Which Physicians Prescribe More Opioids?
There is no free lunch.
Currier & Ives—A free lunch
This post was earlier posted in Psychology Today in a slightly altered form.
You heard the prescription opioid crisis is getting better? If so, I commend the May 30, 2018 issue of the Chicago Tribune.
Karen Kaplan in the Chicago Tribune brought to my attention a Research Letter by Scott E. Hadland and colleagues.1 We learn that there has indeed been a slight reduction in deaths from physician-prescribed opioids, but 40% of fatal overdoses still involve them.
If that doesn’t alarm you this will. Prescription opioids are the first drug taken by those who eventually overdose on heroin and illicit fentanyl. Illicit drug overdoses are now increasing. As the prescription drugs became more expensive on the street than the illicit drugs, for example, heroin became cheaper than prescription fentanyl or OxyContin.
But that’s just the background of the Hadland research. His group wondered if physicians who had received monetary-based benefits—such as fees for speaking or free meals—from drug companies would prescribe more opioids than those who did not, previously an unresolved question. They compared non-research payments made in 2014 to physicians (from the Open Payments database) to opioid prescribing practices in 2015 (from the Medicare Part D Opioid Prescriber Summary File).
369,139 physicians prescribed opioids in 2015. While 25,767 (7%) of them received $9,071,976, just 436 (1.7%) received more than $1000. Half the payments came from INSYS Therapeutics (manufactures Subsys, a fentanyl sublingual spray) with Teva and Janssen Pharmaceuticals second and third in amounts expended. Payments were for speaking fees and/or honoraria, meals, travel, consulting, and education (the smallest expenditure).
Total opioid prescribing decreased slightly from 2014 to 2015 for Medicare recipients, from 60.1 million to 59.8 million Medicare claims. Physicians receiving no drug company benefits had fewer claims in 2015, while physicians receiving benefits had more claims. Receipt of any opioid-related monetary benefit in 2014 was associated with a 9.3% increase in opioid claims in 2015. As a graphic example, the more the number of free meals, the greater the increases in prescribing!
Hadland and colleagues emphasize that this does not prove the 2014 benefits caused the 2015 prescribing increases. Indeed, it could be that physicians are predisposed by other factors to prescribe. It is best to say there is an association rather than cause.
Nonetheless, with a strong national effort to curtail prescribing opioids they propose two options based on their findings:
- Manufacturers voluntarily curb or completely stop marketing efforts that provide financial gain to physicians
- Federal and state governments consider legal limits on the amounts and numbers of payments for physicians.
Addressing this group of physicians receiving drug company benefits cannot be expected to resolve the crisis, it’s only 7% of all prescribers. But this group includes those physicians receiving monetary benefits for speaking and touting the value of various opioids, ignoring the fact that there is no proven benefit for chronic pain in using them at all.2 Their falsehoods would be under cut—and their impact on the remaining, very large group of physicians would be nonexistent. Although only a few, they have had a profound impact on their unwary colleagues. That was an early pattern in the spread of prescription opioids. Respected, well-paid physicians went “on the circuit” with slides and travel provided for them by their pharmaceutical sponsors. Going from medical groups to teaching institutions to conventions, they spread the erroneous word that the new opioids, like OxyContin, were safe because they were less addicting and less subject to abuse than older drugs like morphine.
Recall that physicians in training receive next to no clinical experience using opioids and managing the frequently associated mental disorders of chronic opioid users. By curtailing drug company support for teaching conferences, we can remove the negative impact of their “teaching.” For example, they often provide free meals for trainees in return for being able to present their drug at an academic teaching conference.
“There is no free lunch.”
Peter Trimming from Croydon, England—Seen on Brownsea Island, Dorset.
If you’re a squirrel, there is such a thing as a free lunch.
1. Hadland SE, Cerda M, Li Y, Krieger MS, Marshall BDL. Association of Pharmaceutical Industry Marketing of Opioid Products to Physicians With Subsequent Opioid Prescribing. JAMA Intern Med 2018:E1-2.
2. Centers for Disease Control and Prevention. Prescribing Opioids for Chronic Pain. In: Prevention CfDCa, ed. Washington, DC: CDC; 2016.