How Big Pharma Gets Doctors to Push Its Drugs

This piece on Continuing Medical Education Units was written by Anthony Gallo, a student of mine last year at the Rutgers School of Social Work. Anthony graduated with his BASW last month. He is now enrolled in the Rutgers MSW program and is interning this year for the NASW-NJ.

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Continuing Medical Education (CME) units are the professional educational requirements for renewing a doctor’s medical license. The requirements differ from state to state: Arkansas requires 20 CMEs in a 2-year cycle while Washington requires 200 (to search your state’s requirements, click here). According to the Accreditation Council for Continuing Medical Education (ACCME) they are intended to help physicians by improving “their practice and delivering high-quality, safe, effective patient care.” They are generally designed to influence physicians’ practices in positive ways, but this is not always the case.

CMEs can cost several hundred dollars for a six hour class, so keeping up with them could potentially cost a thousand to upwards of ten thousand dollars every two years. Conflicting motives arise when CMEs are paid for by companies who can introduce intentional or unintentionally bias. The late Arthur Sackler, co-owner of Purdue Pharma and founder of modern pharmaceutical marketing, was one of the originators of the concept of commercially sponsored CME units. He rightly believed that by influencing medical education he could increase sales of his pharmaceuticals to doctors. This strategy was showcased in the American prescription pain pill boom in the 1990s.

Purdue flew doctors to resorts and conferences where they would hear lectures from corporate sponsored experts on the benefits of prescribing opiates for pain. These speakers would deliver messages that downplayed the risks of these medications and portrayed Purdue’s opiate drug, OxyContin, as a wonder drug that was “virtually non-addictive.” An unnamed CME organizer quoted in Sam Quinones’ book Dreamland described the effectiveness of one of Purdue’s paid speakers, Russel Portenoy:

All you need is one guy to say what he was saying. The other guys who are   sounding a warning about these drugs don’t get funded. They get a journal article, not a megaphone.

In this way CMEs were used to reassure the medical community that opiate painkillers were safe and effective when they were actually overstating the benefits and understating the side effects (including addiction).

In all, the U.S. General Accounting Office reported that Purdue Pharma helped to fund over 20,000 educational programs and their efforts proved wildly successful. Pain pill prescriptions rose from 670,000 in 1997 to 6.2 million in 2002, in part due to their CME programs. This was also before strict regulations governed commercial influence in CMEs.  Many of Purdue Pharma’s statements were false. Several executives eventually faced criminal charges for misrepresenting the dangers of their drug, and Purdue Pharma continues to pay fines to this day. America’s current heroin epidemic was partially created and compounded by the misuse of pharmaceutical marketing and education.

Regulations have been since tightened, limiting the commercial influence on CMEs. CME providers are now required by the Accreditation Council for Continuing Medical Education to be independently structured from “any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.” There are also strict reporting requirements for financial contributions and prohibitions on direct or indirect influence of course material.

The potential for abuse is still real, however, and in the first quarter of 2009 the pharmaceutical company Eli Lilly paid out roughly $44.5 million in speaking fees to company approved experts. One of their highest paid was Dr. Manoj V. Waikar, who received $74,850 for speaking at 51 events for the company. These speeches are generally scripts written by the company.

In 2014 the ACCME reported that 41.4% of CME providers received commercial financial support.  Eleven CME providers received in excess of $10 million from commercial companies. Dr. Michael Steinman, an associate professor of medicine at the San Francisco V.A. Medical Center described the conflict perfectly by stating, “The course providers have a subtle and probably unconscious incentive to put on courses that are favorable to industry because they know where their bread is buttered.”

CME programs are receiving more scrutiny than before. Recent tightening of accreditation standards for CME programs and shifting public opinions have lowered commercial influence. Doctors receiving reimbursements for CME credits dropped from 26% to 12.7% between 2004 and 2009. Doctor’s receiving payments for speaking on behalf of companies dropped from 16% to 8.6% in the same timeframe.

Major universities have taken steps to prevent commercial bias. Stanford recently expanded its ban on faculty involvement in commercially sponsored speaking activities to include adjunct professors as well. Harvard also has strict regulations regarding commercial involvement.

The move away from commercial funding will be difficult and expensive, likely requiring more doctors to pay for their CMEs. Despite the challenges, this change will likely be vital for the unbiased advancement of the medical sciences. The industry has made progress since the early days of OxyContin, but Big Pharma continues to get into trouble for using CMEs to push medications on doctors (you really should click on that). We’ve seen some of the dangers of commercial influence and we must push ahead in fixing the CME funding system.