Drug samples are insidious. They may seem benign. They are just small quantities of a medication, dropped off in medical offices by drug company representatives, to be handed out to patients who may benefit from them. What could be more harmless than that?

Well, let’s start by defining the term “Trojan horse.” A Trojan horse is something intended to secretly undermine an opponent. Drug samples fit this definition to a T. So to speak. They are so seductive. A patient given a drug sample gains immediate gratification. The clinician is seen as even nicer and more caring than they normally are, because she or he is giving the patient something “for free.” The sample may save the patient a little money at the pharmacy. And the drug sample may prove effective for whatever condition is being treated.

OK, so far, so good. Now let’s define another phrase: “Don’t look a gift horse in the mouth.” This phrase is another way of saying do not question a gift you receive from someone. Just be grateful.

I will now submit a new phrase which, with your help, I hope to widely popularize in the English lexicon: “Do look a Trojan gift horse in the mouth.” What is the meaning of this expression? Let me deconstruct it for you. Drug samples may seem benign, even helpful. But they can serve to influence clinicians’ practice and therapeutic approach. The drug companies distribute samples as forms of advertising. They count on doctors providing the samples to patients, who will then subsequently request the same medication be provided by prescription. This is the Trojan horse component.

A large problem with this scenario is that drug samples are usually newer medications, not yet widely prescribed, and often much more expensive than established treatments. It is uncommon for samples of atenolol or metformin to be handed out. These drugs are commonly used, available generically, and do not need to be promoted. On the other hand it is not unusual for brand new hypertension or diabetes drugs to be made available as samples for doctors to hand out for free. Big pharma knows that doctors are very busy, and having a drawer-full of samples can be a tempting and time-saving resource. Once a patient gets started on a new drug provided initially as a “free sample,” they are often reluctant to switch to an older drug which is equally effective. Switching to the older drug may seem like taking a step backward. This is why physicians should look these Trojan gift horses in their mouths and question whether using samples is really a good idea.

It is especially questionable to provide samples to Medi-Cal patients, since they have no pharmacy co-pays. Providing a Medi-Cal patient a drug sample does not save them any money. If the drug sample is not on PHC’s formulary, handing it out is unlikely to save the doctor time. When the day comes to prescribe the drug initially given out as a sample, a Prior Authorization form needs to be filled out. Most commonly, the request will be denied and we will ask the prescriber to instead use a formulary medication which is just as effective. This process not only requires more physician time, it can undermine the patient’s trust in their doctor. It would have been so much easier to start with a formulary medication in the first place. Since these medications are established and well-tested, they will rarely be available as drug samples.

So, when it comes to drug samples, do yourself and your patients a favor and “Do look a Trojan gift horse in the mouth.”

Hmmm.  As I read that phrase one more time, I acknowledge it may not rapidly gain a foothold in our English language usage. So, I’m happy to borrow an alternative way of saying the same thing, which I will gladly attribute to a former first lady. When it comes to drug samples, “Just say no.”

Richard Fleming, MD