
Opioid makers made payments to one in 12 U.S. doctors - metheus
https://news.brown.edu/articles/2017/08/opioids-influence
======
lr4444lr
Maybe it's because Americans just have this cognitive dissonance that their
trusted doctor could be any less than 100% conscientious about their health,
but we need to plainly face the fact that if members of the press were able to
write exposés about drug makers' fudging the data about the addictiveness and
effectiveness of their products, that doctors with their medical training and
responsibility over actual people's lives should have proceeded with more
caution and not written scripts mindlessly to get rid of every tiny pain
patients had just because they kept asking for something. It's just
unconscionable.

EDIT: this survey was also very damning:
[http://www.chicagotribune.com/news/local/breaking/ct-
prescri...](http://www.chicagotribune.com/news/local/breaking/ct-prescription-
painkiller-overuse-met-20160324-story.html)

~~~
zjaffee
Your ignoring the fact that up until recently, pain was considered to be the
fifth vital sign and was just as important to treat as things like a fever.

Medicine as a field is largely about removing discomfort, as many medical
conditions could be relatively debilitating. Think how many times taking an
ibuprofen/acetaminophen just made it possible for you to go on with your day,
rather than needing to lay in bed in agony. For people with chronic pain, or
those coming out of surgery, perceived recovery time can be a big thing for
people.

Additionally, the article didn't address the fact that it could very well be
that doctors were being paid off to prescribe a particular brand of opioid
rather than just opioids in general, something that is relatively common when
there are a large number of drugs that can equally help treat a given ailment.

~~~
lr4444lr
I think you're raising an interesting point, but I disagree with your example
- what pain that is so bad its sufferer needs "to lay in bed in agony" can be
relieved by ibuprofen, acetaminophen, or any other OTC pain reliever? The
Great Binge[0] ended long ago - perhaps for the wrong reasons, but ended
nonetheless, until recently when legal opioid prescriptions spiked.

This is about doctors putting their patients at risk in the process of
treating them for routine problems which did not result in opioid addiction
rates as recently as 25 years ago, and certainly were not prescribed with any
other side benefit as far as I've heard.

[0][https://en.wikipedia.org/wiki/The_Great_Binge](https://en.wikipedia.org/wiki/The_Great_Binge)

~~~
mnm1
Headaches can easily be that bad and relieved with ibuprofen. Otherwise yeah,
it's lay in bed and try to sleep and hope they don't last into the next day.

~~~
abakker
Or, sometimes, they're not. My wife gets bad migraines. For the most part,
nothing works.

She has not tried, and is not interested in trying opioids for them, though.

~~~
GordonS
She should try sumatriptan. Works amazingly well for me.

------
elipsey
Reminds me of what Rostand said about murder: "Kill one man, and you are a
murderer. Kill millions of men, and you are a conqueror. Kill them all, and
you are a god."

Sell one oxycontin and you're drug dealer; sell a million and you're a C
level.

~~~
bostik
That can be generalised.

Petty thieves break the law. Mafiosos skirt and avoid the law. The real
kingpins write the law.

~~~
stephengillie
Smart criminals don't commit crimes; they change the laws and then act freely.

------
lootsauce
I have two relatives that died from prescription opioid addiction and abuse
and I don't think a few payments here and there is what motivates doctors to
prescribe these drugs at a higher rate. Maybe it does maybe not. The fact is
they are powerful drugs that can stop pain AND they make LOTS of money so they
get pushed as the best option.

The thing that is in question in a doctors mind is, can I say this is the best
option. Thats what the face-time with reps, meals, conferences etc are doing,
giving the MD a perception that this is best practice. It's the professional
cover to prescribe what everyone knows is a highly addictive and dangerous
narcotic.

If the same kind of money were spent on informing, reminding and reminding
again, face-time with addiction prevention advocates, conferences on the
opioid epidemic, payments for speaking on alternatives to opioids for pain
treatment, giving doctors the facts about these drugs, the addiction and death
rates, the impact on families and communities of the inevitable proportion of
people who will become addicted and of those who will die, it will be much
much harder to say this is a best practice.

But even then doctors are pushed hard to deal with as many patients as
possible. A quick answer that deals with the immediate problem is what the
patient wants and its all the doc has time and support from the system to
give. This situation lends itself to the potential for those who truly
benefit, the makers of these drugs, to take advantage of the situation and
push drugs they know will make people addicted leading to higher use and
profits. Lost lives and destroyed families be damned.

------
ransom1538
Feel free to browse doctors' opioid counts here. I was able to match them to
their actual profiles. Take into account their field, but, even with that the
numbers are ridiculous. If you are in "Family Practice" and prescribe opioids
9167 times per year you probably have a very sore hand.

[https://www.opendoctor.io/opioid/highest/](https://www.opendoctor.io/opioid/highest/)

~~~
microcolonel
> _If you are in "Family Practice" and prescribe opioids 9167 times per year
> you probably have a very sore hand._

Though Bruce D. Mackey works at a Family practice, he specializes in Pediatric
Occupational Therapy[0] (pediatrics broadly covering patients up to 21 years
of age). It's fairly common for a Family Practice to have some specialty
staff, and some such clinics have very large patient throughput. I used to be
registered to one which specialized in sports medicine, others specialize in
things like dietary/lifestyle intervention.

[0]: [https://www.opendoctor.io/bruce-d-mackey-
otr-1146468](https://www.opendoctor.io/bruce-d-mackey-otr-1146468)

------
ams6110
"the average payment to physicians was $15, the top 1 percent of physicians
reported receiving more than $2,600 annually in payments"

Neither is enough to sway most physicians IMO. This seems to me like trying to
stir up a scandal where there really isn't one.

I did hear on the radio today that 90% of prescription opiates are sold in USA
and Canada, with the bulk of that being the USA. Other countries treat pain
more holistically.

~~~
gvd
When I was living in Europe and had my wisdom-tooth removed I only got a local
anesthetic so I wouldn't feel the cutting. Recently I heard a friend of mine
(here in the US) say she was given vicodin afterwards. To me that's just
insane. Sure I was a little uncomfortable for half a day but I'm not going to
take bloody opioids because of that. It might also be the case that people
just don't ask for it as easily as in the US (I mean, it's much more common to
hear Americas place food orders with a bunch of custom stuff, Europeans
usually just order what's on the menu).

~~~
icelancer
I didn't get any pain pills after wisdom teeth. I had local anesthetic and
nitrous oxide gas to ease me, but not enough to sedate me (and obviously, no
IV).

Some people are given pain pills because their teeth are impacted and the
doctors have to break bones; the surgery is far more painful in the recovery
stage than if it goes normally.

Even still, a common theme amongst my friends who got vicodin after the
surgery was them not taking the pills, or only taking a single dose the day
after to manage the pain.

~~~
gvd
I'm not saying this happens everywhere, but there are plenty of odd cases
where medication is given way to easy. They should create some central
registry to monitor these prescriptions.

------
gayprogrammer
>> Q: What connection might there be between drug-maker payments to physicians
and the current opioid use epidemic?

The article is pure speculation. They did not correlate the payments made to
doctors with the prescriptions those doctors made, nor even more broadly with
national prescription rates.

This article just makes the implied assumption that doctors push pills onto
patients. I don't discount that at one time doctors may have been incentivized
to play it fast and loose with pain pills, but those days are LONG gone now.

I would like to see research on the population in terms of predisposition to
addiction and susceptibility to chemical dependence.

------
11thEarlOfMar
I don't like the 'pigs at the trough' image of this type of report. There are
almost certainly pigs, but there is much more to resolving it than just
revoking some licenses or throwing some people in jail.

Standard practice in business of all types is to take clients out for a meal
to talk business. Usually, the meal setting enables a different type of
legitimate, sober interaction. Many types of business are conducted this way.
Some companies have policies that limit the value of what a salesperson can
share with a client, for example, Applied Materials limits the value of any
type of entertainment by a vendor to $100. This is good corporate policy to
inhibit undue influence by vendors.

But it is not 'a payment'.

Likewise, it is pretty easy to see that pharma would want a Dr. who is
prescribing their medication and has a positive story to tell to speak at one
of their seminars. The Dr. might say that his time is worth $x, and the Pharma
needs to cover his travel expenses, and then he'd consent to presenting. In
this case, any fees paid would be considered payment. The question is, how
much is being paid and does that payment present undue influence. Many doctors
are independent contractors and can choose to do this type of activity without
a policy to override or limit the value of it. On the other hand, state
medical boards which license physicians should have policies that limit all
medical and pharmaceutical companies in how they can influence physicians.

~~~
tiggybear
I think that is ridiculous.

Learning about new medicine is continuing education for physicians. It is
their job. Having a third party paying them or even just offering dinner to
them so they can do their jobs is a huge conflict of interest.

Further, they are getting a completely biased education on these new drugs in
addition to being "taught" by pharma reps who often do not even have a BS in
life sciences...so they are very limited in being able to relay nuanced
medical information.

~~~
bionoid
> Having a third party paying them or even just offering dinner to them so
> they can do their jobs is a huge conflict of interest.

Not directly related, but my sister studied to become an audiologist some 15
years ago (in Norway). I was absolutely stunned at the corporate sponsorship -
full on weekend trips with a nice hotel room and paid drinks and fun
activities (plus a conference). Not once, but many times during the studies,
for all students, sponsored by different companies (I'm not sure if they were
competing companies, but you'd think so..)

There must be a lot of money in hearing aid for that to make financial sense..
Is/was this type of sponsorship common for students in other areas, medical or
elsewhere?

------
liveoneggs
check your doctor:
[https://openpaymentsdata.cms.gov/](https://openpaymentsdata.cms.gov/)

~~~
api_or_ipa
This really should be more widely known. TIL my doctor got a meal + beverages
worth $130. Seems reasonable compared to the national average of over $3k.

~~~
tylersmith
When I was younger I was prescribed Paxil and strongly encouraged to stick
with it despite horrible side effects. Brain shocks, hateful feelings, and
definitely horrible depression to name a few of the non-personal ones. I still
have them occasionally 6 years later. I eventually ran away from my old life,
moved across the country, and eventually stopped the Paxil and eventually got
better but not after burning a ton of bridges. After this site came out I
found the doctor had been given nearly $30k from Glaxo Smith Kline over a few
years.

------
esm
Payments may affect prescribing, but I think that system factors count for
more than many people realize. By way of an example, imagine the following
case, which is reasonably common at the outpatient medicine office I am
rotating through:

A 46 yo M with diabetes, hypertension, a 30 pack year smoking history, and low
back pain that has been treated with oxycodone ever since a failed back
operation 1.5 years ago presents to your office for routine follow-up. It's
10am, the hospital allots 15 minutes for routine appointments, and your next
patient is in the waiting room. You are his physician -- what do you
prioritize?

Smoking, diabetes, and hypertension are a perfect storm for a heart attack in
the next 10 years, so how much time do you want to spend optimizing
antihypertensive meds and glucose control? You could talk to him about
quitting smoking, which is pretty high-yield since it would lower his
cardiovascular and cancer risk. On the other hand, he doesn't seem
particularly motivated to quit right now.

You would like to see him exercise more and eat better, since his blood sugars
are not too bad yet, and you might be able to spare him daily insulin
injections. But, his back pain is so bad that walking is difficult and
exercise is out of the question. Tylenol and ibuprofen only "take the edge
off". Oxycodone is the one thing that seems to really help. He asks you to
refill his prescription, especially because "the pain is so bad at night, I
can't sleep without it".

His quality-of-life is already poor, and it would become miserable if you took
away his opioid script without providing some other form of pain control. You
believe that he might benefit from physical therapy and time. He is willing to
try PT, but he is adamant that he will not be able to "do all of the stretches
and stuff" without taking oxycodone beforehand.

You now have 7 minutes to come up with a plan he agrees on (you're there to
help him, after all), put in your orders, and read up on the next patient. How
do you want to allocate your time? What if you suggest cutting down on his
oxycodone regimen and he pushes back?

I don't know if there is a good answer. But these situations happen all the
time, and someone has to make a decision. Most doctors are normal people. The
different backgrounds, personalities, willingness to engage in confrontation
or teaching, and varying degrees of concern for public health vs. individual
patient needs, etc. lead to a variety of approaches. In the end, I think that
pharma payments have a marginal effect on most doctors who have families,
bosses, insurance constraints, a full waiting room, and are faced with the
patient above.

~~~
RhysU
Car mechanics tell you that you need a new transmission when you need a new
transmission.

------
jasonkostempski
Are there any rules that if a doctor has such a deal, it must be clearly
expressed to the patient verbally and in writing? I think that would help not
only deter doctors for making the deal at risk of being viewed as
untrustworthy but also help people who blindly trust their doctor to maybe
think twice before accepting their solution. I don't think there's a fix for
the patients that just want the drug, and as long as they're informed,
consenting adults, it should be their prerogative.

------
refurb
This should be kept in context. Let's say the manufacturer presented new data
at a conference. During that presentation they provided lunch and
refreshments. Everyone of those doctors that attended will now show up in the
CMS database.

Do we think that a $15 lunch is going to influence a physician to over-
prescribe a drug?

~~~
analog31
They could eliminate the suspicion by not buying lunch.

A relative of mine was a pharma salesman. She had a database with the lunch
preferences for every doctor on her circuit, and bought several lunches a day.

~~~
thaumasiotes
> bought several lunches a day

Sequentially, or in parallel?

~~~
analog31
Parallel. For any given clinic, she would know which doctors worked there, and
what their preferences were at the nearby take-out sandwich shops.

Whenever I used to go to a clinic, I noticed that if it was around lunchtime,
the salesmen started piling up in the lobby.

------
robmiller
There is an irony here that the US invaded Afghanistan, the world's largest
opium exporter[1].

[1]
[https://en.wikipedia.org/wiki/Opium_production_in_Afghanista...](https://en.wikipedia.org/wiki/Opium_production_in_Afghanistan)

~~~
Theodores
...and those drugs go North towards the former Soviet Union. This is chemical
warfare by other means. When our Russian friends cannot afford the heroin any
more they make 'Krokodil':

[https://en.wikipedia.org/wiki/Desomorphine](https://en.wikipedia.org/wiki/Desomorphine)

Whatever you do, don't do image or video searches on this 'flesh eating
drug'!!!

This product came about in part due to codeine being as available as aspirin
(no prescription needed) and a crackdown on heroin by the teetotal Putin.

In the USA and places like Australia 'crystal meth'/'ice' took hold in same-
but-different circumstances.

When you look at the UN report on opium cultivation in Afghanistan for 2002
you see why there was such an important need to bomb the country - those evil
Taliban ('students') had wiped out this important (to the Americans) industry.
Thankfully with the British protecting the poppy fields the trade has been
restored and we are back to business as usual.

------
ddebernardy
Is this really news? John Oliver ran a piece on the topic and the industry's
many other dubious practices over 2 years ago, and I'm quite sure he wasn't
the first to try to raise awareness.

[https://www.youtube.com/watch?v=YQZ2UeOTO3I](https://www.youtube.com/watch?v=YQZ2UeOTO3I)

~~~
tylersmith
Not everyone watches John Oliver. Lots of things you and I know would be news
to a lot people and many things they know would be news to us.

~~~
ddebernardy
Of course, but like you and I those in his team don't have a single source of
information, and as Oliver quips in said video, you know you have a problem
when your marketing practices are notorious enough to make it into TV series.

------
vkou
Not related to payments, but related to opioids:

My father broke his thumb a few weeks ago, while operating a woodchipper.
After getting a cast, he went to see a specialist, who recommended that
K-wires be surgically installed - small metal rods that go into his thumb,
until it heals, at which point they will be pulled out.

He got local anesthetic, got the wires installed, and got sent home. Because
he lives in Canada, they gave him nothing for the pain. Two days later, the
pain died down, and he's now waiting for the bones to heal.

In America, I can't imagine that doctor would get many positive reviews from
his patients, for not prescribing painkillers. Market forces would push him
towards over-prescribing... And statistically, some of his patients will
become addicted.

~~~
mnm1
Sounds like a shitty doctor. It takes longer than two days on weak opiates to
get addicted and the doctor knows that.

------
zeep
And they tell them that their patients suffer from "pseudo-addiction" and
should get more of the drugs...

------
CodeWriter23
If it walks like a marketing program and quacks like a marketing program,
guess what...

------
oleg123
bribes - or payments?

~~~
diogenescynic
In America it's all the same. Or you can call it 'lobbying' if you really want
to dress it up.

~~~
deelowe
Doctor's aren't public officials. So no, you wouldn't call it that.

~~~
alexandercrohde
Doctors have taken an oath and have a public responsibility. They are liable
for bad medical behavior (particularly if deliberate) [malpractice].

So let's not quibble over semantics.

~~~
outside1234
Believe it or not, this grew out of the threat of lawsuits if they DIDN'T
prescribe opioids because they were ignoring the "5th vital sign" (pain).

The real culprits here are the corporations - they should be liable for paying
for the treatment of the folks addicted to the drugs they pushed.

~~~
smackingly
5th vital sign is urine output :)

What is actually driving this is that income (and other hospital measures) is
tied to patient satisfaction. Don't want to lose 30k/year because I didn't
give the patient what they want.

I'm an inpatient physician (ICU), so I never prescribe chronic opioids, but I
am pretty liberal with them in the hospital. And no, I've never received a
Panera lunch for the privilege of hearing about OxyContin.

It's an extremely complex and difficult problem. I think doctors are taking
too much of the blame. Maybe we should simply ban the use of chronic opioids
for non-cancer pain (or other similar etiologies). When I was a resident, I
made all my patients sign an agreement that I would not prescribe chronic
opioids unless they had metastatic cancer, were otherwise in a hospice
facility, or I made a special exception. Don't sign? Then you find another
doctor.

I realize that will evoke some strong emotions from some of you, but you don't
see the everyday begging from patients for more opioids when they obviously
don't need them. Some people with legit use-cases will suffer under such a
scheme. And that could drive up the use of heroin.

There's no easy solution to this problem.

~~~
DanBC
> 5th vital sign is urine output :)

US doctors began prescribing many more opioids after a campaign by the VA
describing pain as the 5th vital sign. Doctors began having to ask people
about pain, which meant they had to treat that pain. The VA also said that
opioids are not addictive when used to treat pain. They're not so addictive
when used to treat acute pain, but they're more addictive when used to treat
chronic pain. Very many more people got opioids to treat chronic pain because
of this campaign.

[https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital...](https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital_Sign_Toolkit.pdf)

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/)

> It's an extremely complex and difficult problem. I think doctors are taking
> too much of the blame.

A lot of americans get opioids from doctors.

[https://www.cdc.gov/drugoverdose/data/prescribing.html](https://www.cdc.gov/drugoverdose/data/prescribing.html)

> An estimated 1 out of 5 patients with non-cancer pain or pain-related
> diagnoses are prescribed opioids in office-based settings

> However, primary care providers account for about half of opioid pain
> relievers dispensed.

Some states have between 93 and 143 opioid prescriptions per 100 people!!

~~~
smackingly
Yeah it was kind of an inside joke, as urine output is really important in
critically ill patients and I have to constantly remind my residents and
nurses of that.

As for the VA's campaign: yes, I remember it. And it's why we have those emoji
scorecards all over the hospital. Which doctors never use. My subjective
opinion is that we still vastly under-treat pain in the acute-care setting.

And I could talk all day long about how stupid the VA health system is.

