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Opioid makers made payments to one in 12 U.S. doctors (brown.edu)
270 points by metheus on Aug 18, 2017 | hide | past | web | favorite | 98 comments

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...

The problem seems to me that in the United States, the most common metric for success is money. Within most fields, if someone has a nice house, takes great vacations with the family, drives a nice car, those around them will say: Wow, { person.name } has really done well for themselves!

The example I always use is imagine two foot doctors (podiatrists). One has all those things above, the other doesn't (or at least not to the same extent). The reason the first has all those nice things is because this doctor performs the job well and makes extra money working with big pharma and big consumer-screwing insurance companies. The second doctor, while he/she also does a great job, decides not to work with big pharma or cut deals with insurance companies that screw his/her patients because that's the right thing to do.

Most people these doctors come into contact with, will not know (or even care to listen to [ever brought up server config during a family reunion?]) what goes into podiatry and what makes a good podiatrist actually good. They will perceive wealth and judge based on that for the most part. Can you really blame the doctor? They aren't being rewarded for doing the right thing, they are being penalized.

The travesty to me is that the doctors really are just being given peanuts compared to what big pharma and insurance are making with the rigged system.

A third alternative is, he just doesn't feel the need to spend all his money? They both could be making the same amount of money, with one blowing it all on random shit, and the other actually not having a need to do that?

This doesn't sounds like an issue of too much money though, it sounds like a combination of baseline compensation not yielding a high enough return, inadequate oversight agencies to catch this sort of behavior, and the consequences of being caught not being strict enough. It could even be argued that just paying more would discourage the corrupt behavior in your hypothetical examples because the doctors are taking those actions to simply make more money.

I'm just saying because of the lack of systemic solutions (or cures to fit the subject of the thread) you're describing, conscientious doctors are penalized to some extent and that's not cool.

Addendum: More oversight and regulation over all the doctors would be much more complex than just concentrating on the two enormous industries muddling the situation in the first place. Doctors' jobs have already become incredibly bureaucratized over the years and introducing more complex rules to simply address the symptoms rather than the root cause seems wasteful.

Agreed. There will always be doctors who 'bend' the rules or just don't care. Not to mention those who literally have no idea of the kind of damage they can be introducing in someone's life by prescribing certain drug. Until someone stands up to Big Pharma, the massacre will never stop.

I agree with your addendum, I actually paused for about a minute while I was writing my reply to contemplate the right word to use for current oversight. Originally I was going to say insufficient/weak oversight but that seemed too much like it implied that the solution would simply be stronger/more oversight.

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.

The problem in my mind, that the parent is intimating at, is that we confer far too much control to and assume far too much competence and beneficence on the part of physicians.

I am not saying they are a corrupt class, nor would I mean to imply that. But I do think we need to think of physicians as a part of health care, rather than at the top of it.

The entire drug regulation system is predicated on the idea that you have certain providers, namely physicians, who are competent to make decisions, and shifting that decision-making power to those providers protects us from harm.

The opioid crisis has demonstrated that whole paradigm is faulty.

The problem is that no one profession should be entrusted with that level of power or command over decisions.

Imagine, instead, a system where there was no drug regulation. Rather than assuming that physicians were making the best decisions about opioid use and sweeping the problem under the rug, such use would be constantly scrutinized.

We need more competition, and fewer gatekeepers. Gatekeeping means there's only one thing that needs to be breached.

Aren't there multiple groups that provide the guidelines for treatment? Specifically all of the specialty associations. (Gastro, Oncology...)

Going outside recommended guidelines can be very very expensive for a physician.

The understanding of opioid use has clinically changed drastically in the last 40 years, similar to SSRIs in the last 70 years.

Not that I do not agree with your premise, but the issue seems to be much more institutional and related to human, research, and implementation error than a bunch of individual bad actors.


I'm not sure I understand what you're trying to say. Is it your contention that, if anyone could get opiates without any regulation or prescription, fewer people would take them than they do now? Why would scrutiny of any kind by anyone lead to reduced usage in a case like this if that scrutiny had no regulatory effect on who could obtain narcotic painkillers?

I understand (though disagree with) the libertarian philosophy that you should be free to take anything you please, but I fail to see how such a situation would lead to decreased use.

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.


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.

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.

She should try sumatriptan. Works amazingly well for me.

Tangental - having never heard of The Great Binge described before, it's interesting to note the time period begins just at the end of the Opium Wars. Almost as though it was just a shifting of focus.

> Think how many times taking an ibuprofen/acetaminophen just made it possible for you to go on with your day...

I used to think like that. But since starting meditation practice, I've come to experience pain very differently from the way that I did before. And I've come to realize that only around 10% of pain is physical. The rest is mental...it's how your mind responds to the 10% physical pain. If I react with equanimity...distancing myself from the pain and just observing it rather than feeling it, it all but goes away.

I have more chronic pain than I've ever had and, yet, I haven't taken a single pain killer in the past 3 years. I want to believe that somehow my pain is less than everyone who's getting caught in the net of opioids and that they do really need pharmaceutical help to deal with their pain, but my experience leads me to believe otherwise...that much of their need for drug help comes from their mental state and the unproductive way they accept pain into their lives. I also can't help but wonder whether today's increasingly disconnected society leads people to seek connection with a substance rather than other people. Would we still have an opioid epidemic if people spent more time having in-person conversations and less time liking things on Facebook?

Good for you, but, even if - if!- meditation would work for everyone,it's unrealistic to expect everyone to start meditating.

Exercise is good for virtually everyone, and that's common knowledge. Yet relatively few go through the trouble.

I'm not saying that everyone should meditate. I'm only bringing it up because I think it sheds a light on the true nature of pain and why simply removing it with chemicals at all costs is a very dangerous thing to be doing. We need to better understand that nature of pain and understand how to deal with it both physiologically and psychologically rather than taking the naive approach using chemicals, because a mind-body solution will be so much more successful than one that only considers one side of the equation.

>We need to better understand that nature of pain

Pain science is a very well-researched field that gets plenty of funding and is worked on by some of the best scientists and doctors in the world who have no corrupt agenda.

There is no conspiracy. Just doctors over-prescribing opioids, patients lying to get them, and a few very corrupt "pain management" shops - primarily in Florida - handing them out like candy.

>There is no conspiracy. Just doctors over-prescribing opioids, patients lying to get them, and a few very corrupt "pain management" shops - primarily in Florida - handing them out like candy.

I would say the root problem goes far deeper. Big pharma make big politic donations which buys the ability to do this. Big pharma heavily pushed these onto Drs. Big pharma lied about the addiction potential. Big pharma fudged the facts.

I am not 100% sure of the governmental process to get moving, but their is political oversight and they have been negligent for decades, but as government bodies > big corporations seem to have a personnel revolving door, no one wants to rock the boat and lose the chance of landing a high paying job later down the line.

What about pharma that lies about the addiction potential? With billions $ on the line?

That is a reality you did not include.

> Pain science is a very well-researched field that gets plenty of funding and is worked on by some of the best scientists and doctors in the world who have no corrupt agenda.

Perhaps, but there is a fundamental problem with a purely scientific approach to a problem like this.

Science has a measurement problem when it comes to pain. You can take an entirely disciplined approach to studying the problem but there is no way to measure pain that isn't subjective on the part of the patient. There's no way to separate actual pain from psychosomatic pain, no matter how good the scientists and doctors are or how non-corrupted their agendas. It's only when you start to realize that pain is primarily a mental illness, not a physical one, that can even begin to understand it. And that's a conclusion that is very difficult to reach from a purely scientific perspective, especially since you can cause pain so easily through physiological means. I've only been able to arrive at that point through my own subjective experience in seeing just how effective an approach based on disciplined thought can be.

You know what's also a very well-researched field that gets plenty of funding and is worked on by some of the best scientists and doctors in the world? Depression. And, like pain, depression is a condition that can only be measured subjectively by the patient. Scientists can (and have) deluded themselves into thinking they're measuring it more accurately, with fMRI scans and other non-subjective physiological responses, but it's just as likely they're measuring second-order responses in the brain rather than the primary symptoms.

And, like pain killers, those doctors and scientists largely favored an approach using medication, since that approach is most amenable to being studied scientifically. But what's been realized in the past decade is that medication is no more effective than mindfulness practice, despite having significantly more side effects. And, even more recently, there's now pretty good evidence that depression may not even be a problem of the mind and, instead, may be primarily a problem in a patient's gut bacteria. Scientists, in their belief that everything mental originates in the brain, have very possibly misunderstood for decades the basic nature of the problem they were studying.

Science isn't magic. It's a way of refining our thinking on a subject, but it doesn't automatically arrive at correct conclusions when those conclusions are difficult to conceive. My personal experience with pain leads me to believe this is one of these situations. It's no knock against scientists, but given the damage that we're seeing from the side effects of pain medications, I do believe it's long past time to expand the scope of the problem they're studying.

>. For people with chronic pain, or those coming out of surgery, perceived recovery time can be a big thing for people

Chronic / serious pain yes. I read that 1/3 of people in the US are on (or perhaps have taken?) an opiod prescribed pain killer. If true, that is insane! That is not chronic pain.

* Drs have over prescribed opiate based painkillers. Fact. * Big Pharma corporations have pushed opiate painkillers recklessly. Fact * Profits became more important than the health of the customers/(patients). Fact

This has caused the death of 1000s. Yet no one actually responsible will be held accountable. Sure some Drs will lose their license, but the real guilty parties are further up the tree and will be untouchable.

Unfortunately, that seems to be the American way.

If the metric is 'has ever taken' then I would believe that number is low. Most people will get opioids after they get their wisdom teeth out.

Big Pharma companies are the problem of US health care crisis. They have figured out ways to manipulate the doctors and the patients for gains.

If you are a drug addict,there is a pill for that.

If there are side-effects to the pill you are taking to get you off addiction,there is a pill for that.

And if you take too much pills,there is a pill for that one too.

As if "taking a kickback to promote a particular pharmaceutical company's products" isn't equally bad. Yeah -- BigPharma is going to account for the kickback under "Research and Development (Of Profit)".

Let's also keep in mind that as recently as the 1970s doctors in the US often did not prescribe opioid medication, whatsoever. In some cases, even for terminally ill patients.

I think this made fertile ground for huge swing back that pharma got from prescribing it. The situation of such massive underprescribing allowed massive overprescribing, in a way.

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.

Agreed. When a C level is profiting it is hard to change course. The onion nails it http://www.theonion.com/article/sweating-shaking-pharmaceuti...

31 billion$ earned on the sale of oxycontin...


Lipitor was over $150B through it's lifecycle.

That can be generalised.

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

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

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.

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.


> 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

Also, consider that doctors must re-subscribe them every month or so. I think federal law requires the patients to have an office visit every 3 months. It's probably shorter now.

I dare say if someone went to the doctor's office and said they were hooked on pain killers and would like to be subscribed a step down prescription, they would be denied and told to tough it out, out of fear of DEA retribution. That's one of the problems with government in healthcare.

"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.

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).

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.

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.

> Neither is enough to sway most physicians IMO.

It is not just a bribe.

Companies spend a few dollars on advertisment per person to get more customers. When you can spend $2,600 on one doctor for advertisment purposes, you can do a lot to get their attention.

The question I immediately had, is which drug companies DON'T have an opiate in their lineup? Because as profitable, and easy to make as they are, I'd imagine most would qualify, and then saying "Opiod Makers".. becomes a bit misleading.

>> 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.

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.

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.

> 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?

My doctor had 16 payments in 2016. Mostly in the $10-$13 range for food and drink. Looks like a rep paying for lunch at the medical center cafeteria. Sounds a lot like "ok, I want to hear about your product, but I'm not giving up billable hours for it, so talk at lunch".

I'm not sure how doctors think, but there is no meal you can buy me that would make me go hear about your product if I didn't want to hear about your product.

The mean is $3,000 USD while the median is only $160. Some doctors must be getting a windfall.

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.

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.

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.

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

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.

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?

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.

> bought several lunches a day

Sequentially, or in parallel?

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.

Sure free lunch has always been seen as a perk even for the supposedly rational and logical people like programmers (being slightly sarcastic there). I've heard of people going for a lower paying jobs and citing free lunch as deciding factor.

Moreover there are other ways to influence doctors. In some states they have to pass certifications or exams for continued education. Pharma companies would pay the companies writing the tests to insert names of their drugs in there.

There are speaking fees and other such things. Eventually the law catches up but by then they find a new loophole.

Getting lunch from your employer isn't the same and doesn't cause a conflict of interest. Its not about the lunch but rather who the lunch is coming from.

If you worked for google and Uber was buying your lunches then there would be a conflict of interest.

I was just trying to point out that rational people will do silly things for free lunches. And the original claim that lunches wouldn't make a difference in opiod prescription is not always true.

They would not be providing lunch if it did not work. Advertising demonstrates how easy people are swayed by subconscious connections.

Yeah, but I'm not sure how much of an effect it has on the quantity of opioids prescribed. Drug lunches probably influenced which drug I prescribe (for some reason Norco was the most popular oral opioid in our hospital, maybe because it only has 2 syllables). Though I've never attended an opioid lunch.

Free lunches, pens, merchandise, cruises...all of these tactics work and have proven ROI for the drug manufacturers. They've known for years that they're worthwhile investments. It's not really the doctor's fault, it's just reality until there's stricter regulation.

It is absolutely a doctor's fault if they prescribe medications that are unnecessary because of kickbacks.

Yes, but it's also human nature, or big pharma couldn't rely on it. If we care about this stuff, it needs to be legislated or reorganized away, it's not realistic to expect 'people to do a better job'.

It's not really their fault if companies exploit their subconscious biases. They aren't taking any meaningful bribe and acting on it, they are just interacting with those companies.

Norco is common because it's a mild opioid that is able to treat the majority of "intermediate" pains. If your pain can be treated with ibuprofen you don't need urgent care. If it can't then Norco is the lightest alternative most likely to help.

I honestly think it makes a difference. People don't necessarily think about the monetary value of something. It's like paying for employees' lunches every day. At $10 each the cost is 5104= $200/month. I am pretty sure they will be more excited about free lunch than $200/month more.

Why not? When my wife worked at an insurance agency they always refered people to mechanics/etc that stopped by and gave them candy every few months. Not all doctors handle their profession with the respect and care we'd like.

Cognitive dissonance actually means that a small payment can be stronger than a large one. If you accept a large payment to listen to a pitch, it's easy to tell yourself it's just for the money. If it's not enough to believe that, then you must actually be interested in hearing about it.

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

Why then does the manufacturer spends that $15? Are you an marketing expert? On which studies and data do you base this conclusion?

Except you organize that conference in Hawaii, all expenses paid.

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...

...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':


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.

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.


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.

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.

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.

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

What? You've responded to a rigorous research paper with a completely baseless guess of what America might be like...

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

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

bribes - or payments?

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

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

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.

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.

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.

> 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.



> 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.


> 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!!

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.

I was given strong Opioids (Hydromorphone etc) for less than 3 weeks after major surgery. They clearly worked, but even that much exposure IMO was not worth the risk as I very quickly started to get cravings.

Even without getting high, freedom from pain is a ridiculously powerful motivator. And because they have such strong peaks and valleys you make a very strong association with those pills.

I was given a 30 day supply of oxy-something when I had my wisdom teeth removed. I needed 0 of the pills.

People have different pain tolerances and if you wait until it's at that point to get a prescription you'll have a real bad time. But 30 days is certainly more than necessary. They should do a few days and make it easy to get more for a couple weeks. Then require seeing the patient again for evaluation.

Well if the root is the corporation, I think civil suits have proven ineffective at preventing such abuses.

I wonder if the answer may be criminal suits and a greater emphasis on whistleblowing. Most people I know would rat out their company's immoral/illegal behavior for a million dollars.

> They are liable for bad medical behavior (particularly if deliberate)

Malpractice is in many senses a reduced standard of negligence liability compared to that faced by the general public, since it turns on established professional practice in the field not objective reasonableness in the circumstances.

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