CUTRONA ET AL. RESPOND

We appreciate the comments made by Vincent et al. They raise several important points about the disadvantages of free drug sample use. Free samples tend to be newer, more costly medications.1 By influencing prescribing, samples increase pharmaceutical costs for patients.2 For indigent patients who are given prescriptions to use after the sample is exhausted, these high costs can be prohibitive, which might lead to nonadherence. Patients relying exclusively on free samples instead of using affordable generic options or patient assistance programs encounter different challenges. These patients face an inconsistent free-sample supply and difficulty returning to a provider’s office in time for a refill. They may have poor control of their chronic condition as a result,3 which might lead to increased health care expenditures. New medications are not only more costly, they are also the medications about which the least is known. New drugs are frequently released onto the market before their safety profile is fully understood.4 Vioxx (rofecoxib) was the most frequently distributed free sample in 2002; Celebrex (celecoxib) was the third most frequently distributed sample in the same year.1 The 2 medications have been associated with an increased risk of cardiovascular events. In 2004, Vioxx was withdrawn from the US market because of these safety risks. Samples bypass the pharmacist, introducing several other safety concerns. Pharmacists can capture information on allergies, drug interactions, pregnancy, or lactation. Medication inserts (frequently missing in samples)5 and pharmacist counseling can make patients aware of important side effects. Sample closets often lack the documentation necessary to instigate a safety recall6 or to reliably discard expired medications. It is possible that some uninsured patients in our study did not receive samples because their medical care is provided by practitioners who are well informed regarding the associated risks of giving out free samples: heavier financial burden, nonadherence, and safety hazards. However, recent research suggests that doctors are rarely aware of patients’ out-of-pocket costs,7 rarely communicate with patients about these costs even when patients have no insurance,8 and do not feel responsible for identifying lowest-cost options for patients.7 We therefore believe that practitioners’ redirection of free samples away from uninsured populations can be at best only a small part of the bigger story. We believe that pharmaceutical marketing and selective sampling to more affluent populations is the primary force behind our finding that poor and uninsured people were less likely to report receiving free samples. Free samples influence provider prescribing, which increases health care costs and poses safety risks. We agree that the energies of health care providers and legislators need to be focused on providing sustainable sources of affordable medication to all our patients. Free samples are not the solution.