Health Letter, May 2019
By Meena Aladdin, M.S., Ph.D.
According to the Centers for Disease Control and Prevention (CDC), 47,600 opioid-related overdose deaths occurred in the U.S. in 2017, an alarming statistic that more than doubled in magnitude from the reported number of such deaths in 2012. Approximately 17,000 (36%) of these deaths in 2017 involved prescription opioids.
Although multiple efforts are currently underway to reduce opioid overdose deaths, a new study published in the Journal of the American Medical Association (JAMA) has found that direct opioid pharmaceutical industry marketing to physicians may be undermining these efforts, as such marketing is linked to higher rates of opioid-related overdose deaths.
JAMA study design
In order to elucidate the relationship between the direct marketing of opioids to doctors and prescription opioid-related overdose deaths, the study researchers used data from the Centers for Medicare and Medicaid Services’ (CMS’) publicly available Open Payments database — which tracks all payments made by pharmaceutical and medical device companies to doctors — and linked them with data from the CDC on prescription opioid-related overdose deaths and on opioid prescribing rates from August 1, 2013, to December 31, 2016, in a county-level analysis.
The researchers first used CDC data to identify all deaths from prescription opioid overdoses for all counties in all 50 states and the District of Columbia. Then, utilizing data from the CMS Open Payments database, they calculated the total amount of payments made to doctors in each county by pharmaceutical companies to market Food and Drug Administration-approved opioid drugs. The types of payments included in their analysis were for meals, travel costs, speaking fees, honoraria, consulting fees and educational costs. Finally, the researchers gathered data from the CDC on the number of initial prescriptions and refills for opioids that were dispensed by retail pharmacies.
The researchers’ primary outcome of interest was the county-level annual deaths from prescription opioid overdoses. They assessed whether pharmaceutical marketing of opioids to physicians affected the rate of such deaths. The researchers measured pharmaceutical marketing to physicians in three ways: total marketing value in dollars, number of payments to physicians and number of physicians receiving marketing per 1,000 people in the county.
JAMA study findings
The study found that from August 1, 2013, to December 31, 2016 approximately 435,000 payments totaling $40 million were made to 67,500 doctors in 2,200 counties across the U.S. The Northeast region had the highest concentration of opioid-related marketing. The researchers also found that opioid marketing expenditures were most highly concentrated in counties with a higher prevalence of high school completion, higher median household income, lower poverty and greater unemployment.
Most importantly, study results showed that the rate of death from prescription opioid overdoses was significantly associated with all three measures of pharmaceutical marketing to physicians but was most strongly associated with the number of payments to physicians. Similarly, opioid prescribing rates were associated with all three measures, but the number of payments made to physicians had the greatest association, which also had been observed in a previous study.
Implications and limitations of the study
These data suggest that the number of payments and interactions between pharmaceutical companies that market prescription opioids and physicians are more strongly associated with the number of opioid-related deaths than are the monetary values of these payments. This is of particular concern because frequency of interactions, irrespective of the monetary value of the payments, appears to drive physicians to increase opioid prescriptions.
Additionally, the results imply that the targets of company marketing are not selected at random, and that the socioeconomic status of specific counties may cause pharmaceutical companies to direct their advertising efforts strategically to increase opioid prescribing. It is for this reason that many states, cities and counties across the nation have filed lawsuits against opioid manufacturers and distributors. Additionally, the results imply that the targets of company marketing are not selected at random, and that the socioeconomic status of specific counties may cause pharmaceutical companies to direct their advertising efforts strategically to increase opioid prescribing. It is for this reason that many states, cities and counties across the nation have filed lawsuits against opioid manufacturers and distributors.,,
Importantly, this study has limitations. It identified associations between pharmaceutical company-to-physician marketing and opioid-related deaths, but it did not prove that advertising was a causative factor. The researchers also noted the possibility of reverse causality, in which counties with high prescription rates and high rates of opioid-related mortalities are more likely to fall prey to aggressive advertising strategies by pharmaceutical companies.
Additionally, the researchers examined deaths due to prescription opioid overdose but acknowledge that other potent drugs, such as heroin, were involved in many of these deaths. This study also did not analyze the relationship between opioid marketing and deaths due to abuse of multiple substances. Furthermore, some opioid-related deaths may have been the result of illegally procured drugs rather than drugs obtained via prescription, which the study did not examine. The data also does not explain long-term effects of opioid company marketing on opioid-related deaths. Finally, appropriate versus inappropriate opioid prescribing are indistinguishable in these datasets.
In conclusion, this study demonstrates a direct association between direct marketing of prescription opioid products by pharmaceutical companies to doctors and opioid-related mortality, as well as opioid prescription rates. In light of these results and the increasing number of opioid-related overdose deaths, pharmaceutical companies must cease marketing of opioid products to physicians.
 Centers for Disease Control and Prevention. Drug overdose deaths. December 19, 2018. https://www.cdc.gov/drugoverdose/data/statedeaths.html. Accessed April 10, 2019.
 National Institutes of Health: National Institute on Drug Abuse. Overdose death rates. January 2019. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed April 10, 2019.
 Hadland SE, Rivera-Aguirre A, Marshall BD, Cerda M. Association of pharmaceutical industry marketing of opioid products with mortality from opioid-related overdoses. JAMA Netw Open. 2019;2(1):e186007.
 Spell L. Bristol, Va files $40M lawsuits against opioid companies. Bristol Herald Courier. March 27, 2019. https://www.heraldcourier.com/news/bristol-va-files-m-lawsuit-against-opioid-companies/article_c8841424-509e-11e9-8f27-83049ebebd79.html. Accessed April 10, 2019.
 Klamann S. Rock Springs files federal suit against opioid companies, becomes latest Wyoming entity to join sprawling litigation. Star Tribune. March 20, 2019. https://trib.com/news/state-and-regional/govt-and-politics/health/rock-springs-files-federal-suit-against-opioid-companies-becomes-latest/article_355030d1-04b8-5e33-bdd6-f65bfd72e573.html. Accessed April 10, 2019.
 Associate Press. Purdue Pharma, maker of OxyContin settles opioids lawsuit in Oklahoma. STAT. March 26, 2019. https://www.statnews.com/2019/03/26/purdue-pharma-maker-of-oxycontin-settles-opioids-lawsuit-in-oklahoma/. Accessed April 10, 2019.