13 ms·

I was a drug rep and know how pharma companies pushed opioids

158 points by vo2maxer 7y ago

brenden2 7y ago
Title should be "I was a drug rep. I know how pharma companies pushed opioids.", as per the original article. Here's a tl;dr of the article (quoted from the article itself) to save you a click: > Medical students and doctors didn’t just learn how to assess and pay attention to patients’ pain — they also internalized the idea that prescribing opioids was a professional, even an ethical, obligation. Exaggerating the clinical significance of pain drastically expanded the market for opioids, bringing them to populations with a high risk for addiction, like adolescents.
- vo2maxer 7y ago
  The code of conduct changed around 2009 as the author points out. Prior to that time it was a torrent of all kinds of expensive gifts, which were not restricted to opioid prescriptions. The higher the number of “scripts” a physician had, the more extravagant the giveaways. Interestingly, prior to the opioid frenzy, the culture was one of great restraint often leading to under medication of pain and unnecessary suffering for patients. This was superseded by the conviction that pain had to be eliminated if at all possible, it was a physician’s moral imperative to do so. Now in hindsight, it’s clear that Pharma was driving a lot of this ethos.
docdeek 7y ago
> Since I left the industry in 2000... That's a significant time to be out of the industry and still speak with credibility about today's methods and practices. Not impossible to be entirely on point, but it would be more credible from someone closer to practices in at least the last decade.
- mThumbnail 7y ago
  I suppose if it were "since I left Google/Microsoft .." you'd be more right, but industry-wide practice is usually something that's relatively out in the open especially for former insiders
- danso 7y ago
  The author left the pharmaceutical marketing industry in 2000; now, the author works as a doctor. From the bottom of the essay: > When I was a drug rep, I really believed my pitch for our products — and I believed that by exerting influence over doctors, I helped patients access medicine they needed. As a doctor, I now have colleagues — colleagues with sharp, clinically trained minds and only the best of intentions — who think they write prescriptions on a wholly rational basis. In 2000, the author would have been witness and/or a party to the industry most excessive and unmonitored marketing practices, i.e. well before the federal push for transparency and disclosure [0]. Now, as a doctor – albeit an ER doctor, who may not be the biggest target for pharma reps – he likely has decent awareness of how both pharma marketing and doctor attitudes have changed. [0] https://www.propublica.org/article/we-found-over-700-doctors-who-were-paid-more-than-a-million-dollars-by-drug-and-medical-device-companies https://www.propublica.org/article/we-found-over-700-doctors...
philwelch 7y ago
Isn't there a professional and ethical obligation to prescribe painkillers to people who are in significant pain?
- baxtr 7y ago
  I guess it depends. In other countries, like Germany, doctors have a very different stance on people in pain. “Pain is a part of life. We cannot eliminate it nor do we want to. The pain will guide you. You will know when to rest more; you will know when you are healing. If I give you Vicodin, you will no longer feel the pain, yes, but you will no longer know what your body is telling you. You might overexert yourself because you are no longer feeling the pain signals. All you need is rest. And please be careful with ibuprofen. It’s not good for your kidneys. Only take it if you must. Your body will heal itself with rest.” From: https://www.nytimes.com/2018/01/27/opinion/sunday/surgery-germany-vicodin.html https://www.nytimes.com/2018/01/27/opinion/sunday/surgery-ge...
  - grabbalacious 7y ago
    Yes. When stubbing a toe I've historically employed two strategies for dealing with it. In my youth I would shout and hop around the room, i.e. distract myself. Nowadays I pay as much attention to the pain as is possible and practical. Remarkably this approach does seem to alleviate the pain. So my guess is that the function of pain is to direct attention to injury. Not just for thinking about ways to avoid repeat injuries but purely and simply to promote the healing response. Which is not to say that I wouldn't welcome a painkiller if the pain was great enough. It's just that the suffering caused does seems to increase with the efforts one makes to distract oneself from it.
    - Ididntdothis 7y ago
      There is a level of pain where it becomes totally debilitating and all consuming. I can meditate over light headaches or other pain but from time to time I get migraines where I either want to die or take anything that will make it go away.
thrownjustnow 7y ago
This may be completely unpopular opinion, but as a temporary user of pain killers I am thankful I was prescribed them. I was experiencing chronic and hard to diagnose pain. I was in a very dark and scary place and was constantly wondering how people without access to these medicines continue their will to live. I was having difficulty making it through a work day and as a desk worker I was able to tolerate them during the day. I am thankful my doctor was so willing to prescribe them for me. Looking back on the experience in hindsight I would have preferred to stay on them longer instead of transitioning to other medicines during physical therapy. There was a lot of suffering during that time.
- rm_-rf_slash 7y ago
  If you’re all right with my asking, where was the pain located, and from what cause?
  - mThumbnail 7y ago
    In my own case it was in the throat, literally unable to swallow anything for days due to severe pain, cause was mono. Fun fact I discovered through the ordeal is that the very act of thinking about saliva causes saliva to secrete, so it's practically impossible once you realize you have a saliva problem to stop it, since with a problem on hand you cannot but think about it and the very act of thinking about the problem causes the very problem to worsen
- carapace 7y ago
  The problem isn't that they work to relieve pain, it's that they're addictive. Anecdotally, I once knew a fellow who "accidentally" broke his own finger to get a prescription.
  - nostromo 7y ago
    They aren't addictive to the vast majority of people. In this respect it's similar to alcohol: only harmful to a small group of people, but for them very harmful. I think the key is looking for commonalities of the people at risk of addiction and finding alternative therapies for them.
RupertEisenhart 7y ago
I find it pretty terrifying how many people there are in here jumping to defend opioids. Seems kinda off-topic for an article about how predatory practices in marketing potentially harmful substances can be problematic. I mean, nobody is suggesting that opiods shouldn't be used to treat pain, are they? They are just saying that that misinformation campaigns run for the purpose of increasing profit at the expense of human lives isn't a great thing.
- alkonaut 7y ago
  There are certainly cases where opioids should be prescribed as painkillers. But in the US, when weighing two bad things (pain, and adverse effects of a drug), pain seems to be considered more important than elsewhere, since doctors prescribe more of it. It must be that elsewhere doctors more frequently say “yes, your condition is painful, but if normal painkillers don’t help, the next alternative is worse than the pain”. It’s not clear to me why this discrepancy exists. Pharma can’t be the only reason. Maybe the private insurance system is a factor (“I paid a lot for this healthcare now fix my pain or I’ll take my business elsewhere”)?
  - bobthepanda 7y ago
    Anecdotally, I have heard grumblings from nurse friends that a big annoyance is that "patient satisfaction" is now a big portion of performance reviews, since patients' satisfaction can go down for things that make them better. Keep in mind that not only insurance is a factor, but also the fact that many hospital systems themselves are private and have lots of cost pressures. A fair amount of advertising I've seen is for hospital systems.
    - jcims 7y ago
      Or patient satisfaction can go down because they are the face of a system that has many operational 'opportunities' to improve efficacy of care in the inpatient setting. They are grumbling because they have almost zero control over any of it.
    - noelsusman 7y ago
jdkee 7y ago
The fact that so much effort and so many dollars are expended to "sell" drugs to patients via the trust that doctors engender, illustrates just how broken medicine is in the U.S.
mcguire 7y ago
"When my patient’s loved ones ask how this could have happened, or start to blame themselves, I think with anger about how, for years, drug companies promoted the idea that addiction was not a common effect of the medication but rather a personal failing of the addict." Shouldn't that be, "...I promoted the idea..."
- huffmsa 7y ago
  The author says they didn't sell the opioids. Your point is valid though.
hackermailman 7y ago
It would be nice if actual statistics were floating around that identified causes of drug addiction. I grew up surrounded by crack and heroin addicts, anecdotally not a single one I met was pushed opiods by a doctor, they instead had a lifetime of drug seeking behavior and pooled money with other drug addicts, and whatever was cheap and available on the streets they took which often was heroin (now synthetics like fentanyl). In that same country pushing drugs by doctors was not common like it seems it is common in the US, yet we still had an enormous out of control street addict problem with no end in sight. It would also be interesting to see Portugal research as they decriminalized all drugs, if they still have an out of control street addict problem and culture of drug taking, or Japan research why they don't have a drug taking culture.
- danso 7y ago
  That people can become addicted to crack and heroin without being prescribed opioids does not necessarily preclude people getting addicted to opioids after being prescribed opioids.
- vo2maxer 7y ago
  One the best sources is the National Institute on Drug Abuse: https://www.drugabuse.gov/ https://www.drugabuse.gov/
- loeg 7y ago
  In 2005, the large majority of heroin addicts in the US were concurrent or former pill opioid addicts, but as of 2015 or so, it's about 50%.[1] [1]: https://www.ncbi.nlm.nih.gov/pubmed/28582659 https://www.ncbi.nlm.nih.gov/pubmed/28582659
zarkov99 7y ago
My 5 year old had to have surgery to repair a small abdominal hernea. Not a big deal, most kids recover incredibly fast and are back to running around within 2 or 4 days. We were given a prescription for enough opioids for 3 months at the maximum daily dosage. She needed one day, half the daily max.
- Terr_ 7y ago
  After some dental surgery, I was given a prescription for some powerful painkillers, and the pharmacist told me they could only fill all of it or none of it. I literally couldn't obtain a lesser amount. (And thankfully, ultimately didn't need any of it.)
  - kungtotte 7y ago
    I think that's just a property of the prescription system. Even if you were prescribed something harmless like anti-histamines it's still all-or-nothing, otherwise it would count as the pharmacy not honoring the specifics of the prescription.
- riahi 7y ago
  There's a lot of anecdotes in this thread about people being prescribed "too much". What would your anecdote be if your child was in severe pain after the surgery, occurring in the middle of the night, and you needed to get the meds after hours? What if you had to drive back in to get a paper script? What if you had to wait 2 days? I rarely (almost never as a radiologist now) write outpatient narcotic prescriptions anymore, but when I did, I often prescribed in a pattern so I could avoid people becoming uncomfortably symptomatic in an inconvenient time for them (and us). I'm not sure what the best situation here is, other than giving you the RX and telling you to not fill it?
  - zarkov99 7y ago
    There is a big difference between a reasonable margin of safety, say double what was expected, and the 3 months which was 30x the expected need. Three months is not an emergency contingency.
dwd 7y ago
Back in the early 2000s I built a web app for a big pharma that was used to compile doctor's responses to questions on survey cards that were mailed out. These could be anything from multi-choice questions about awareness of drug products, whether they prescribed particular drugs for specific treatments and I think from memory there may have been incentives like prize draws like trips to conferences for filling in the survey (return postage paid as well). I can't imagine this having changing so much (maybe more online or in partnership with clinic software) as it served as both promoting a drug for a specific treatment and identifying individual doctors responsiveness to future marketing.
- noelsusman 7y ago
  Things have tightened up a bit since then, though not completely. My dad ran hospitals for a living when I was a kid and we got tons of free tickets to sporting events from various vendors trying to sell him stuff. He would have to listen to a 10 minute pitch from some salesman (that he always made fun of later) and in return he got a free night out with the family. I remember being mad when that dried up in the mid-2000s. I later learned that CMS had implemented some regulations cracking down on the practice. These days, thanks to the ACA, you can look up exactly how much money your doctor has received from medical device manufacturers or pharmaceutical companies (https://www.cms.gov/openpayments/ https://www.cms.gov/openpayments/)
vmurthy 7y ago
Hmmm... this article seems like a real world demonstration of the principles outlined in "Influence:The Psychology of Persuasion" by Robert Cialdini [0] 1. Reciprocity - check 2. Social Proof - check 3. Authority induced bias - check 4. Scarcity - check 5. Commitment and consistency - check Damn scary how even highly qualified professionals fall prey to the same old tactics. [0] https://en.wikipedia.org/wiki/Influence:_Science_and_Practice https://en.wikipedia.org/wiki/Influence:_Science_and_Practic...

158 points by vo2maxer 7y ago

Title should be "I was a drug rep. I know how pharma companies pushed opioids.", as per the original article. Here's a tl;dr of the article (quoted from the article itself) to save you a click: > Medical students and doctors didn’t just learn how to assess and pay attention to patients’ pain — they also internalized the idea that prescribing opioids was a professional, even an ethical, obligation. Exaggerating the clinical significance of pain drastically expanded the market for opioids, bringing them to populations with a high risk for addiction, like adolescents.

vo2maxer 7y ago
The code of conduct changed around 2009 as the author points out. Prior to that time it was a torrent of all kinds of expensive gifts, which were not restricted to opioid prescriptions. The higher the number of “scripts” a physician had, the more extravagant the giveaways. Interestingly, prior to the opioid frenzy, the culture was one of great restraint often leading to under medication of pain and unnecessary suffering for patients. This was superseded by the conviction that pain had to be eliminated if at all possible, it was a physician’s moral imperative to do so. Now in hindsight, it’s clear that Pharma was driving a lot of this ethos.

docdeek 7y ago

> Since I left the industry in 2000... That's a significant time to be out of the industry and still speak with credibility about today's methods and practices. Not impossible to be entirely on point, but it would be more credible from someone closer to practices in at least the last decade.

mThumbnail 7y ago
I suppose if it were "since I left Google/Microsoft .." you'd be more right, but industry-wide practice is usually something that's relatively out in the open especially for former insiders
danso 7y ago
The author left the pharmaceutical marketing industry in 2000; now, the author works as a doctor. From the bottom of the essay: > When I was a drug rep, I really believed my pitch for our products — and I believed that by exerting influence over doctors, I helped patients access medicine they needed. As a doctor, I now have colleagues — colleagues with sharp, clinically trained minds and only the best of intentions — who think they write prescriptions on a wholly rational basis. In 2000, the author would have been witness and/or a party to the industry most excessive and unmonitored marketing practices, i.e. well before the federal push for transparency and disclosure [0]. Now, as a doctor – albeit an ER doctor, who may not be the biggest target for pharma reps – he likely has decent awareness of how both pharma marketing and doctor attitudes have changed. [0] https://www.propublica.org/article/we-found-over-700-doctors-who-were-paid-more-than-a-million-dollars-by-drug-and-medical-device-companies https://www.propublica.org/article/we-found-over-700-doctors...

philwelch 7y ago

Isn't there a professional and ethical obligation to prescribe painkillers to people who are in significant pain?

baxtr 7y ago
I guess it depends. In other countries, like Germany, doctors have a very different stance on people in pain. “Pain is a part of life. We cannot eliminate it nor do we want to. The pain will guide you. You will know when to rest more; you will know when you are healing. If I give you Vicodin, you will no longer feel the pain, yes, but you will no longer know what your body is telling you. You might overexert yourself because you are no longer feeling the pain signals. All you need is rest. And please be careful with ibuprofen. It’s not good for your kidneys. Only take it if you must. Your body will heal itself with rest.” From: https://www.nytimes.com/2018/01/27/opinion/sunday/surgery-germany-vicodin.html https://www.nytimes.com/2018/01/27/opinion/sunday/surgery-ge...
- grabbalacious 7y ago
  Yes. When stubbing a toe I've historically employed two strategies for dealing with it. In my youth I would shout and hop around the room, i.e. distract myself. Nowadays I pay as much attention to the pain as is possible and practical. Remarkably this approach does seem to alleviate the pain. So my guess is that the function of pain is to direct attention to injury. Not just for thinking about ways to avoid repeat injuries but purely and simply to promote the healing response. Which is not to say that I wouldn't welcome a painkiller if the pain was great enough. It's just that the suffering caused does seems to increase with the efforts one makes to distract oneself from it.
  - Ididntdothis 7y ago
    There is a level of pain where it becomes totally debilitating and all consuming. I can meditate over light headaches or other pain but from time to time I get migraines where I either want to die or take anything that will make it go away.

thrownjustnow 7y ago

This may be completely unpopular opinion, but as a temporary user of pain killers I am thankful I was prescribed them. I was experiencing chronic and hard to diagnose pain. I was in a very dark and scary place and was constantly wondering how people without access to these medicines continue their will to live. I was having difficulty making it through a work day and as a desk worker I was able to tolerate them during the day. I am thankful my doctor was so willing to prescribe them for me. Looking back on the experience in hindsight I would have preferred to stay on them longer instead of transitioning to other medicines during physical therapy. There was a lot of suffering during that time.

rm_-rf_slash 7y ago
If you’re all right with my asking, where was the pain located, and from what cause?
- mThumbnail 7y ago
  In my own case it was in the throat, literally unable to swallow anything for days due to severe pain, cause was mono. Fun fact I discovered through the ordeal is that the very act of thinking about saliva causes saliva to secrete, so it's practically impossible once you realize you have a saliva problem to stop it, since with a problem on hand you cannot but think about it and the very act of thinking about the problem causes the very problem to worsen
carapace 7y ago
The problem isn't that they work to relieve pain, it's that they're addictive. Anecdotally, I once knew a fellow who "accidentally" broke his own finger to get a prescription.
- nostromo 7y ago
  They aren't addictive to the vast majority of people. In this respect it's similar to alcohol: only harmful to a small group of people, but for them very harmful. I think the key is looking for commonalities of the people at risk of addiction and finding alternative therapies for them.

RupertEisenhart 7y ago

I find it pretty terrifying how many people there are in here jumping to defend opioids. Seems kinda off-topic for an article about how predatory practices in marketing potentially harmful substances can be problematic. I mean, nobody is suggesting that opiods shouldn't be used to treat pain, are they? They are just saying that that misinformation campaigns run for the purpose of increasing profit at the expense of human lives isn't a great thing.

alkonaut 7y ago
There are certainly cases where opioids should be prescribed as painkillers. But in the US, when weighing two bad things (pain, and adverse effects of a drug), pain seems to be considered more important than elsewhere, since doctors prescribe more of it. It must be that elsewhere doctors more frequently say “yes, your condition is painful, but if normal painkillers don’t help, the next alternative is worse than the pain”. It’s not clear to me why this discrepancy exists. Pharma can’t be the only reason. Maybe the private insurance system is a factor (“I paid a lot for this healthcare now fix my pain or I’ll take my business elsewhere”)?
- bobthepanda 7y ago
  Anecdotally, I have heard grumblings from nurse friends that a big annoyance is that "patient satisfaction" is now a big portion of performance reviews, since patients' satisfaction can go down for things that make them better. Keep in mind that not only insurance is a factor, but also the fact that many hospital systems themselves are private and have lots of cost pressures. A fair amount of advertising I've seen is for hospital systems.
  - jcims 7y ago
    Or patient satisfaction can go down because they are the face of a system that has many operational 'opportunities' to improve efficacy of care in the inpatient setting. They are grumbling because they have almost zero control over any of it.
  - noelsusman 7y ago

jdkee 7y ago

The fact that so much effort and so many dollars are expended to "sell" drugs to patients via the trust that doctors engender, illustrates just how broken medicine is in the U.S.

mcguire 7y ago

"When my patient’s loved ones ask how this could have happened, or start to blame themselves, I think with anger about how, for years, drug companies promoted the idea that addiction was not a common effect of the medication but rather a personal failing of the addict." Shouldn't that be, "...I promoted the idea..."

huffmsa 7y ago
The author says they didn't sell the opioids. Your point is valid though.

hackermailman 7y ago

It would be nice if actual statistics were floating around that identified causes of drug addiction. I grew up surrounded by crack and heroin addicts, anecdotally not a single one I met was pushed opiods by a doctor, they instead had a lifetime of drug seeking behavior and pooled money with other drug addicts, and whatever was cheap and available on the streets they took which often was heroin (now synthetics like fentanyl). In that same country pushing drugs by doctors was not common like it seems it is common in the US, yet we still had an enormous out of control street addict problem with no end in sight. It would also be interesting to see Portugal research as they decriminalized all drugs, if they still have an out of control street addict problem and culture of drug taking, or Japan research why they don't have a drug taking culture.

danso 7y ago
That people can become addicted to crack and heroin without being prescribed opioids does not necessarily preclude people getting addicted to opioids after being prescribed opioids.
vo2maxer 7y ago
One the best sources is the National Institute on Drug Abuse: https://www.drugabuse.gov/ https://www.drugabuse.gov/
loeg 7y ago
In 2005, the large majority of heroin addicts in the US were concurrent or former pill opioid addicts, but as of 2015 or so, it's about 50%.[1] [1]: https://www.ncbi.nlm.nih.gov/pubmed/28582659 https://www.ncbi.nlm.nih.gov/pubmed/28582659

zarkov99 7y ago

My 5 year old had to have surgery to repair a small abdominal hernea. Not a big deal, most kids recover incredibly fast and are back to running around within 2 or 4 days. We were given a prescription for enough opioids for 3 months at the maximum daily dosage. She needed one day, half the daily max.

Terr_ 7y ago
After some dental surgery, I was given a prescription for some powerful painkillers, and the pharmacist told me they could only fill all of it or none of it. I literally couldn't obtain a lesser amount. (And thankfully, ultimately didn't need any of it.)
- kungtotte 7y ago
  I think that's just a property of the prescription system. Even if you were prescribed something harmless like anti-histamines it's still all-or-nothing, otherwise it would count as the pharmacy not honoring the specifics of the prescription.
riahi 7y ago
There's a lot of anecdotes in this thread about people being prescribed "too much". What would your anecdote be if your child was in severe pain after the surgery, occurring in the middle of the night, and you needed to get the meds after hours? What if you had to drive back in to get a paper script? What if you had to wait 2 days? I rarely (almost never as a radiologist now) write outpatient narcotic prescriptions anymore, but when I did, I often prescribed in a pattern so I could avoid people becoming uncomfortably symptomatic in an inconvenient time for them (and us). I'm not sure what the best situation here is, other than giving you the RX and telling you to not fill it?
- zarkov99 7y ago
  There is a big difference between a reasonable margin of safety, say double what was expected, and the 3 months which was 30x the expected need. Three months is not an emergency contingency.

dwd 7y ago

Back in the early 2000s I built a web app for a big pharma that was used to compile doctor's responses to questions on survey cards that were mailed out. These could be anything from multi-choice questions about awareness of drug products, whether they prescribed particular drugs for specific treatments and I think from memory there may have been incentives like prize draws like trips to conferences for filling in the survey (return postage paid as well). I can't imagine this having changing so much (maybe more online or in partnership with clinic software) as it served as both promoting a drug for a specific treatment and identifying individual doctors responsiveness to future marketing.

noelsusman 7y ago
Things have tightened up a bit since then, though not completely. My dad ran hospitals for a living when I was a kid and we got tons of free tickets to sporting events from various vendors trying to sell him stuff. He would have to listen to a 10 minute pitch from some salesman (that he always made fun of later) and in return he got a free night out with the family. I remember being mad when that dried up in the mid-2000s. I later learned that CMS had implemented some regulations cracking down on the practice. These days, thanks to the ACA, you can look up exactly how much money your doctor has received from medical device manufacturers or pharmaceutical companies (https://www.cms.gov/openpayments/ https://www.cms.gov/openpayments/)

vmurthy 7y ago

Hmmm... this article seems like a real world demonstration of the principles outlined in "Influence:The Psychology of Persuasion" by Robert Cialdini [0] 1. Reciprocity - check 2. Social Proof - check 3. Authority induced bias - check 4. Scarcity - check 5. Commitment and consistency - check Damn scary how even highly qualified professionals fall prey to the same old tactics. [0] https://en.wikipedia.org/wiki/Influence:_Science_and_Practice https://en.wikipedia.org/wiki/Influence:_Science_and_Practic...