Dear Mr. McDonald -
The Palm Beach Post recent series, “Pay to Prescribe? The Fentanyl Scandal,” (April 4) sheds a welcome light on one of the major contributing factors to the opioid crisis, pharmaceutical company manipulation of physicians. The heinous activities of the Insys Corporation were made public in the national media last year. The Post has now revealed the significant role of major players with local roots.
Fentanyl, a synthetic opioid 100 times stronger than heroin, is the leading cause of drug overdose deaths in the United States. Insys makes a spray form of fentanyl called Subsys. While Subsys only accounts for a very small percentage of total fentanyl use, when prescribed inappropriately it adds that many more names to the fatality list.
The Post reports that Insys masterminded a plan. Doctors would be paid large sums of money to be a “speaker whore,” promoting Subsys, often inappropriately, in exchange for writing more prescriptions. The plan was successful. Just looking at Florida, U.S. government data shows the three physicians who received the most money for speaker fees were also the top three Florida prescribers of Subsys.
While this behavior is highly suspect, it is not necessarily an indictment of unethical activity. When a physician finds a particular drug safe and effective it’s reasonable to share this experience with colleagues in an educational forum. Doctors are often paid a nominal fee to be a speaker. There are strict rules that require full disclosure of any funding source so that the audience is aware of potential conflicts of interest. However, when the speaker compensation becomes exorbitant this is an ethical problem. When that same physician writes excessive numbers of prescriptions for the drug this is also an ethical problem.
The pharmaceutical industry is a curious bunch. The 2009 industry-sponsored PhRMA guidelines banned gifts lacking an educational component. No more coffee mugs, pens and sticky notes to the doctors. On the surface, they were taking the ethical high road. In practice, the drug companies became incredibly creative. Since the 2009 new rules, the speaker’s fees have become increasingly generous. There has also been a surge in the number of compensated studies conducted in physician offices. Some of these studies are valid, but many generate nothing more than junk data. At the end of the day there are less sticky note pads, but more cold cash in some doctor’s pockets.
We have a problem with manipulative drug companies. We have a problem with physicians who fall prey to industry tactics. In the case of Subsys, we have all of the above plus addicted patients and dead patients.
What is the solution? A general ban on these “kickback” activities is one approach. I believe a better alternative is a comprehensive program that would generate a higher culture of ethics. At all levels, from medical students to older established doctors, we need to teach and reinforce ethical thinking skills. We need to provide tools for resilience to drug industry influence. Through the Hippocratic Oath, we unequivocally pledge to place patients first. Allegiance to the pharmaceutical industry should be way down on the list.
There are over 45,000 licensed physicians in the state of Florida. Only seven Florida doctors received very large sums from Insys. It is encouraging that the vast majority of Florida physicians have nothing to do with this type of scheme.
For those physicians who are found guilty of taking “quasi-legal bribes” in exchange for irresponsibly prescribing a specific medication to their trusting patients, there needs to be severe disciplinary action taken.
BRENT SCHILLINGER MD, WEST PALM BEACH
We are in debt to Doctor Schillinger for this important essay. Doctor Schillinger is chairman of the Palm Beach Medical Society’s Opioid Healthcare Response Initiative.