The Insidious Relationship between Pharmaceutical Marketing to Physicians, Opioid Prescriptions, and Overdose Deaths

In 2017, as opioid-related deaths surpassed deaths from car accidents and gun homicides combined, the Trump Administration declared the opioid crisis a public health emergency. Since then, policymakers have responded with solutions ranging from pharmacological remedies to prescription drug monitoring programs; however, there has been little accountability of those who have profited off of the epidemic. While the criminal actions of pharmaceutical companies contributing to the opioid epidemic have received significant media attention, there has been far less focus, and little research, on the role that pharmaceutical marketing to physicians played in creating the opioid epidemic.

In a recent study, Hadland et al. sought to determine the association between pharmaceutical companies’ direct-to-physician marketing of opioid products, opioid prescribing rates, and mortality from prescription opioid overdoses. To do so, they linked county-level data from August 2013 to December 2016 across several national databases and obtained data on opioid-related deaths, opioid prescriptions, pharmaceutical marketing, and sociodemographic characteristics. Hadland et al. obtained data on overdoses and opioid prescribing rates from the Centers for Disease Control and Prevention (CDC); data on pharmaceutical marketing to physicians from the Centers for Medicare & Medicaid Services (CMS) Open Payments database; and sociodemographic characteristics from the U.S. Census Bureau’s American Community Survey. This linkage of data across disparate sources allowed researchers to not only analyze the association of pharmaceutical marketing with opioid overdoses, but also to assess the mediating role of opioid prescriptions.

The researchers then measured the relationship between opioid marketing from 2013-2015 and mortality rates from prescription opioid overdoses one year later, using three major markers of pharmaceutical opioid marketing to physicians: marketing spending in dollars, number of payments to physicians, and number of physicians receiving marketing. The researchers found that all three measures of pharmaceutical companies’ direct-to-physician opioid marketing were correlated with increased mortality rates. Additionally, they found that mortality rates were most strongly correlated with the number of payments made to physicians and most weakly correlated with marketing spending per capita. The authors speculated that the reason for this is that most marketing interactions with physicians include industry-sponsored meals, free samples, and other low-cost interactions unlikely to sum to large amounts over time. Furthermore, the researchers found that all three forms of marketing were positively associated with opioid prescribing rates.

This is valuable information for policymakers, as it provides evidence regarding which types of policy intervention are most likely to succeed. This study suggests that interventions limiting the number of payments to physicians will likely have a stronger impact on mortality rates than those limiting total annual payments to physicians. Hadland et al. cited recent regulation in New Jersey, which capped total annual payments from pharmaceutical marketers to physicians at $10,000. Such a policy, the authors argued, will likely be minimally effective because it does not address the component of pharmaceutical marketing most likely to impact mortality rates.

These results should worry physicians accepting any gifts from marketers. While some physicians may believe that pharmaceutical marketing does not affect their medical decisions due to their training, experience, and knowledge of the literature, this study suggests that their prescribing habits are, in fact, compromised by even the smallest gifts.

While prior research has assessed potential risk factors for individual patients, including genetic factors, psychiatric diseases, and social and economic determinants of health such as poverty and unemployment, this paper shows that there are systemic causes of the opioid epidemic involving pharmaceutical companies and physicians which can be addressed by either self-regulation or policymaker intervention. While there have been some attempts at stymieing the opioid epidemic already, broader efforts are clearly needed. At the same time, questions remain about the role of other actors outside of this study, such as federal bureaucrats—whose errors included inappropriate FDA approvals of opioids for long-term use and the decision to adopt pain as the “fifth vital sign” by the Department of Veterans Affairs. Given the incomplete scope of this paper, more research is certainly needed. Still, this study provides valuable insight not only for policymakers trying to combat the ongoing epidemic, but also for those who want to understand how the opioid epidemic transpired or hope to prevent similar pharmaceutical epidemics in the future.

Article source: Hadland, Scott, Ariadne Rivera-Aguirre, Brandon Marshall, and Magdalena Cerdá. “Association of Pharmaceutical Industry Marketing of Opioid Products With Mortality From Opioid-Related Overdoses,” JAMA Network Open 2(1) (2019): e186007.

Featured photo: cc/(Andrei Orlov, photo ID: 1146247155, from iStock by Getty Images)