Analysis of Pharmaceutical Industry Marketing of Stimulants, 2014 Through 2018

Use of prescription stimulants doubled from 2006 to 2016 in the United States¹ and, as of 2013, it resulted in more pharmaceutical expenditures for children than any other medication class.² Although the rise in stimulant use parallels increasing attention-deficit/hyperactivity disorder diagnosis rates, stimulants, even when appropriately prescribed, are commonly diverted and used nonmedically.³ It is important to consider factors that may contribute to a potential oversupply of stimulants. Pharmaceutical company marketing is associated with increased prescribing.⁴ The extent to which physicians receive marketing for stimulants is not well described.

All US industry-physician marketing interactions are compiled by the Centers for Medicare & Medicaid Services (CMS). Using these data, we characterized stimulant marketing to physicians.

Data were extracted on industry-physician marketing interactions (termed payments) occurring between January 1, 2014, and December 31, 2018, from the Open Payments database.⁵ We extracted data on nonresearch payments for stimulants listed by generic or brand name. Payments were tabulated with regard to the products marketed; the type, number, and dollar value of payments (inflation adjusted using the Consumer Price Index); and the number of unique physicians receiving payments overall and by medical specialty. Unique physicians were identified by CMS based on name, medical license number, and National Provider Identifier number. The 5-year prevalence of marketing among physicians was estimated using as a denominator the number of active physicians between 2014 and 2018 in each specialty per historical National Provider Identifier data.⁶ Medical specialties were defined by CMS in the Open Payments and National Provider Identifier databases. The study was not considered human subjects research by the Boston University School of Medicine institutional review board and was thus exempt from ethical review and informed consent procedures. Analyses were undertaken with Stata version 15.1 (StataCorp).

Between 2014 and 2018, there were 591 907 payments to physicians totaling $20 101 250 (Table 1) in the Open Payments database. The median value of payments was $14 (interquartile range [IQR], $12-18). Payments for food and beverage were the most common types (578 105 [97.7%]) and made up the greatest percentage of dollars spent ($9 988 670 [49.7%]). Median payments were highest for consulting fees ($3045 [IQR, $1920-$3750]). The most commonly marketed stimulant was Vyvanse (lisdexamfetamine), which made up 274 502 payments (46.4%) and $7 076 729 (35.2% of all dollars spent).

Annual marketing was $2 429 626 in 2014, increased to a peak of $4 817 619 in 2016, and decreased to $3 861 186 in 2018. Annually, physicians received a median of 2 payments (IQR, 1-4 payments; maximum, 286 payments) and $35 (IQR, $17-$81; maximum, $22 248) in marketing.

Overall, 55 105 physicians received payments, resulting in an estimated 5.6% five-year prevalence among 989 789 physicians. Pediatricians received the most payments (239 217 payments [40.4%]), and psychiatrists received the most marketing in dollars ($11 392 037 [56.7%]; Table 2). Pediatrics had the highest percentage of physicians receiving marketing (5-year prevalence, 19.2%).

During the 5-year study period, 1 in 18 physicians appear to have received marketing for stimulants. Payments were most typically high-frequency, low–dollar value marketing in the form of food or beverage. Pediatricians, psychiatrists, and family physicians (ie, clinicians who often care for children and adolescents) received the greatest share of marketing.

Pharmaceutical industry marketing may be partly contributing to rising stimulant-prescribing rates.⁴ The most heavily marketed product was Vyvanse (lisdexamfetamine), which is not available as a generic drug and costs more than other stimulant drugs.² Despite a misuse-deterrent formulation that prevents intranasal and injection use, Vyvanse can be used nonmedically.

Limitations of this study include its descriptive nature; associations between marketing and prescribing cannot be established. Some marketing may have been educational and served to mitigate potential underprescribing. Some physicians receiving marketing may not have had active National Provider Identifier numbers. Information on nonphysician prescribers was excluded.

In the context of rising stimulant prescribing, examining the potential role of pharmaceutical industry marketing is warranted. In particular, since prescription medication misuse commonly begins during adolescence and young adulthood, the intensity of marketing to clinicians who care for individuals at these developmental stages may deserve scrutiny.

Accepted for Publication: October 8, 2019.

Corresponding Author: Scott E. Hadland, MD, MPH, MS, Grayken Center for Addiction, Boston Medical Center, 801 Albany St, Room 2055, Boston, MA 02119 (scott.hadland@bmc.org).

Published Online: January 21, 2020. doi:10.1001/jamapediatrics.2019.5526

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

Concept and design: Hadland, Cerdá, Marshall.

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

Drafting of the manuscript: Hadland.

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

Statistical analysis: Hadland, Earlywine, Krieger.

Obtained funding: Hadland.

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

Supervision: Hadland, Cerdá, Marshall.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Hadland is supported by the National Institute on Drug Abuse (grant K23DA045085), Thrasher Research Fund (Early Career Award), and the Academic Pediatric Association (Young Investigator Award). Dr Cerdá is supported by the National Institute on Drug Abuse (grant R01DA039962). Dr Marshall is supported in part by National Institute of General Medical Sciences (grant P20GM125507).

Role of the Funder/Sponsor: The funders 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.