Docs Pen More Opioid Scripts When Pharma Reps Provide Perks

Megan Brooks

May 15, 2018

UPDATED May 16, 2018 // Physicians who accept free meals and other small perks from companies that manufacture opioids are more likely to prescribe these drugs to their patients, a new study suggests.

"There was a modest increase of about 9% in opioid prescribing the year after doctors got opioid marketing. When you think about this on a large scale, this has a huge impact in terms of output of opioid prescriptions," Scott Hadland, MD, MPH, from the Grayken Center for Addiction at Boston Medical Center, Massachusetts, told Medscape Medical News.

The study was published online May 14 in JAMA Internal Medicine.

Pressure to Prescribe?

"There has been a lot of attention paid to speaking fees and large sums of money going to a small number of doctors, but this study looked at the other side of the coin — the small, subtle, low-value payments that are taking place on a widespread basis around the country," said Hadland.

Using two linked databases — the Open Payments database and the Medicare Part D Opioid Prescriber Summary File — the researchers assessed the extent to which the marketing of opioid products by drug companies to physicians during 2014 was associated with opioid prescribing during 2015.

Among the 369,139 physicians who prescribed opioids under Medicare Part D in 2015, 7% accepted 105,368 nonresearch payments in 2014 that involved opioid products (excluding buprenorphine), totaling about $9 million.

Pain medicine specialists accepted the most drug company money ($2.9 million), followed by physical medicine and rehabilitation specialists ($1.8 million) and anesthesiologists ($1.4 million).

Insys Therapeutics, which makes fentanyl sublingual spray (Subsys), shelled out the most in opioid-related payments in 2014 (roughly $4.5 million). Teva Pharmaceuticals USA and Janssen Pharmaceuticals paid physicians $869,155 and $854,251, respectively.

Marketing included speaking fees and/or honoraria (about $6.2 million to 3115 physicians), meals ($1.8 million to 97,020 physicians), travel ($730,824 to 1862 physicians), consulting fees ($290,395 to 360 physicians), and education ($79,660 to 3011 physicians).

Overall, physicians wrote 0.6 fewer opioid prescriptions in 2015 than in 2014, but those who had taken opioid-related payments wrote 1.6 more opioid prescriptions.

Meal payments of a median value of $13 were reported for 25,471 physicians. In multivariable modeling, each additional meal a drug company paid for was associated with a 0.7% increase in opioid prescriptions.

A Little Money Goes a Long Way

"I truly believe that the majority of doctors are trying to do the right thing for their patient. This marketing is subtle, and I think if you asked most doctors, 'Does marketing influence your prescribing?,' my expectation is that the majority would say no," said Hadland.

"What this study really shows is that the effect is small, but when it's enacted over large populations of hundreds of thousands of doctors, it makes a big difference," said Hadland.

He noted that legislation recently introduced in New Jersey would cap annual drug company marketing payments at $10,000 per year per physician. But in this study, fewer than 2% of physicians received $1000 or more in total payments.

"It's only a very small minority of doctors that are getting a lot of money from drug companies. Instead, it's really this subtle, widespread practice of small, low-value payments for things like meals that is having the bigger public health effect," Hadland told Medscape Medical News.

"This mean we shouldn't just be looking at the total dollar value that doctors are getting per year but actually think about the number of pharmaceutical company interactions that doctors are having, because if you look at the data, each meal that a doctor received for opioid marketing was associated with more and more opioid prescribing, in an almost dose-effect type fashion," said Hadland.

Walid F. Gellad, MD, MPH, of the University of Pittsburgh Center for Pharmaceutical Policy and Prescribing in Pennsylvania, said the results of this study are not surprising. "It fits with the literature and with common sense. But it's important to document, and the study appears well executed," he told Medscape Medical News.

It's quite striking how many physicians in certain specialties received payments. Dr Walid Gellad

"It's quite striking how many physicians in certain specialties received payments — over half of pain medicine doctors and almost a third of physiatry doctors," said Gellad.

"You can debate if these payments are good or bad," he added, "but there's no debate that they are everywhere. Even more striking is that half of all nonresearch payments came from one company [Insys] whose leader and employees were indicted for conspiracy and kickbacks related to inappropriate payments for educational speakers," said Gellad.

Caitlin Carroll, director of public affairs for the Pharmaceutical Research and Manufacturers Association (PhRMA), told Medscape Medical News the organization has not expressed a point of view on this study, but she noted that PhRMA supports a "wide array of policies to ensure appropriate prescribing and pain management, including mandatory prescriber education."

The study had no commercial funding. Dr Hadland and Dr Gellad have no relevant conflicts of interest.

JAMA Intern Med. Published online May 14, 2018. Full text

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