By Anna Lembke
February 13, 2018

It’s a harried morning in the clinic when suddenly there’s a good-looking guy at my office door holding out a steaming cup of coffee and a freshly baked muffin.

“Dr. Lembke,” he says, “I was just in the neighborhood and thought I’d stop by and say ‘Hi.’ Here, I brought you some coffee and a snack. I was hoping you might have a moment to chat about some exciting new information I think you’ll appreciate.”

“I’m so sorry,” I say, taking the coffee and the muffin he’s straight-arming my way. “I wish I could.” And I really do. I’d love to spend a few moments indulging in a cup of Joe with a hunky guy. “But I’m in the middle of a busy clinic day…”

“No problem,” he says, smiling brightly and thereby absolving me of my guilt. “I’ll just leave the information with you.” He hands me a couple of brochures and some sciency-looking articles.

“Great! Thanks so much. I’ll definitely read these the second I get a chance.” He leaves. I slurp, and dash off to see my next patient.

When I get a moment later in the day, I scan the brochures he left and read through the abstract of the article. I get the gist. Drug X, let’s call it, the one made by the company the hunky guy works for, is more effective with less risk than its competitors. That afternoon, I see a patient with a problem that Drug X is meant to fix, and I prescribe it.

If you were to ask me the same day if I prescribed it because of the hunky guy and the treats, I would say, “No way! You think I’m that easily bought? I prescribed it because, well, it happens to be an effective drug … I just read an article about it …”

Numerous studies show that even small gifts given to doctors can influence prescribing, whether or not doctors think they’re immune to promotion. ProPublica reported on the effects of gifts on prescribing for 150,323 physicians, and found that internists, family physicians, cardiologists, psychiatrists, and ophthalmologists who received any gifts from drug or device manufacturers prescribed a higher percentage of branded drugs overall than doctors who received no gifts.

So the fact that Purdue Pharma, the maker of OxyContin—the opioid pain reliever at the heart of the current opioid epidemic—announced on Saturday that it will no longer send out drug reps to market opioids to doctors, is actually a pretty big deal. It’s an admission of sorts that drug reps really do influence prescribing practices, an about face from previous messaging from drug companies, which implied that doctors make prescribing decisions based on the fine print on package inserts (the magnifying-glass worthy document tucked inside the box the drug comes in).

Although drug reps are just one small piece of the puzzle, and heroin and illicit fentanyl account for at least half of all opioid overdose deaths today, prescription opioids are still a huge part of the problem, and opioid prescribing has decreased only 15% to 20% since its peak in 2012, despite widespread awareness of the epidemic.

Will cutting Purdue’s sales force and eliminating OxyContin drug reps solve the opioid crisis? Of course not. The damage has already been done. But it’s a symbolic gesture, and as such counts for something. Two points for Purdue.

 

What will make a difference? Actively re-educating doctors about the real risks (there are lots) and benefits (not very many) of opioids used long-term to treat chronic pain. Creating access and reliable insurance coverage for quality opioid addiction treatment. Providing de-prescribing clinics for those dependent on dangerously high doses of opioids, but not necessarily addicted, who will need time, compassion, and support tapering off. Promoting non-opioid, non-medication treatments for chronic pain (physical therapy, massage, mind-body work).

A big question is who should pay for the remedy, or more to the point, should opioid manufacturers like Purdue Pharma foot the bill? That question will be answered in federal court, where Judge Dan Polster is presiding over a multi-district litigation case against opioid manufacturers, distributors, and retailers. To my mind, there’s plenty of evidence to date that opioid manufacturers like Purdue Pharma had a huge hand in the epidemic, and should be held partly responsible for the public health tragedy we face today.

Dr. Anna Lembke is associate professor of psychiatry and behavioral sciences at Stanford University Medical Center and author of Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop.

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