CNN Exclusive: The more opioids doctors prescribe, the more money they make
As tens of thousands of Americans die from prescription opioid overdoses each year, an exclusive analysis by
In 2014 and 2015, opioid manufacturers paid hundreds of doctors across the country six-figure sums for speaking, consulting and other services. Thousands of other doctors were paid over
Physicians who prescribed particularly large amounts of the drugs were the most likely to get paid.
"This is the first time we've seen this, and it's really important," said Dr.
"It smells like doctors being bribed to sell narcotics, and that's very disturbing," said Kolodny, who is also the executive director of
The Harvard researchers said it's not clear whether the payments encourage doctors to prescribe a company's drug or whether pharmaceutical companies seek out and reward doctors who are already high prescribers.
"I don't know if the money is causing the prescribing or the prescribing led to the money, but in either case, it's potentially a vicious cycle. It's cementing the idea for these physicians that prescribing this many opioids is creating value," said Dr.
Then she learned that opioid manufacturers paid her doctor more than a million dollars over two years.
"Once I found out he was being paid, I thought, 'was it really in my best interest, or was it in his best interest?' " she said.
To do the analysis,
The
Fifty-four percent of those doctors -- more than 200,000 physicians -- received a payment from pharmaceutical companies that make opioids.
Doctors were more likely to get paid by drug companies if they prescribed a lot of opioids -- and they were more likely to get paid a lot of money.
Among doctors in the top 25th percentile of opioid prescribers by volume, 72% received payments. Among those in the top fifth percentile, 84% received payments. Among the very biggest prescribers -- those in the top 10th of 1% -- 95% received payments.
On average, doctors whose opioid prescription volume ranked among the top 5% nationally received twice as much money from the opioid manufacturers, compared with doctors whose prescription volume was in the median. Doctors in the top 1% of opioid prescribers received on average four times as much money as the typical doctor. Doctors in the top 10th of 1%, on average, received nine times more money than the typical doctor.
"The correlation you found is very powerful," said
Paying doctors for speaking, consulting and other services is legal. It's defended as a way for experts in their fields to share important experience and information about medications, but it has long been a controversial practice.
Pharmaceutical company payments to doctors are not unique to opioids. Drug companies pay doctors billions of dollars for various services. In 2015, 48% of physicians received some pharmaceutical payment.
It's illegal, however, for doctors to prescribe the drug in exchange for kickback payments from a manufacturer.
Dr.
"They know those medicines, and so they're going to be more likely to prescribe those because they have a better understanding," Stanos said, adding that some of the money paid to doctors may have been to teach other doctors about new "abuse-deterrent" opioid drugs.
Stanos' group accepted nearly
Stanos said the money was used for various projects, including courses on safe opioid prescribing.
"I would obviously hope that a physician would not prescribe based on some type of kickback or anything like that, that they'd obviously be prescribing [in] the best interest of the patient," he said.
But Dr.
"It's not proof positive, but it's another very significant data point in the growing evidence base that marketing payments from drug companies are not good for medicine and not good for patient care," said Carlat, a psychiatrist who blogs about conflicts of interest. "It makes me extremely concerned."
Barnett, one of the Harvard researchers who worked with
"It's not like they're spending this money and just letting it go out into the ether," he said. "They wouldn't be spending this money if it weren't effective."
According to a statement by the
"PhRMA supports a number of policies to ensure patients' legitimate medical needs are met, while establishing safeguards that prevent overprescribing," according to the statement from the group.
'I trusted my doctor'
She says Dr. Aathirayen Thiyagarajah, a pain specialist in
Subsys is an ultrapowerful form of fentanyl, which is 50 to 100 times more potent than morphine, according to the
"He said it would do wonders for me, and it was really simple and easy. You just spray it in your mouth," Cantone said.
She says Subsys helped her pain, but it left her in "a zombie-like" state. She couldn't be left alone with her three young children, two of whom have autism and other special needs.
"I blacked out all the time. I'd find myself on the kitchen floor or the front lawn," she said.
She says that if she missed even one day of the drug, she had uncontrollable diarrhea and vomiting.
She said she brought her concerns to Thiyagarajah, but he assured her it couldn't be the Subsys that was causing her health problems.
"I trusted him. I trusted my doctor as you trust the police officer that's directing traffic when the light is out," she said.
She says that when she eventually asked Thiyagarajah to switch her to a non-opioid medication, he became belligerent.
"He said it was Subsys or nothing," she said.
Cantone would later learn that from
Nearly all of the payments were for fees for speaking, training, education and consulting.
Cantone is now suing Thiyagarajah, accusing him of setting out to "defraud and deceive" her for "the sole purpose of increasing prescriptions, sales, and consumption of Subsys to increase ... profits."
Through his attorney, Thiyagarajah denied any wrongdoing but declined to comment on this story due to the pending litigation.
In a court filing responding to Cantone's lawsuit, Thiyagarajah denied all of the allegations against him and said that all medical care provided to Cantone was "reasonable and appropriate and in keeping with the standard of care."
His attorney,
Thiyagarajah might be expected to write a relatively high number of prescriptions for opioid painkillers, given that he's board-certified in physical medicine and rehabilitation with a subspecialty in pain medicine.
But he wrote an unusually high number of prescriptions for Subsys and other opioids even when compared with other doctors with the same certifications.
In 2014 and 2015, physicians with Thiyagarajah's certifications wrote an average of 3.7 opioid prescriptions per Medicare patient per year, according to the analysis by
After about two years on Subsys, Cantone says, she took herself off the drug cold turkey.
According to an affidavit by an investigator for the
In
The
Cantone is also suing Insys, the company that makes Subsys. Insys denied allegations of wrongdoing in a court filing responding to Cantone's lawsuit.
Separate from Cantone's lawsuit,
"
Kapoor resigned from the Insys board of directors in October, according to a company news release.
Several other Insys executives were arrested in connection with an alleged racketeering scheme.
Separately, Sen.
According to her investigation and the federal indictment, Insys used a combination of tactics, such as falsifying medical records, misleading insurance companies and providing kickbacks to doctors in league with the company.
"I stand with you and share the desire to address the serious national challenge related to the misuse and abuse of opioids that has led to addiction and unnecessary deaths and has caused so much pain to families and communities around the country," Motahari added.
The analysis
Sometimes, pharmaceutical companies pay doctors to do medical research. They also pay doctors for promotional work: for example, to speak with other doctors about the benefits of a drug.
Among the doctors who prescribe the highest volume of opioids, the
Concerns about payments to doctors by opioid manufacturers were brought to light last year in a study by researchers at
Several studies published in medical journals in recent years have found an association between payments by pharmaceutical companies for various types of drugs and doctors' prescribing habits.
For example, researchers at the
"This study suggests that conflicts of interest with the pharmaceutical industry may influence oncologists in high-stakes treatment decisions for patients with cancer," the authors concluded.
Some studies have looked at whether the amount of money a doctor receives makes a difference. Studies by researchers at
Dr.
It's "not a cause and effect relationship," said Harris, chairwoman of the association's opioid task force, adding that more research should be done on the relationship between payments and prescriptions.
"[We] strongly oppose inappropriate, unethical interactions between physicians and industry," she added. "But we know that not all interactions are unethical or inappropriate."
Harris added that relationships between doctors and industry are ethical and appropriate if they "can help drive innovation in patient care and provide significant resources for professional medical education that ultimately benefits patients."
Stanos, the pain physician, said a doctor who gets paid by a pharmaceutical company and prescribes that company's drug might truly and legitimately believe that the drug is the best option for the patient.
"I hope physicians that do promotional talks prescribe because they think the medicine has a benefit," he said.
But Jena, one of the two Harvard researchers who collaborated on the
"Every decision, every recommendation a physician makes, should be in the best interest of the patient and not a combination of the patient's interest and the financial interest of the doctor," said Jena, associate professor of health care policy at
"If we lived in a different world where none of these payments to physicians occurred, how many fewer Americans would have [been prescribed] opioids, and how many fewer deaths would have occurred?" he asked.
From 1999 to 2015, more than 183,000 people in
At least one company has decided to stop paying doctors for promotional activities such as speaking engagements.
"We have restructured and significantly reduced our commercial operation and will no longer be promoting opioids to prescribers," a company statement said.
More than
Though Thiyagarajah's opioid prescription rates were particularly high, many other doctors who have prescribed large amounts of opioids have also been paid large amounts of money by pharmaceutical companies that make the drugs.
Several patients have filed lawsuits against these high prescribers.
From
Most of the payments were fees for speaking, training and education.
Ballou, one of his patients, says she remembers Simon bragging about how drug companies were flying him across the country to give lectures to other doctors.
"He said he was going to
Simon's lawyer,
In court documents, he asked for the case to be dismissed, saying in part that Ballou's complaints that Simon improperly prescribed Subsys were "simply incorrect."
The clinic said in a statement that it is "fully and willingly cooperating with all investigations" and that Simon has not been employed there since
"We had a lawful presence at that facility," Patton said. She declined to say whether investigating Simon himself was the purpose of the
The owner of the pain clinic, Dr. Srinivas Nalamachu, told
Simon and his lawyer told CNN they couldn't comment due to the pending litigation.
Ballou said that when she was Simon's patient, it didn't give her pause that the same doctor who was prescribing opioids to her was also taking money from the companies that made the drugs.
But now she looks back with anger.
Cantone, the patient who went to Thiyagarajah, the pain specialist in
She cries as she remembers the
Her card said her mother liked to sleep.
"Instead of saying 'she gives me hugs and kisses or takes me to the park,' it was the years of her finding me on the floor," Cantone said. "I feel like I failed as a parent."
She becomes angry when she thinks about the hundreds of thousands of dollars her doctor was paid by the drug company.
"The medication that was being prescribed to me was for his benefit, not my own," she said.
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