Pharma Payments to Doctors Associated With Spike in Opioid Deaths; Implications for HIV Epidemic

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Confirming what many had suspected, a new study shows a correlation between the marketing of prescription opioids to physicians, prescriptions written to patients, and higher numbers of people dying from overdoses.

The study, published in Journal of the American Medical Association (JAMA) today, sought to "identify the association between direct-to-physician marketing of opioid products by pharmaceutical companies and mortality from prescription opioid overdoses across the country."

The researchers used pharmaceutical-to-physician marketing information collected by the Centers for Medicare and Medicaid Services Open Payments database from Aug. 1, 2013 to Dec. 31, 2015 to look at any transfer of value to a doctor, and what medication was being marketed, selecting the payments that were related to an opioid medication. (The Affordable Care Act included a Physician Payments Sunshine Act that created mechanisms for more disclosure of these kinds of transactions between industry representatives and physicians.)

To determine the number of overdose deaths from prescription opioids, researchers used data collected by the Centers for Disease Control and Prevention (CDC) from Aug. 1, 2014 to Dec. 31, 2016. Using data from every county in the United States, they examined the mortality from prescription opioids, the total cost of marketing opioid drugs to doctors, the number of pharma rep interactions with doctors, prescribing rates of opioids, and sociodemographic factors.

They found that during the 29-month period, there were 434,754 payments made to 67,507 doctors by pharmaceutical companies in over 2,200 counties for nonresearch-based opioid marketing, for a total of $39.7 million. Researchers noted that the Northeast states had the highest concentration of opioid marketing, while the Midwest had the lowest. They also state that the amount of money per capita was less important than the number of payments in increasing the likelihood of overdose deaths, which suggests spreading the money out to as many doctors as possible played a greater role than making higher payments to a few doctors.

"In this study, across US counties, marketing of opioid products to physicians was associated with increased opioid prescribing and, subsequently, with elevated mortality from overdoes," the researchers write. "Amid a national opioid overdose crisis, re-examining the influence of the pharmaceutical industry may be warranted."

"The results from this study demonstrate the lethal impact of reckless pharmaceutical marketing," said Tracie Gardner, vice president of policy advocacy with the Legal Action Center. "As the nation's opioid crisis continues to escalate and evolve, we must be clear-eyed about the role of pharmaceutical industry greed and recklessness and equally damning of the clear failure of our medical system as a complicit partner to these efforts."

The study comes out just days after STAT reported on a lawsuit filed by the state of Massachusetts against Purdue Pharma, the makers OxyContin, for intentionally misleading doctors and the public by downplaying the addictive nature of the drug in order to flood the U.S. market with the dangerous opioid. The lawsuit accuses the drugmaker of doing, since 2001, exactly what the JAMA study shows happened in 2015: Using pharma reps to go into hospitals, create tight relationships with medical centers, and use their marketing payment dollars to increase the prescriptions of the opioid and to persuade doctors and medical students to combat negative reports about the drug being highly addictive and dangerous. The lawsuit accuses Purdue Pharma of targeting Tufts University Health Sciences Campus and Massachusetts General Hospital, resulting in over 70 million doses of OxyContin alone being sold in Massachusetts since 2007. And the study researchers seem to agree that these payments have helped fuel a national problem.

But as the JAMA study suggests, the issue of pharma payments to doctors contributing to the overprescribing of opioids isn't just a problem in Massachusetts. It may also have implications for increasing HIV and hepatitis C rates among white communities that have not historically been at high risk. Nationally, this issue came to prominence because of a spike in HIV diagnoses in Scott County, Indiana in 2015, a mostly white rural county where opioid use was very high. But opioid overdoses are still happening in cities and among people of color -- and people with HIV may be at particular risk.

Another study released this month in JAIDS, titled "Opioid Misuse Among HIV-Positive Adults in Medical Care: Results from the Medical Monitoring Project, 2009-2014," reported existing data showing that "people living with HIV are more likely to be prescribed opioids than those not living with HIV and at higher doses, in part because pain is a commonly reported symptom among patients with HIV infection. PLWH are also more likely to experience mental health issues and substance use disorders, which are known risk factors for opioid misuse."

They found in this study that among adults receiving HIV medical care, opioid misuse was associated with lack of adherence to antiretroviral therapy, insufficient viral suppression, and a higher risk of transmitting HIV to sexual partners.

"Today, more members of our communities are dying from drug-related overdoses than those lives lost at the height of the HIV/AIDS crisis," said William McColl, vice president for policy and advocacy with AIDS United. "Let this be a wakeup call to everyone that we cannot adequately address or end the HIV epidemic unless we also tackle the intersecting challenges posed by the harms associated with opioids and other drugs. We must renew our focus on access to prevention, treatment, housing, and harm reduction services for everyone, especially people living with HIV."

The CDC also published new data in the Jan. 18, 2019 Morbidity and Mortality Weekly Report showing that between 2014 and 2017, opioid prescription rates were higher in nonmetropolitan counties than in urban counties. And the rate of opioid prescriptions rose between 2014 and 2015 in counties that were rural or had small cities, but they fell in both urban and rural areas in 2016, when CDC released new guidance on prescribing opioids. The authors note, however, that while the rate of opioid prescriptions has fallen, the rate of opioid-related deaths has not, likely due to heroin use or opioids purchased on the street. But advocates express a need to rethink the urban-rural divide, which is often code for black/Latinx users versus white users, and the differential public empathy and treatment these groups receive from physicians, law enforcement, and the criminal justice system.

"As a result of the longstanding and scientifically inaccurate view within the health field that addiction is a moral failing rather than a health issue, physicians have not been educated or proactive in learning about the risks of prescription opioids and, as a result, have been making biased prescribing decisions based on implicit or explicit beliefs about what an 'addict' looks like," said Gardner. "It is not sufficient to increase oversight of pharmaceutical marketing practices. Medical professionals must be trained and required to understand and treat addiction -- and to simultaneously treat chronic pain patients with opioids when appropriate."