PharmedOut Fodder:
A Million Ways to Market A Pill
By Judy Butler
Consumers may believe that doctors are taught to choose treatments based on the best-available evidence and for which benefits outweigh harms. That’s the definition of rational prescribing. Yet rational prescribing is not a given because of something not covered in medical training—pharmaceutical company influence. Pharmaceutical companies profit through the sale of new, patented drugs, so they spend millions on marketing to shape the environment in which doctors write prescriptions.
Take, for example, opioids. In 1990, the president of the industry-supported American Pain Society (APS) called for a new approach to pain, including expanded therapeutic opioid use; the APS argued that such use rarely results in addiction. APS went on to produce guidelines encouraging expanded opioid use and trumpet their slogan “Pain: The 5th Vital Sign”, adding the highly subjective concept to the four objectively quantifiable measures of temperature, blood pressure, respiration, and pulse.
Policy changes followed: in 1998 the Federation of State Medical Boards issued a policy that physicians would not face regulatory action for prescribing large amounts of opioids; the same year, the Veterans Health Administration required all clinicians to ask about patients’ pain at each visit; and in 2001 the Joint Commission (JCAHO) issued management standards requiring its accredited health care facilities to measure pain and prioritize its treatment. One need only to look at Purdue Pharma’s 2001 OxyContin marketing report to confirm industry involvement in these policies: “corporate initiatives and partnering efforts were very successful with the Veterans Administration, American Pain Society, and JCAHO in an effort to make Pain: The 5th Vital Sign. This ‘call to action’ was an important promotional initiative for Purdue. In addition to building sales for OxyContin Tablets, it also positioned Purdue as the leader in pain management education.”
By 2006, the government implemented a patient survey that would determine hospital reimbursement rates. Patients were asked, "How often did the hospital staff do everything they could to help with your pain?" thus leaving patients to assess their own treatment with possibly unrealistic expectations and without regard for rational prescribing.
These policy changes occurred alongside an unprecedented effort by Purdue Pharma to market OxyContin (oxycodone), introduced in 1996. Hundreds of highly incentivized sales reps wooed doctors based on prescribing patterns discovered with sophisticated marketing data. The company funded and trained a speakers’ bureau for medical conferences and other events, treated doctors to pain symposia at resorts, ran ads in medical journals, sponsored web sites about chronic pain, and produced promotional videos. All these efforts were backed up with commercially-influenced medical literature citing physicians and research funded with undisclosed support from Purdue. The too-good-to-be-true message behind the marketing—here’s a safe, effective, “‘virtually’ non-addicting” drug that can treat long-lasting pain.
The consequences of the opioid industry misdeeds continue. Consider a July 2018 study finding that of opioid-naive patients reporting to an emergency room for an ankle sprain, 25% were prescribed opioids from 2011 to 2015. Rational prescribing? Definitely not—inexpensive NSAIDs treat ankle sprains most effectively and opioids are unlikely to have any clinical benefit. The researchers estimate that “more than 140,000 opioid tablets could have been prevented from entering the community if opioids had not been prescribed for our study sample.” Because large numbers of tablets are commonly left over after acute pain prescriptions and are poorly secured, it’s unclear how many of these tablets may have been diverted.
The study also found that while less than 5% of prescriptions were written above 225 morphine milligram equivalents (MMEs) per day, patients with these prescriptions were nearly five times more likely to transition to prolonged use than those with lesser dose prescriptions. The study authors note that without specificity about how many tablets and MMEs constitute a day’s supply, common 5- to 7-day supply limit policies aimed at safer opioid prescribing could be above 225 MMEs per day.
It’s easy to see problems with misprescribing opioids and even easier to blame doctors for writing these prescriptions. It’s important to realize, however, the context in which these doctors’ decisions are made. The opioid industry flooded the environment with misinformation and distorted evidence reaping billions of dollars of profits along the way. These tactics continue, and not just with opioids. Is it any wonder doctors have difficulty with rational prescribing?
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