Let’s talk about the doctors.
Lawsuits by the Massachusetts attorney general and others have detailed Purdue Pharma’s brazen efforts to manipulate physicians into prescribing OxyContin and other potentially deadly opioids. Purdue sales reps made an astounding 150,000 visits to doctors and pharmacists in Massachusetts between 2007 and 2018. And boy, did they pay off: The AG claims the company raked in $500 million in revenue, after doctors here prescribed 70 million doses of its opioids.
But why did so many fall for Purdue’s pitch?
Some doctors were nakedly corrupt, testaments to the fact that a white coat is no guarantee of probity. The attorney general’s complaint includes examples of doctors who got tens of thousands in payments and gifts from Purdue, and who wrote blizzards of prescriptions that fed an epidemic of addictions and overdoses.
But Purdue put the hard sell on decent health workers, too: doctors and others whose prescriptions also fueled the crisis.
“Most of the patients who went to the pill-mill doctors were already hooked because of prescriptions written by well-meaning doctors,” says Dr. Andrew Kolodny, a Brandeis University researcher and head of Physicians for Responsible Opioid Prescribing.
And those professionals were distressingly easy to sway. It turns out, it doesn’t take much to persuade upstanding doctors to do what a sales rep wants: Even cheap meals — say, a lunch for $13 — can do the trick.
“The more meals they get, the more they ultimately prescribe,” said Dr. Scott Hadland, a pediatrician and addiction researcher at Boston Medical Center. His research shows that facetime is a crucial factor influencing doctors’ prescriptions. For most doctors, writing prescriptions to please a sales rep isn’t intentional, Hadland said. But physicians are persuaded by marketing, just like everybody else. Now, there’s a discomfiting thought.
And that marketing isn’t always as obvious as a hefty speaking fee or a free burrito. Purdue and other companies helped grow the market for their drugs not just through an army of sales reps, but also by changing the culture around pain: pushing the notion that there was a vast epidemic of untreated chronic pain and that opioids should be a first-line treatment rather than a last resort.
“They launched a brilliant, multifaceted campaign,” said Kolodny, who has been a paid consultant to plaintiffs who have sued Purdue. “We were hearing these messages from eminent pain specialists, from our professional societies, from our state medical boards and trade associations.”
Drug companies poured hidden millions into patient advocacy and other groups pushing opioid-friendly messages. A US Senate report found that Purdue, Insys Therapeutics (currently the subject of a federal racketeering prosecution over its sales tactics), and three other opioid manufacturers contributed a whopping $10 million to these groups between 2012 and 2017.
All of this is not to say that opioids aren’t sometimes the best treatment for people in pain. But we’re in big trouble if the decisions of trained medical professionals can be swayed by corporate marketing departments.
Massachusetts has enacted legislation designed to monitor and slow the flow of opioid prescriptions. The CDC and the Massachusetts Medical Society have narrowed guidelines, too.
But the ugly ecosystem exposed by the Purdue case goes beyond opioids. Sales reps and stealth marketing influence doctors to write more prescriptions for other potentially dangerous drugs, too, like Ritalin or Klonopin. Or to prescribe a more expensive, name-brand drug over a generic one, raising costs for everyone.
It’s hard to legislate all of that away. Instead, we need better firewalls. It’s up to doctors to protect themselves — and their patients — from the dark arts practised by Purdue and other drug companies.
Most of our hospitals already limit contact between sales reps and doctors, and prohibit or monitor payments and gifts from drug companies. Family doctors, and those in small practices, must do the same, capping their interactions with sales reps to avoid being swayed by them.
The safe dose? Zero.
Clarification: This column has been updated to note that Dr. Andrew Kolodny, a Brandeis University researcher, has been a paid consultant to plaintiffs who have sued Purdue.