil law applied to personal importation

ObjectiveA significant proportion of Australians defer or do not fill prescriptions they require due to cost. This article explores whether, and under what circumstances, physicians have a duty to assist these patients by disclosing how they can access more affordable medicines via personal importation.MethodsThis study involved a critical examination of Australian statutory and case law pertaining to physicians' duty to disclose material information to identify key principles applicable to the context of cost-motivated personal importation.ResultsThere are several legal principles that suggest that physicians have a duty to advise patients of options for accessing more affordable medicines, including via personal importation. These include a duty to warn of inherent and non-inherent risks, a duty to disclose treatments that offer clear advantages, and a duty to facilitate access to the means for achieving patients' health goals. However, it is unclear whether, and on what grounds, responsibility for harm arising from a patient's inability to afford prescribed medicines should be attributed to the prescribing physician. Arguments supporting attribution of such a responsibility are proposed to motivate further legal, policy and ethical debate.ConclusionsPhysicians have a duty to take reasonable steps to mitigate foreseeable harm to their patients, however the law is silent on whether this duty extends to taking steps to help patients access medicines that they can afford. This investigation provides a framework to guide the development of sound policy and law on informed financial consent and economically motivated prescribing.

Promoting the personal importation of therapeutic goods: recent legislative amendments to advertising regulations may impact consumer access and understanding

ObjectiveThe personal importation scheme is a legislative mechanism that allows health consumers to import unapproved medicines under certain conditions. This article analyses the legal and policy basis for the scheme and considers how reforms to advertising laws for therapeutic goods may restrict communications about it. The article represents the first published analysis of the personal importation scheme's interaction with the communications of health professionals and buyer's clubs. It considers how these communications may be affected by legal amendments, particularly where unapproved medicines may be accessed through the scheme.MethodsAn examination of Australian therapeutic goods law concerning the personal importation scheme was conducted, including both the historical law and recent regulatory reforms. Illustrative tables were prepared to identify scheme-related advertising that may contravene therapeutic goods law. Risk estimates were allocated to several new legal rules to indicate whether health professionals or buyer's clubs would contravene these laws when promoting the scheme to health consumers for unapproved medicines.ResultsRepresentations made directly to the public by health practitioners or on buyer's clubs websites about accessing unapproved therapeutic goods through the personal importation scheme are likely to contravene one or more advertising laws.ConclusionsThe Therapeutic Goods Administration has very strong powers to initiate compliance or enforcement action for advertising breaches in Australia for many promotional practices. Arguably, in the age of the internet and in the context of emerging expensive medicines, these powers should not be used to restrict health practitioners or buyer's clubs from sharing information about the lawful personal importation scheme to health consumers in need. Nevertheless, the study finds that health practitioners who promote or refer to the availability of unapproved medicines through the personal importation scheme outside of a consultation are likely to contravene the law and may be subject to disciplinary or enforcement action.

Do doctors have a responsibility to help patients import medicines from abroad?

Almost any medicine can be purchased online from abroad. Many high-income countries permit individuals to import medicines for their personal use. However, those who import medicines face the risk of purchasing poor-quality products that may not work, or that may even harm them. Many people are willing to accept this risk for the opportunity to purchase more affordable medicines. This is especially true of individuals from low socioeconomic backgrounds who already struggle to afford the medicines they need if they are not subsidised by insurers or if copayments are high. As medicine prices and out-of-pocket healthcare spending continue to climb, the online marketplace provides an important alternative for individuals in high-income countries to source medicines. In this article, I argue that doctors have a responsibility to help patients access medicines online and I propose a framework that can be used to facilitate responsible personal importation.

Situating commercialisation of assisted reproduction in its socio-political context: a critical interpretive synthesis

BACKGROUND

In many countries, ART service provision is a commercial enterprise. This has benefits, for example creating efficiencies and economies of scale, but there are also concerns that financial imperatives can negatively impact patient care. The commercialisation of ART is often conceptualised as being driven solely by the financial interests of companies and clinicians, but there are in fact many complex and intersecting socio-political demands for ART that have led to, sustain and shape the industry.

OBJECTIVE AND RATIONALE

To use the academic and policy discourse on the commercialisation of ART to build a theoretical model of factors that influence demand for ART services in high-income countries in order to inform potential policy responses.

SEARCH METHODS

We searched electronic databases for journal articles (including Web of Science, Scopus, PubMed) and websites for grey literature, carried out reference chaining and searched key journals (including Human Reproduction, Fertility and Sterility). The terms used to guide these searches were ‘assisted reproductive technology’ OR ‘in virto fertilization’ AND ‘commerce’ OR ‘commercialisation’ OR ‘industry’ OR ‘market’. The search was limited to the English language and included articles published between 2010 and 2020. We used an established method of critical interpretive synthesis (CIS) to build a theoretical model of factors that influence demand for ART services in high-income countries. We developed initial themes from a broad review of the literature followed by iterative theoretical sampling of academic and grey literatures to further refine these themes.

OUTCOMES

According to contemporary academic and broader socio-political discourse, the demand for ART has arisen, expanded and evolved in response to a number of intersecting forces. Economic imperatives to create sustainable national workforces, changing gender roles, and concerns about the preservation of genetic, national/ethnic, and role-related identities have all created demand for ART in both public and private sectors. The prominence given to reproductive autonomy and patient-centred care has created opportunities to (re)define what constitutes appropriate care and therefore what services should be offered. All of this is happening in the context of technological developments that provide an increasing range of reproductive choices and entrench the framing of infertility as a disease requiring medical intervention. These socio-political drivers of demand for ART can be broadly organised into four theoretical categories, namely security, identity, individualisation and technocratisation.

LIMITATIONS, REASONS FOR CAUTION

The primary limitation is that the interpretive process is ultimately subjective, and so alternative interpretations of the data are possible.

WIDER IMPLICATIONS

Development of policy related to commercial activity in ART needs to account for the broad range of factors influencing demand for ART, to which commercial ART clinics are responding and within which they are embedded.

STUDY FUNDING/COMPETING INTEREST(S)

This project was supported by a National Health and Medical Research Council Ideas Grant (APP1181401). All authors declare they do not have a conflict of interest in relation to this work.

Personal Importation and the Law: Protecting Patients Who Import Medicines for Legitimate Health Care Needs

Australians who cannot access medicines locally are able to find most medicines for sale online. Australia's therapeutic goods legal regime permits individuals to purchase medicines directly from overseas suppliers via the Personal Importation Scheme. Individuals can either import medicines for their own use or that of an immediate family member. For some patients, importing medicines is the only way they can access the medicines they need due to lack of availability or affordability in Australia. This article analyses the therapeutic goods law to clarify offences that may apply to those who import medicines for their own use or that of an immediate family member. Considering the findings, legislative amendments are recommended for the purpose of protecting patients who import medicines for legitimate health care needs.

Regulating autologous stem cell interventions in Australia: updated review of the direct-to-consumer advertising restrictions

Objective This paper provides an update and overview of the law governing direct-to-consumer (DTC) advertising of autologous stem cell interventions (ASCIs) in Australia. It follows significant changes to the advertising regulations made in 2018. Methods The paper reviews the three primary sources or 'centres' of law regulating ASCIs in Australia, together with the relevant guidance documents that supplement these sources. It provides analysis of how the post-2018 advertising regulations, contained in the Therapeutic Goods Act 1989 (Cwlth), apply to all 'biologicals', including ASCIs. It demonstrates how these three sources of law interact with one another and outlines the new tiered offence regime that applies to contraventions of these prohibitions. Results The analysis demonstrates that DTC advertising of ASCIs in Australia is strictly controlled, with primary legislation prohibiting the advertising of biologicals altogether. Conclusions The polycentric legal regime regulating biologicals in Australia clearly makes DTC advertising of ASCIs unlawful. Health practitioners who promote ASCIs, either online, in print or in other media forms, may be penalised in different ways and by different authorities. What is known about the topic? Although several analyses have examined the regulation of ASCIs in Australia, no analysis has studied the reforms made in 2018 relating to the advertising of biologicals. As such, this analysis contributes a fresh examination of these relatively recent reforms. What does this paper add? This analysis clarifies the effects of these new advertising regulations, providing clear guidance on the relevant legal provisions for the benefit of health practitioners and health professionals more generally. What are the implications for practitioners? Health practitioners, especially those who offer ASCIs, should be aware that civil and criminal penalties are likely to be imposed on individuals who promote biologicals in Australia by any means.

Consumer perspectives of accelerated access to medicines: a qualitative study

PURPOSE

In this study, the authors aimed to explore consumer perspectives on accelerated access to medicines. The authors were particularly interested in how they balance competing considerations of safety, efficacy, equity and access; whether and how their views change when there are different levels of uncertainty surrounding the safety and efficacy of new medicines; and the procedures that they think should be used to make decisions about accelerated access to new medicines.

DESIGN/METHODOLOGY/APPROACH

This was an exploratory qualitative study. Thirteen semi-structured interviews with patient advocates and two focus groups with patients were conducted and analysed thematically. Interviews and focus groups were audio recorded and transcribed verbatim. Data were analysed through inductive thematic analysis.

FINDINGS

Participants outlined a range of justifications for accelerated access, including addressing unmet medical needs and encouraging further research and development. However, they were also cognisant of the potential risks and viewed ongoing data collection, disinvestment and market withdrawal as ways to address these. They also emphasised the importance of transparent decisions being made by people with relevant expertise, based on a thorough consideration of scientific evidence and stakeholder perspectives.

ORIGINALITY/VALUE

This is the first study to comprehensively explore Australian consumers' views of accelerated access to medicines. The results suggest that consumers want timely access to new medicines, but not at the expense of safety, efficacy, equity and sustainability. While accelerated access programs are likely to be welcomed by consumers, they must be fully informed of their conditions and limitations, and robust post-market data surveillance must be implemented and enforced to protect the interests of both individual patients and the broader community.

A survey of Australian public attitudes towards funding of high cost cancer medicines

BACKGROUND

In the past decade many novel, and in some cases transformative, cancer medicines have entered the market. Their prices and the amount spent on them by governments have increased rapidly, bringing to the forefront trade-offs that must be made. In this paper we explore the Australian public's attitude towards the funding of high cost cancer medicines (HCCM) to inform reimbursement and health technology assessment (HTA) policy.

METHODS

A survey consisting of 49 questions about the funding of HCCMs was developed by the investigators. Recruitment was conducted via Qualtrics. 1039 Australian adults completed the survey.

RESULTS

The Australian public overwhelmingly supports funding of HCCMs (95.5 %) to enhance equity of access (97.8 %), and to respond to patients' needs (98 %). When respondents were challenged to balance equity versus access in different contexts inconsistencies emerged. Different demographic factors were important in predicting support for various strategies.

CONCLUSION

Our results suggest that the Australian public strongly supports government funding of HCCMs and values both equity and access. Equally, however, the public is uncertain about how equity and access are to be balanced and achieved, and such ambivalence needs to be both further explored and accommodated in policy processes. Our results may be used by policymakers in Australia, and countries with similar systems and values, to further develop policies and processes for funding HCCMs.

Emergency department care for low back pain: Should we adopt recommendations from primary care guidelines?

ED visits for low back pain are increasing, but the lack of specific guidance for emergency physicians impedes evidence-based care, and adopting primary care recommendations may not be appropriate. The ED sees a different spectrum of low back pain presentations, where physicians are likely to encounter a larger proportion of patients with an underlying serious pathology or non-spinal diseases than in primary care. Current low back pain guidelines do not adequately cover screening for these conditions, but making a differential diagnosis is crucial in emergency patients with low back pain. In this article, we also discuss the challenges in developing specific ED guidelines for low back pain, the limited evidence on the profile of these patients and the surprising dearth of randomised trials.

"Some sort of fantasy land": A qualitative investigation of appropriate prescribing in cancer care

RATIONALE, AIMS, AND OBJECTIVES

Increasing the appropriateness of prescribing has long been a focus of government, non-government, and professional organizations. Progress towards this is made difficult by the fact appropriate prescribing remains inconsistently defined and is the subject of ongoing intense disagreement. In this study, we attempted to understand why this is the case within the context of oncology and haematology.

METHODS

We performed a qualitative empirical analysis of semi-structured interviews with 16 Australian oncologists and haematologists.

RESULTS

We found that oncologists framed appropriate prescribing in terms of the following inter-related, and at times opposed, values: civic mindedness, hope and compassion, realism, and virtue in motivation.

CONCLUSIONS

These values cannot be ranked a priori, and therefore, any definition of appropriate prescribing must be aligned with what communities want from their health system. When one value is privileged over another in any specific context, a compelling argument must be provided to justify the choice. In an era of shared decision making, patient rights, and high-cost medicines, we need to reassess what we mean by appropriate prescribing in cancer care.

Are my religious beliefs anyone's business? A framework for declarations in health and biomedicine

Conflicts of interests (COI) are typically divided into those that are financial and those that are not. While there is general agreement that financial COIs have a significant impact on decisions and need to be declared and managed, the status of non-financial COIs continues to be disputed. In a recent BMJ feature article it was proposed that religious beliefs should be routinely declared as an interest. The article generated over 41 responses from the medical community and health researchers, which put forward diverse and opposing views. In this paper, we analyse the discourse to shed further light on the reasons put forward for and against declaring religious beliefs. We argue for a middle path in which only material beliefs should be declared, and then only when there are no extenuating circumstances. To this end, we present a framework to help evaluate the materiality of interests that can be used for both financial and non-financial interests.

Unconventional Practice, "Innovative" Interventions and the National Law

This column explores a recent health profession disciplinary case which throws light on the problems of unconventional interventions by medical practitioners under the Health Practitioner Regulation National Law Act 2009 (Qld). The case involved "innovative" practices which were later found to have been scientifically unsupported, dangerous to patients and grounds for cancelling the health practitioner's registration. This column looks at common features of these kinds of cases in Australia and then examines recent attempts by the Medical Board of Australia to draft policy guidance around the use of unconventional practice in medicine. This column concludes with a number of changes to improve the effectiveness of the proposed policy.

A return to reasonableness and virtue in medical epistemology

The foundationalist and anti-foundationalist conceptions of medical knowledge have been at loggerheads for decades. Evidence-based medicine (EBM), the most prominent form of foundationalism, has attained wide appeal and acceptance among authorities. It proposes that evidence is the "base" upon which all clinical decisions should be grounded. Others have countered that the clinical encounter is far too complex for a singular base, and the different factors that impose on a clinical decision cannot be neatly and permanently ranked a priori. By its very nature, this anti-foundationalist outlook has resisted simplistic description, which is perhaps the reason it has not been as popular. In this paper, I provide a survey of the foundationalist and anti-foundationalist debate in medicine and defend anti-foundationalism on the basis that foundationalist approaches are anachronistic, and in the case of evidence-based medicine ultimately confuses inputs (evidence) for consideration in making a judgement with outputs (conclusions). I further propose that virtue ethics is inseparable from anti-foundationalism and conclude that the current infatuation with EBM implies something rather troubling; that physicians cannot be trusted to utilize their extensive training and skills to make reasonable decisions in the best interests of their patients. If this is in fact true, it suggests a crisis in virtue amongst medical professionals.

Does Consumer Engagement in Health Technology Assessment Enhance or Undermine Equity?

Consumer engagement in decisions about the funding of medicines is often framed as a good in and of itself and as an activity that should be universally encouraged. A common justification for calls for consumer engagement is that it enhances equity. In this paper we systematically critique this assumption. We show that consumer engagement may undermine equity as well as enhance it and show that a simple relationship cannot be assumed but must be justified and demonstrated. In concluding, we present a number of challenges that need to be overcome in order for consumer engagement to contribute to health technology assessment in a morally and politically sound manner.

Australian regulation of autologous human cell and tissue products: implications for commercial stem cell clinics

In 2018, Australia’s Therapeutic Goods Administration introduced regulatory reforms that set stricter criteria around the regulation of products derived from a patient’s own cells and tissues, posing significant implications for clinics offering stem cell treatments. We review the regulatory framework and discuss its potential commercial implications, including the ambiguities that may arise from it in practice, as well as the likely impact it will have on product development and advertising practices in the future.

'Treat them into the grave': cancer physicians' attitudes towards the use of high-cost cancer medicines at the end of life

The prescribing of high-cost cancer medicines at the end of life has become a focus of criticism, due primarily to concerns about the safety, efficacy and cost-effectiveness of these medicines in this clinical context. In response to these concerns, a number of interventions have been proposed - frequently focused on improving physician-patient communication at the end of life. Underpinning these strategies is the assumption that the prescribing of high-cost cancer medicines at the end of life is primarily the result of poor communication on the part of cancer physicians. In this paper, we explore the factors perceived by cancer physicians to be driving the use of high-cost cancer medicines at the end of life. Drawing on semi-structured interviews with 16 Australian oncologists and haematologists, we demonstrate that these physicians believe that the use of high-cost medicines at the end of life is driven by multiple factors - including individual, interpersonal, socio-cultural and public policy influences. We conclude that these factors, and their interactions, need to be taken into account in the development of public policy and clinical interventions to address the use of high-cost medicines at the end of life.

Caution needed in introduction of provisional approvals for medicines

The Australian government recently released its response to the Review of Medicines and Medical Devices Regulation, accepting most recommendations. One recommendation involves the introduction of provisional approvals for perceived life-saving and innovative new treatments, allowing these to be approved on the basis of more limited data on the condition that further safety and efficacy data (including real-world evidence) are collected to determine whether full approval should be granted. However, experience with similar schemes overseas raises significant questions about the safety and efficacy of products made available through these pathways. These uncertainties are compounded by the challenges associated with the collection and use of 'real-world' data and the difficulty of withdrawing products from the market once patients and clinicians become familiar with them. Although there may be good reasons to provide patients with earlier access to medicines on the basis of provisional evidence (including providing treatment options and hope to patients with serious illnesses), we must exercise caution in order to protect both current and future patients from potentially harmful and futile treatments and ensure that healthcare systems use their resources wisely.

Access to High Cost Cancer Medicines Through the Lens of an Australian Senate Inquiry-Defining the "Goods" at Stake

Cancer is a major burden on populations and health systems internationally. The development of innovative cancer medicines is seen as a significant part of the solution. These new cancer medicines are, however, expensive, leading to limited or delayed access and disagreements among stakeholders about which medicines to fund. There is no obvious resolution to these disagreements, with stakeholders holding firmly to divergent positions. Access to cancer medicines was recently explored in Australia in a Senate Inquiry into the Availability of New, Innovative, and Specialist Cancer Drugs in Australia. We analysed the resultant Senate Report to identify competing stakeholder values. Our analysis illustrates that there are four main "goods" prioritized by different stakeholders: 1) innovation, 2) compassion, 3) equity, and 4) sustainability. We observe that, with the exception of sustainability, all of these "goods" put pressure on payers to provide access to cancer medicines more quickly and based on less rigorous evaluation processes. We then explore the consequences of giving in to such pressure and suggest that deconstructing the implicit values in calls for "enhanced access" to cancer medicines is necessary so that more nuanced solutions to the challenge of providing access to these high cost medicines can be found.

Challenges to the validity of using medicine labels to categorize clinical behavior: An empirical and normative critique of "off-label" prescribing

This study aimed to determine whether the label status of a medicine penetrates into the clinical reasoning of Australian medical practitioners and to explore the possible reasons for our findings using semistructured interviews with 14 Australian physicians. The interviews revealed 3 broad catalysts for off-label prescribing. The first of these was lack of awareness or understanding of the regulatory process in general and labels more specifically. The second was the perception that labels are not meaningful guides for clinical practice. The third was the recognition of alternative mechanisms for ensuring safe, rational, and evidence-based prescribing occurs. This research suggests that Australian physicians do not consider whether a medicine is off-label to be a reliable measure of the appropriateness of their prescribing practices. Rather, the legitimacy of prescribing practices is determined by the abilities, skills, and knowledge base of particular prescribers by a culture that encourages and supports evidence-based practice, and safe prescribing. Although labels are of minimal clinical significance, there are real conceptual, practical, and moral problems associated with conflating "good" or "better" practice with "on-label" practice, and "bad" or "worse" practice with off-label prescribing as often occurs. To ascribe greater meaning to the term "off-label" than is warranted can have the unintended consequence of casting suspicion on and making it more difficult for physicians to provide appropriate clinical care. We conclude that labeling can, in some cases, provide assurances to both clinicians and patients that their medications have been demonstrated to be safe and effective, but that clinicians should be able to continue to prescribe responsibly off-label without having any stigma attached to their practice.

The complex legal and ethical issues related to generic medications. Viral hepatitis: a case study

The economic impact of medications is significant, with many countries unable to afford the essential medicines listed by the WHO. Generic medications are one strategy to address this issue. Generic medications are similar to but not the same as originator medications. They have a significant cost advantage because they do not require the background research and development studies to support registration. Consequently, they are gaining increased market share in both the developed and developing world. Many new medications are now licensed to generic manufacturers in the developing world. As a result, it is possible for patients to bypass regulatory and cost barriers by importing medications directly from generic producers. Importation of the novel hepatitis C direct-acting antiviral therapy into Australia before it was registered in the country is an illustrative case study. This review will characterise generic medications and some of the legal and ethical issues around their utilisation, focusing on the relevant players, including pharma, government, patients and doctors.

The Right to Health: Implications for the Funding of Medicines in Australia

Australia’s health system is characterised by an ongoing tension between a commitment to utility and a commitment to individual rights. This tension is particularly problematic for the Australian Government when deciding which cancer medicines to add to the Pharmaceutical Benefits Scheme in order to make them cheaper for patients. This article investigates how the right to the highest attainable standard of health has influenced decisions about funding high-cost cancer medicines in Australia. It considers the value of the right to health for funders and concludes that resource allocation decisions should not be entirely informed by the right to health. It is maintained that, instead, regard should be had to the cost-effectiveness and affordability of cancer treatments before they are subsidised.

Off-Label Promotion of Prescription Medicine: Is It Ever Justifiable?

Off-label promotion has attracted intense scrutiny from regulators in recent decades, resulting in many pharmaceutical companies paying hefty penalties for illegal marketing practices. At the same time, the pharmaceutical industry has accused governments of applying double standards by encouraging the use of cheaper off-label alternatives to registered treatments, and defended their "right" to promote off-label drugs on freedom of speech grounds. However, the debate about off-label promotion and the prescribing that results has largely failed to address the issue that really matters-what impact does off-label promotion and prescribing have on patients and the health system? This paper explores the benefits and problems with off-label prescribing to determine whether off-label promotion is ever justified and, if so, under what conditions.

Evidence, regulation and 'rational' prescribing: the case of gabapentin for neuropathic pain

RATIONALE, AIMS AND OBJECTIVES

In 2004, the pharmaceutical company Warner-Lambert paid US $430 million to resolve criminal and civil legal liability for aggressive off-label marketing of gabapentin. Perhaps surprisingly, however, regulatory and legal concerns regarding the marketing of gabapentin has not significantly impacted upon the attitude of doctors towards using gabapentin for neuropathic pain. In this paper, we attempt to understand the reasons for this discrepancy between clinical practice and regulatory/legal concerns through an analysis of published discussions about gabapentin prescribing.

METHODS

We performed a qualitative empirical analysis of the published clinical debate surrounding the use of gabapentin for the management of neuropathic pain.

RESULTS

The ongoing use of gabapentin for neuropathic pain was primarily driven by the perception that it was a safe, non-addictive drug with few drug interactions, by possible similarities between the physiology of chronic pain and other neurological conditions, by the well-established clinical precedent of using antiepileptic drugs in pain management, and by the lack of alternative options available in the market. Emerging evidence of lack of effectiveness and controversies about the integrity of the scientific record appeared to be of relatively little importance to practising clinicians.

CONCLUSIONS

Those who want to promote 'rational' prescribing need to recognize that prescribing is driven by many factors other than epidemiological data and regulatory indications and that even intensely negative publicity about medicines may not penetrate clinical reasoning. This suggests that a range of measures may be needed to 'incentivize' rational prescribing and to promote research integrity. Regulators must be more sensitive to the contextual issues that are relevant to clinical practice when evaluating drugs for approval and developing guidelines.