A recent analysis from CNN and the Harvard School of Public Health reveals a strong correlation between opioid prescribing and industry payments. Among doctors who wrote at least one opioid prescription between 2014 and 2015, doctors who prescribed more opioids were more likely to receive money from a pharmaceutical company than doctors who prescribed the median amount. Additionally, the more opioids doctors prescribed, the more money they received from pharma, on average.
These findings are certainly “powerful” and “disturbing,” as experts have said in reaction to the study. But unfortunately, for those who have been following industry involvement in clinical practice, these results are not surprising.
Payments to clinicians from the pharmaceutical and medical device industries are extremely common. In 2015, almost half (48%) of all doctors in the US received some kind of payment from the drug or medical device industry, according to a JAMA study.
Kickbacks are illegal, but it’s not illegal for pharma to pay physicians fees for speaking, consulting, meals, travel, and more. These payments are widespread; doctors in every state and every specialty receive payments, according to ProPublica‘s Dollars For Docs, a database of all the reported payments to doctors from 2009-2015. This data is available because of a provision in the Affordable Care Act known as the Physician Payments Sunshine Act, which requires drug and device companies to report the payments they make to doctors.
CNN reports millions of dollars paid to doctors by companies that make opioids, but these payments are just the tip of the iceberg. Using ProPublica‘s database, we looked at all pharmaceuticals that had at least $10 million in payments to doctors between 2013 and 2015. The indications for these drugs run the gamut, from diabetes to Parkinson’s to skin disorders and more.
But the drugs for which companies paid the most to doctors were not opioids – they were cancer drugs, blood thinners, and drugs to treat mental health conditions. Companies also shelled out a substantial amount (more than $150 million) for drugs to treat diabetes and multiple sclerosis. (For breakdown of payments by drug type, brand name, and company, see the chart below.)
The researchers of the CNN/Harvard report acknowledge that correlation is not causation; paying doctors for consulting and speaking does not necessarily lead them to prescribe more medications. However, it is “cementing the idea for these physicians that prescribing this many opioids is creating value,” said Dr. Michael Barnett, assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health, quoted in CNN. The article also includes stories of patients who felt pushed into taking opioids and later found out their doctor was being paid hundreds of thousands by opioid manufacturers. These connections are hard to ignore.
We should be concerned about the same effects if industry payments on physician prescribing when it comes to other drug categories. A report from the DC Department of Health found that pharma payments to doctors for new diabetes drugs like Invokana contributed to a 350% increase in Medicaid spending for diabetes between 2010 and 2014. This could be worth the cost if the new drugs were significantly better than existing drugs, but there is no evidence that new combination drugs offer an additional clinical benefit compared to cheap generic drugs like metformin. Report author Dr. Susan F. Wood explained how payments can turn into prescriptions:
“Physicians who are thought leaders and experts receive much larger-value gifts as well as speaking and consulting fees and travel. They then influence the field by speaking at conferences or educational activities. We see this happening quite regularly.”
The efficacy of new cancer drugs has also been called into question. The majority of the cancer drugs approved in the past two years have no evidence they extend survival at all. Only one in five were shown to improve overall survival for 2.5 months, the goal for new drugs set by the American Society of Clinical Oncology. The amount of money being paid to doctors for cancer drugs that can cost patients hundreds of thousands of dollars, when there’s such a small clinical benefit, is concerning.
Industry payments to physicians does not necessarily mean physicians are being “bribed” to write more prescriptions. But if paying physicians did not increase the sales of their medications, why would pharma spend hundreds of millions to do it? We’ll be eagerly watching this lawsuit, to find out if our suspicions about these financial conflicts of interest are true.