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Pharmaceutical perks have significant impact on prescribing rates

PharmaceuticalA US study shows the significant impact that even a meal or two paid for by a pharmaceutical company can have on opioid prescribing rates, despite a national decline of in these rates. Researchers from Boston Medical Centre's Grayken Centre for Addiction examined pharmaceutical payments from 2014, ranging from consulting fees to meals, and found that doctors who received any opioid pharmaceutical marketing increased their prescribing in 2015, writing 9% more opioid prescriptions than doctors who received no marketing.

The study authors recommend that opioid pharmaceutical manufacturers consider voluntarily decreasing or ceasing marketing to physicians and that federal and state governments should also consider setting legal limits on the number and amount of payments that can be made to physicians.

The researchers looked at pharmaceutical marketing in 2014 using the Open Payments database, where they compiled information on all opioid-related payments to physicians. This includes industry-sponsored meals, speaking fees/honoraria, education, travel, consulting fees, and education. They also gathered data from Medicare Part D claims, where they studied physicians who wrote opioid prescriptions (new and refill) for Medicare beneficiaries in 2015.

The authors identified 369,139 physicians who prescribed opioids under Medicare Part D in 2015, a sample representing 43% of actively practicing physicians in the US. In 2014, 7% of these physicians (25,767) received a total of 105,368 opioid-related pharmaceutical company payments amounting to $9,071,976. The three companies with the highest payment totals were INSYS Therapeutics ($4,538,286), Teva Pharmaceuticals USA ($869,155) and Janssen Pharmaceuticals ($854,251).

Receipt of any opioid marketing in 2014 was associated with 9.3% more opioid claims in 2015. The vast majority of opioid marketing was meals, which comprised 92% of the number of payments and had a median value of $13. For each additional meal that physicians received, the number of opioids they prescribed increased. Only a small group of 436 physicians, or 1.7% of physicians receiving marketing, received payments totalling more than $1,000.

"These results indicate that while payments from opioid pharmaceutical companies to individual physicians are typically small in value, the impact on prescribing habits is quite large when considered across the entire workforce," said Dr Scott Hadland, lead author and addiction expert at BMC's Grayken Centre.

Consistent with national trends, the overall number of Medicare opioid claims decreased slightly between 2014 and 2015 (60,055,242 in 2014 to 59,822,155 in 2015), and physicians who received no opioid-related marketing had fewer opioid claims in 2015 compared to 2014. However, physicians who did receive such payments had more opioid claims in 2015 compared to 2014.

"As we continue to confront this pressing public health issue, every avenue must be explored, including marketing practices by pharmaceutical companies," added Hadland, who is an assistant professor of paediatrics at Boston University School of Medicine. "Our data suggest that the influence of marketing on physicians' prescribing is subtle yet widespread, and the pharmaceutical industry must look beyond their bottom lines and make changes to their marketing strategies in order to play a role in helping curb opioid overdose deaths."

"State and federal authorities should improve regulation and oversight of direct to physician marketing of opioid-related products," said Dr Brandon Marshall, associate professor of epidemiology at Brown University School of Public Health, who served as the study's senior author. "In light of our findings that even free meals influence opioid prescribing, legal limits should be placed on both the number of payments and amount of money spent on pharmaceutical opioid marketing."

Abstract
Introduction: Despite the increasing contribution of heroin and illicitly manufactured fentanyl to opioid-related overdose deaths in the United States, 40% of deaths involve prescription opioids.1 Prescription opioids are commonly the first opioid encountered in a trajectory toward illicit consumption.2 Although opioid prescribing has declined nationally, rates in 2015 were triple those in 1999 and remain elevated in regions of the country with higher numbers of overdoses.3
Pharmaceutical industry marketing to physicians is widespread, but it is unclear whether marketing of opioids influences prescribing.4 We studied the extent to which pharmaceutical industry marketing of opioid products to physicians during 2014 was associated with opioid prescribing during 2015.
Methods: We linked 2 US databases. From the Open Payments database, we obtained information on all transfers of value from pharmaceutical companies to physicians (“payments”) during 2014.5 We identified all nonresearch payments involving opioid products, excluding buprenorphine hydrochloride marketed for addiction treatment. From the Medicare Part D Opioid Prescriber Summary File, we obtained information on all claims from physicians who wrote opioid prescriptions (initial or refill) filled for Medicare beneficiaries during 2015.6 We included all physicians with complete, nonduplicate
information who had at least 10 opioid claims during 2015, and matched physicians across databases using name and location.7
We analyzed 2015 opioid claims in relation to marketing using multiple linear regression. Covariates included 2014 opioid claims and the change in total drug claims from 2014 to 2015. We also analyzed 2015 opioid claims in relation to opioid-related marketing meals in 2014, adjusting for these covariates and receipt of industry payments other than meals. Claims were log10-transformed to address skewed data. The study was considered exempt by the Brown University Institutional Review Board.
Results: In 2015, 369 139 physicians prescribed opioids under Medicare Part D and met study inclusion criteria. In 2014, 25 767 (7.0%) of these physicians received 105 368 nonresearch opioid-related payments totaling $9 071 976. Only 436 (1.7%) physicians received $1000 or more in total. The 3 companies with the highest payment totals were INSYS Therapeutics (which manufactures Subsys, the fentanyl sublingual spray; $4 538 286), Teva Pharmaceuticals USA ($869 155), and Janssen Pharmaceuticals ($854 251). Marketing included speaking fees and/or honoraria ($6 156 757; n = 3115), meals ($1 814 340; n = 97 020), travel ($730 824; n = 1862), consulting fees ($290 395; n = 360), and education ($79 660; n = 3011). Payments for meals were reported for 25 471 physicians and had a median payment value of $13 (interquartile range, $11-$17).
Total opioid claims for Medicare beneficiaries decreased from 60 055 242 in 2014 to 59 822 155 in 2015 (mean [SD] difference per physician, −0.6 [138.6]). Whereas physicians receiving no opioid-related payments had fewer opioid claims in 2015 than in 2014 (mean [SD] difference, −0.8 [114.4]), physicians receiving such payments had more opioid claims (mean [SD] difference, 1.6 [317.1]). In multivariable modeling, receipt of any opioid-related payments from industry in 2014 was associated with 9.3% (95% CI, 8.7%-9.9%) more opioid claims in 2015 compared with physicians who received no such payments (Table).
Each meal received in 2014 was associated with an increasing number of opioid claims in 2015 (Figure). In multivariable modeling, each additional meal was associated with an increase of 0.7% (95% CI, 0.6%-0.8%) in opioid claims.
Discussion: Of physicians who prescribed opioids under Medicare Part D, 7.0% received nonresearch payments related to opioid products in 2014. These payments were associated with greater opioid prescribing in 2015. One company, INSYS Therapeutics, accounted for 50% of the nonresearch payments.
Our findings add to prior studies of industry marketing to physicians by examining receipt of payments in 1 year and prescribing in the subsequent year, and adjusting for overall prescribing trends.
Limitations include the possibility of reverse causality because physicians who receive industry payments may be predisposed to prescribe opioids. Our findings establish an association, not cause and effect.
Amidst national efforts to curb the overprescribing of opioids, our findings suggest that manufacturers should consider a voluntary decrease or complete cessation of marketing to physicians. Federal and state governments should also consider legal limits on the number and amount of payments.

Authors
Scott E Hadland; Magdalena Cerdá; Yu Li; Maxwell S Krieger; Brandon DL Marshall

[link url="https://www.bmc.org/news/press-releases/2017/08/09/one-12-doctors-accepts-payment-pharmaceutical-companies-related"]Boston Medical Centre material[/link]
[link url="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2681059"]JAMA Internal Medicine abstract[/link]

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