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Direct-to-Physician Opioid Marketing Linked to Overdose Deaths (CME/CE)

Action Points

  • This population-based cross-sectional study showed that increased county-level opioid marketing was associated with elevated overdose mortality 1 year later, an association mediated by opioid prescribing rates.
  • Per capita, the number of marketing interactions with physicians demonstrated a stronger association with mortality than did the dollar value of marketing.
  • Note that the role that the pharmaceutical industry’s marketing of opioids may play in prescribing these medications and opioid-related deaths merit further investigation.

CME Author: Zeena Nackerdien

Study Authors: Scott E. Hadland, Ariadne Rivera-Aguirre, et al.

Target Audience and Goal Statement:

Pain specialists, emergency department physicians, and primary care physicians

The goal was to identify the association between direct-to-physician marketing of opioid products by pharmaceutical companies and mortality from prescription opioid overdoses across U.S. counties.

Questions Addressed:

  • Could the hypothesis be proven that counties receiving more marketing subsequently experienced a higher rate of deaths from prescription opioid overdoses?
  • Was this putative association mediated by an increase in opioid prescribing rates?

Synopsis and Perspective:

Opioids — a class of drugs that include numerous legal and illicit pain relievers — are effective for controlling many types of pain, including pain due to cancer, traumatic pain, post-surgical pain, and pain at the end of life. Currently, opioids are also prescribed to relieve severe pain in other conditions (e.g., lower back injuries, crippling arthritis, and fibromyalgia). According to a news release accompanying the 2009 guidelines on opioid therapy for chronic noncancer pain issued by the American Pain Society, “opioid pain medications are safe and effective for carefully selected, well-monitored patients with chronic non-cancer pain.”

With the number of overdose deaths involving prescription and illicit opioids more than doubling over a span of 7 years to almost 48,000 in 2017, it is clear that the U.S. is in the midst of an opioid abuse crisis. Prescription opioids are involved in 40% of all overdoses and are often the first opioids patients encounter before transitioning to illicit opioids.

Direct-to-physician marketing has been associated with increased opioid prescriptions. From 2013 to 2015, 1 in 12 U.S. physicians overall and 1 in 5 family physicians received opioid-related marketing. No prior studies examined opioid overdose deaths in association with total marketing of opioid products.

For this population-based cross-sectional study, county-level information from Aug. 1, 2013 to Dec. 31, 2016 was linked across three national databases — the CDC Wide-Ranging Online Data for Epidemiological Research Restricted-Use Mortality Files, Centers for Medicare & Medicaid Services Open Payments database, and the CDC’s National Center for Injury Prevention and Control database. The authors used a 1-year lag time between marketing (2013-2015) and mortality rates (2014-2016) in order to combat possible reverse causation.

Prescription overdose deaths at the county level, total cost of marketing opioids to physicians, number of marketing interactions, opioid prescribing rates, and sociodemographic factors served as the main outcomes and measures.

Scott Hadland, MD, MPH, MS, of the Boston Medical Center, and colleagues showed that pharmaceutical companies spent $39.7 million in non-research-based opioid marketing to 67,507 physicians across 2,208 counties. Marketing dollars were concentrated in counties marked by a higher prevalence of high school completion, greater unemployment, lower poverty, higher median household income, lower income inequality, and metropolitan location. Opioid marketing was highest in the Northeast and lowest in the Midwestern region of the U.S.

While New Jersey has already placed a cap on the total amount a drug representative can give to prescribers in that state, Hadland interpreted the study findings as showing that it was not the dollar amount that mattered, but the number of interactions that took place that impacted a doctor’s opioid prescription rates.

After appropriate adjustments, opioid overdose deaths increased with each 1-SD increase in:

  • Marketing value in dollars per capita (adjusted relative risk [RR] 1.09, 95% CI 1.05-1.12)
  • Number of payments to physicians per capita (adjusted RR 1.18, 95% CI 1.14-1.21)
  • Number of physicians receiving marketing per capita (adjusted RR 1.12, 95% CI 1.08-1.16)

Put another way, for every three extra payments made to physicians per 100,000 people in a county, opioid overdose deaths were up 18%.

“A lot of national attention has been paid to drug companies paying large amounts of money to doctors to promote their product, but what’s actually much more widespread, legal, and occurring practically all across the U.S. is much lower cost meals that drug companies offer to doctors,” Hadland said in an interview with MedPage Today in which a media relations representative was present. “That actually seems to be the more important factor of prescribing and potential overdose deaths.”

Boris Tabakoff, PhD, a pharmacology researcher at the University of Colorado who was not involved in the study commented that, in addition to regulating the quantity of marketing, the nature of these tactics should be monitored.

“These individuals that go out are called detail men, and they should live up to their names,” Tabakoff told MedPage Today. “They should detail not only the benefits of the product that they’re trying to have the physician prescribe but also the side effects and dangers.”

Tabakoff noted that because the data in this study did not indicate deaths in which other substances — such as heroin, fentanyl, or alcohol — were involved, it’s likely that many of the individuals died in this sample because of drug interactions.

Other study limitations included the fact that data sources used did not allow for the differentiation between opioids that were prescribed and those that were illicitly acquired.

Source Reference: JAMA Network Open 2019; DOI: 10.1001/jamanetworkopen.2018.6007

Study Highlights: Explanation of Findings

Almost $40 million in opioid marketing was targeted to nearly 68,000 physicians across 2,208 counties from 2013 to 2015. Hadland and colleagues showed that higher levels of marketing of prescription opioid products to physicians, especially the number of marketing interactions with physicians, were associated with more opioid prescribing and greater overdose deaths.

The authors cautioned that the U.S. still vastly exceeds the rest of the developed world in opioid prescribing. While substantial attention has been paid to the extent to which pharmaceutical company marketing practices may have contributed to the early stages of the opioid overdose crisis, their findings suggested that from 2013 onward, direct-to-physician marketing may have countered national efforts to reduce the number of opioids prescribed.

Hadland and colleagues made some policy suggestions:

  • Consider, as one manufacturer recently did, to voluntarily cease marketing of opioid products directly to physicians
  • Professional medical organizations and licensing boards should continue to support education to help physicians prescribe opioids appropriately
  • Consider the use of non-pharmacologic and non-opioid analgesics

One study implication, co-author Magdalena Cerdá, DrPH, MPH, of NYU School of Medicine in New York City, told Crain’s New York Business is that “when states or healthcare systems think about how to regulate the interactions of physicians with the pharmaceutical industry,” they may want to think about, “not only capping the total value of the payments, but also capping the number of interactions physicians can have with the pharmaceutical industry.”

Jordan Trecki, PhD, of the Drug Enforcement Administration in Washington, noted in an accompanying commentary that, as the opioid epidemic continues to grow, “it is evolving beyond prescription medications and heroin to involve illicitly produced fentanyl, fentanyl-related substances, and other opioids, either alone or in combination. It is clear that a variety of approaches will be necessary to control this epidemic.”

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