By RAFAEL FONSECA, MD & JOHN A. TUCKER, MBA PhD
A Critical Analysis of a Recent Study by Hadland and colleagues
Association studies that draw correlations between drug company-provided meals and physician prescribing behavior have become a favorite genre among advocates of greater separation between drug manufacturers and physicians. Recent studies have demonstrated correlations between acceptance of drug manufacturer payments and undesirable physician behaviors, such as increased prescription of promoted drugs. The authors of such articles are usually careful to avoid making direct claims of a cause-effect relationship since their observations are based on correlation alone. Nonetheless, such a relationship is often implied by conjecture. Further, the large number of publications in high profile journals on this subject can only be justified by concerns that such a cause-and-effect relationship exists and is widespread and nefarious. In this article, we will examine a recent paper by Hadland et al. which explores correlational data relating opioid prescribing to opioid manufacturer payments and in which the authors imply the existence of a cause-and-effect relationship.1
We propose the relationship between transactions between the private sector (e.g., meals provided, consulting payments) and prescribing habits can fall into one of three categories:
| Type | Effect | Comments |
| 0 | There is no cause-effect relationship between these transactions and prescribing habits. Correlative observations may merely be reflections of practice patterns, and likelihood to use a drug category. | No harm exists. |
| Ia | There is a demonstrable cause-effect for transactions and prescribing patterns. However, this relationship is associated with increased use of drugs that have been proven to be an improvement over the current standard. | The effect is beneficial for patients. “Beneficial marketing.” |
| Ib | An adverse causative effect is documented with establishment of causation. There is a possibility of patient harm. | Patient harm occurs because the wrong medication is administered and contravenes medical standards. A minor damage is done but arguably exists, if a physician prescribes a more expensive medication when a cheaper alternative exists.
“Nefarious marketing.” |
Hadland et al.: Opioid Prescriptions and Manufacturer Payments to Physicians
The authors of this paper linked physician-level data from the 2014 CMS Open Payments database to 2015 opioid prescribing behavior described in the Medicare Opioid Prescribing Database. They explored the hypothesis that meals and other payments increase physician opioid prescribing by examining the association between receipt of meals and other financial benefits with the number of opioid prescriptions written[1]. Specifically, they found the following:
