The recent series of settlements linked with claims against advertising and pharmaceutical manufacturing companies involved in the sales and marketing of opioid drugs are encouraging, demanding accountability for promoting highly addictive drugs such as OxyContin as non-addictive. These settlements, ranging from $350 to $465 million, provide a source of optimism for those living with opioid use disorders, especially given the inclusion of funding to support the treatment of such individuals.
Yet questions about the potential future impact of these criminal and civil suit settlements on the opioid overdose epidemic remain. Coupled with the observation that opioid marketing practices have not shifted in the face of lawsuits in the past, under-recognition of addiction and overprescribing of medications with high addiction potential for pain and related conditions remain problematic.
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At the Payer Insights sessions on Day 1 of ViVE 2024, a panel on prior authorization offered compelling insights from speakers who shared the positive developments in this area after years of mounting frustration. Speakers also shared challenges as they work with providers to figure out how policy developments and technology will work in practice.
The role of marketing in the genesis of the opioid overdose crisis
Drug overdose deaths exceeded 106,000 in 2021, largely accounted for by opioids. The history of the opioid crisis dates back to the 1990’s, when opioid prescribing began surging in response to various regulatory guidelines in medicine, combined with misinformation proliferated through advertising, concerning the safety of long-term use of opioids for chronic pain. After the American Pain Society released guidelines that emphasized the importance of addressing pain at every patient visit, the healthcare field developed a culture and practice of assessing pain as a “5th vital sign.” Concurrently, the pharmaceutical industry initiated aggressive marketing campaigns to promote the use of opioid pain relievers. Marketing strategies included downplaying the risk of addiction, marketing for unapproved indications, and providing financial incentives for prescribers. Promotional materials claiming that the risk of addiction to opioid pain killers were “small,” despite the absence of supporting research, led to a false sense of confidence concerning the safety of opioids for treating non-cancer-related pain long-term.
Studies of the link between opioid overdose deaths and opioid marketing found that the more physicians there were who received opioid marketing, the higher the opioid overdose death rate in the year that followed. In fact, for each additional physician who received marketing, the overdose fatality rate was 12% higher. Interestingly, the primary source of marketing influence on opioid prescription rates was not the total dollar amount spent on marketing, but the number of interactions between marketers and physicians, such as receiving meals paid for by drug representatives. Accordingly, although some medical centers have restricted interactions between pharmaceutical sales representatives and physicians, these policies have not been widespread enough to realize large scale impact.
If lawsuits have counterproductive side effects, what can be done?
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Rather than serving as a warning to the rest of the industry, lawsuits and sanctions against major players in opioid manufacturing and advertising such as Purdue Pharma have prompted competitors to increase marketing spending by as much as 160% to promote opioid prescribing. Other compensatory strategies undertaken by opioid manufacturing companies include restructuring via mergers and acquisitions and shifting focus from pain killers to other drug development areas. Yet there is little evidence that newer products will not be targets of similar aggressive marketing practices, prompting concerns that history will repeat itself. Given the link established across studies between marketing practices and the opioid overdose crisis, a few strategic steps can form a path forward for clinicians and policymakers.
First, licensed providers who are prescribing any controlled substance with addiction potential (e.g., opioids, benzodiazepines) need education to learn ways of assessing and mitigating risk, especially among individuals who are vulnerable to addiction.
Second, licensed prescribers must be educated about the signs and symptoms of addiction and how to effectively manage and treat it, particularly addiction to prescription medications. Studies show that 1 in 4 healthcare providers received addiction training as part of their medical education, and despite the availability of highly effective, evidence-based treatments for opioid addiction, less than half of the internal and emergency medicine providers surveyed believed that opioid use disorder is treatable at all. The limited training combined with stigma attached to addiction fuels the existing problem of under detection and undertreatment of opioid and other addictions.
With broadening recognition that getting healthcare providers comfortable with the complex disease of addiction is not so simple, resources for expanding physicians’ knowledge about addiction need to be broadly leveraged.
Finally, policies around continued marketing to both physicians and consumers, particularly for medicines with high addiction potential, should be revisited. Over a decade ago, the Institute of Medicine put forth recommendations for physicians and medical centers to reduce the impact of advertising on prescribing behaviors and preserve the public’s trust in the medical profession. Though these recommendations have not been widely adopted, now is the time, before the next drug or wave of the crisis, to revisit what was learned from the opioid overdose crisis, and give full consideration to the ways clinicians and policymakers can effect change.
Photo: Jeffrey Hamilton, Getty Images
Suzette Glasner-Edwards, Ph.D. is the Chief Scientific Officer at Pelago, the leading digital clinic partner to U.S. businesses and health plans for substance use management. She is also an Associate Professor at the University of California, in the Department of Psychiatry and Biobehavioral Sciences. Her research focuses on making evidence-based treatments for addiction more accessible using digital health platforms; with NIH funding, she has developed and is evaluating, in clinical trials, technology-based treatments that deliver evidence-based behavioral therapy and medications using smartphone apps, text messaging, social media, and other digital platforms. She is the award winning author of The Addiction Recovery Skills Workbook and her new book, Addiction: What Everyone Needs to Know will be released in summer of 2024.
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