January 23, 2019

Are free meals for doctors tied to overdose deaths?

Daily Briefing

    The drug industry's direct marketing of opioids is correlated with higher opioid prescribing and opioid-related overdose mortality rates across the United States, according to a study published Friday in JAMA Network Open.

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    Study details

    For the study, researchers examined the association between the pharmaceutical industry's direct marketing of opioids to physicians and opioid-related overdose deaths. The researchers reviewed county-level CDC data on opioid prescribing rates and opioid-related overdose mortality rates, as well as CMS' Open Payments database, which contains data on direct-to-physician marketing of opioids, including low-value payments to physicians, such as meals, Kaiser Health News reports.

    The researchers compared industry marketing data from Aug. 1, 2013, to Dec. 31, 2015, to mortality data for all U.S. counties from Aug. 1, 2014, to Dec. 31, 2016. The researchers applied a one-year lag period to their analysis "to address the possibility of reverse causality by ensuring that marketing of opioids to physicians preceded observed mortality rates."

    The researchers acknowledged limitations to their study, including a lack of information on long-term marketing trends because CMS only recently began collecting data on the pharmaceutical industry's financial ties to providers, MedPage Today reports. The researchers also noted that some of the direct-to-physician marketing they reviewed for the study could have included educational materials designed to promote safer prescribing, according to MedPage Today.

    Findings

    The researchers determined between Aug. 1, 2013, and Dec. 31, 2015, the pharmaceutical industry spent $39.7 million on opioid marketing, which targeted 67,507 physicians across 2,208 U.S. counties. The researchers said there was an association between that spending, an increase in opioid-related overdose deaths from Aug. 1, 2014, to Dec. 31, 2016.

    In particular, the researchers found that, one year after drugmakers increased their opioid marketing budgets by $5.29 per 1,000 population, the number of opioid prescriptions increased by 82% and the opioid-related overdose mortality rate increased by 9%.

    The researchers said the frequency of a drugmaker's interactions with physicians appeared to have a more substantial effect on opioid prescriptions and overdose deaths than the total amount that drugmakers spent on marketing opioids. For example, the researchers said a pharmaceutical company appears to have the most influence on prescribing practices and overdose deaths when a company representative repeatedly brings lunch to a physician's office or pays for a physician's dinner. Magdalena Cerdá, a co-author of the study and director of the Center for Opioid Epidemiology and Policy at the New York University School of Medicine, said, "Counties where doctors receive more low-value payments," such as meals, "is where you see the greatest increases in overdose rates."

    The researchers concluded, "[A]mid a national opioid overdose crisis, reexamining the influence of the pharmaceutical industry may be warranted." They wrote, "Our findings suggest that direct-to-physician opioid marketing may counter [the] current national efforts to reduce the number of opioids prescribed and that policymakers might consider limits on these activities as part of a robust, evidence-based response to the opioid overdose epidemic in the United States."

    The researchers recommended that drugmakers voluntarily consider no longer marketing opioids directly to physicians.

    Comments

    Scott Hadland, the study's lead author and an addiction specialist at Boston Medical Center's Grayken Center for Addiction, said, "We've had our eyes on these drug companies making large dollar payments—often tens or hundreds of thousands of dollars—to these doctors, yet the public health problem appears to be driven by the subtle acts and the very widespread meals affecting a very large number of doctors."

    Hadland called Purdue Pharma's decision to no longer market opioids directly to physicians "an appropriate response to this crisis," noting that several medical schools no longer allow drugmakers to market their products, and New Jersey has established a cap on the direct payments a pharmaceutical company can make to a physician.

    Cerdá said, "The number of payments actually mattered more than the amount doctors were paid. We hypothesized that that's due to the fact that the more times you interact with pharmaceutical representatives, it can build more of a relationship of trust, and that can have a greater influence in the decisions that you make about what you prescribe." She said, "It's not in any way nefarious or intentional on the part of physicians," explaining, "It's really likely an unintentional change given increased awareness of the products, increased trust of the companies because of these frequent interactions." 

    Pharmaceutical Research and Manufacturers of America, which represents drugmakers, said prescribers involved in pain management "should be educated about the fundamentals of acute and chronic pain management, the range of available treatment options, and relevant benefits and risks" (Hlavinka, MedPage Today, 1/18; Knight, Kaiser Health News, 1/18; Emery, Reuters, 1/18; Ross Johnson, Modern Healthcare, 1/18; Bernstein, Washington Post, 1/18).

    Access our new resources on the opioid epidemic

    The opioid epidemic is a complex, multi-dimensional public health problem. Use this list of helpful resources on how hospitals and health systems can play a role to treat opioid addiction and prevent further increase in opioid abuse.

    Access our Opioid Resources Here

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