Association of Pharmaceutical Industry Marketing of Opioid Products to Physicians With Subsequent Opioid Prescribing

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.

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.

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.

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.

Corresponding Author: Scott E. Hadland, MD, MPH, MS, Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, 88 East Newton St, Vose Hall, Room 322, Boston, MA 02118 (scott.hadland@bmc.org).

Published Online: May 14, 2018. doi:10.1001/jamainternmed.2018.1999

Author Contributions: Drs Hadland and Li had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Hadland, Cerdá, Marshall.

Acquisition, analysis, or interpretation of data: Hadland, Li, Krieger, Marshall.

Drafting of the manuscript: Hadland.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Hadland, Li, Krieger, Marshall.

Administrative, technical, or material support: Hadland, Krieger, Marshall.

Study supervision: Hadland, Cerdá, Marshall.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Hadland was supported by the Thrasher Research Fund Early Career Award, the Academic Pediatric Association Young Investigator Award, and the Loan Repayment Program Award L40 DA042434 (National Institutes of Health/National Institute on Drug Abuse [NIH/NIDA]). Dr Cerdá was supported by R01 DA039962 (NIH/NIDA).

Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Jesse Yedinak, MPA, Brown University School of Public Health, provided research and administrative assistance. Sandra Galea, MD, DrPH, Boston University School of Public Health, David Fiellin, MD, Yale University School of Medicine, and Jason Vassy, MD, MPH, SM, VA Boston Healthcare System and Harvard Medical School, reviewed the manuscript. No compensation was received for these contributions.