Most patients have no idea the extent to which pharma and device companies pay to influence their physicians’ beliefs and practices. Sometimes this is all a subtle dance; other times it’s outright and corrupt. Now a new study confirms and supports other studies that show what I have observed for years, that the payments of the pharma industry to doctors are directly related to their prescribing habits. In addition, a case this week filed against five physicians for blatant pay for play highlights just how bad this practice can be.
Most of the time, the payola game is subtle. More like I’ll scratch your back if you scratch mine. Other times it’s less subtle. Then there are the blatant abuses that usually make the news.
The most common form of the payola game is the use of a product in exchange for stature. Usually, a doctor who would never be asked to lecture or educate other doctors on a topic because he or she has no original research or unique experience on it can get on the podium with a slide deck from a manufacturer. This only happens if the doctor uses a lot of that product. He or she may be paid an honorarium by the conference. In this case, the manufacturer paid for sponsorship of the conference to earn a speaking slot that it can then dole out to a big user of its product. Hence, payments are happening, but it’s a round robin. It’s like Cousin Vinny paid Carmine to pay Johnny for that “thing.”
The next level up in the physician payola game is the direct payment of physicians for research, consulting, and/or speaker’s fees. These doctors are usually bigger fish, those that because of a university appointment or their influence in the field can sway other doctors. These payments are usually reported (but sometimes not) and can be looked up at Dollars for Docs. As an example, a doctor may be paid a consulting fee to provide his advice on how to market a product or how a physician may want to use it. Oftentimes, this is a nebulous consulting arrangement in that the dollars that exchange hands may or may not be actually tied to verifiable hours that physician worked. Another example is a doctor who pulls down a private grant for research and sets his office up as a clinical research site. He or she can pull down big fees per patient placed in the study with a handsome profit for the doctor. This is a bit more like Vinny paid Carmine or his niece too much money for a car out of “respect.”
Finally, there’s out and out fraudulent direct payments for use of a device or writing a prescription. This is what happened this week when five physicians were indicted on the criminal charges of accepting kickbacks for writing scripts for a fentanyl spray. There were multiple e-mails showing that sales reps for the company were placing prescribing quotas on doctors in exchange for money, gifts, lap dances at the local strip club, and trips. Here, Vinny just pays Carmine directly for that “thing.”
Prescription opioids, such as oxycodine, hydrocodone, morphine, Lorcet, Dilaudid, and so on, are narcotics prescribed by physicians to help relieve pain. The problem is that they are highly addictive and dangerous drugs with over 2 million people in the U.S. alone abusing prescription opioids. And with each passing day comes another 100-plus opioid overdose deaths—the majority due to prescription opioids. The opioid epidemic has reached staggering proportions, not just in the U.S. but globally as well, and rarely does a day go by that the news doesn’t report on the state of prescription opioid abuse in our nation. Why is this happening?
A simple look at statistics may give us a jumping-off point for answering this question. In 1991, according to the National Institute on Drug Abuse, 76 million opioid prescriptions were written in the U.S. CNN reported that in 2016, 236 million opioid prescriptions were written. That’s more than three times the amount of opioid prescriptions compared to just 25 years ago. The CDC states that between 1999 and 2010, the sale of prescription opioids to doctors, hospitals, and pharmacies quadrupled (despite the fact that pain hasn’t changed) and that, as of 2016, deaths from prescription opioids have also quadrupled since 1999!
So why the drastic increase in opioid prescriptions over the past couple of decades? A new analysis on this issue may give us some insight…
New reporting by CNN in conjunction with analysis by Harvard University suggests that over half of doctors who are prescribing opioids are getting money to do so from big pharma companies…and the more prescriptions written, the more money they are getting. The data reviewed was from 2014 and 2015 and looked at prescriptions written just for Medicare patients. The analysts reported that over 400,000 physicians wrote opioid prescriptions for these patients.
What did they discover? Fifty-four percent of these opioid-prescribing physicians received big pharma payments. However, perhaps the more disturbing finding was that the more opioids physicians prescribed, the greater the chance they got paid (e.g., 72% of physicians in the top 25th percentile received payments, 84% of physicians in the top fifth percentile received payments, and 95% of physicians in the top 10th percentile received payments). In addition, analysts revealed that the top 1% of doctors who write the most opioid prescriptions in the U.S. received four times higher pharma payments than the average opioid-prescribing physicians.
While the data would seem clearer that the top prescription writers are getting paid handsomely for their loyalty, one question still remaining, however, is whether most of these doctors are intentionally prescribing more opioids because they get stuff. Meaning are the doctors who are just receiving free lunches being psychologically led toward writing more scripts? This is where things get sketchy because while it is controversial, it isn’t illegal for big pharma to buy lunches.
On the other hand, while it’s also not illegal for pharma to pay doctors to speak and promote their drugs, IMHO, once you cross that line, you as the doctor are on the hook to perform by using that drug. For example, pharma knows that if a doctor is going to be paid to stand up in front of other physicians saying he loves drug X and here’s why, they are also purchasing a big user of the drug.
Don’t let your physician write you a prescription for opioids! Refuse it. I recently posted a study showing that opioids are no better for pain than Tylenol, so say no to opioids from the start. A terrible cycle that exists with opioids is that with each prescription, it requires more and more to attempt to address your pain. You body effectively builds up a resistance to them, so don’t get pulled into the opioid loop and put yourself at risk for a horrible and potentially deadly addiction.
The upshot? Payola in medicine takes many forms. While most doctors aren’t making hundreds of thousands or millions a year using certain devices or drugs, it’s the subtle effects and psychological games that manufacturers have mastered that drive physician behavior. Just asking a physician to get on the podium as an “expert” when he or she is likely really not an expert has a huge effect on how much of that product a doctor will use. When it comes to opioids, this is a slam dunk. Don’t buy the song and dance that these drugs are a good idea. However, it’s the myriad of other drugs and devices out there that you also need to watch out for. So just recognize that the next time your doctor recommends X, make sure it’s because X is really the best thing for you!
About the Author
Christopher J. Centeno, M.D. is an international expert and specialist in regenerative medicine and the clinical use of mesenchymal stem cells in orthopedics. He is board certified in physical medicine as well as rehabilitation and in pain management through The American Board of Physical Medicine and Rehabilitation.…