A tangled web: as a new doctor it was easy to be influenced by the opioid industry
As another anniversary of his wife’s death approaches, an acquaintance says it’s easier to explain to his children her untimely death with “Mummy’s heart just stopped beating” than to invoke the spectre of her hidden opioid dependence that even he had not known about until the paramedics came. Pierced by this story and its evident ramifications, I have lately taken a strict approach to patients on long-term opioids for inappropriate indications.
The last such patient was a 50-year-old man who was anxious that no one stop his morphine.
“Tell me why you’re on morphine.”
It helps me sleep.”
After a temporary sport injury 20 years ago, the only thing that helped him on sleepless nights was a prescription from the emergency department – one pill made him forget his worries. In the morning, he started taking a second pill to stay calm. When he ran out, he went to his local doctor for more and so the practice continued even after one doctor left and another took over.
“Your anxiety is real, but morphine is dangerous,” I advised. “We can’t keep renewing such large doses of a powerful drug without good cause.”
“My doctor does.”
“Actually, doctors have been slow to realise the harm opioids cause. We shouldn’t have prescribed it in the first place for back pain,” I reasoned.
“Maybe they should have thought about it earlier when they told me it was fine,” he retorted.
Dejected, we left the room, chalking another failure.
News of the opioid crisis may be ubiquitous but, in the hospital, where one meets the people who use morphine and its equivalents for “nerves”, insomnia, rickety knees and chronic back pain (all inappropriate indications), it is decidedly difficult to change behaviour.
Patients are angry, defensive and so determined to procure another script that reasoning seems all but futile. And yet, contrary to the stereotype, I can’t help but notice that many of these patients are “regular” people – they have a family and a job, they are articulate and literate.
Last week, an Oklahoma judge fined leading pharmaceutical company Johnson & Johnson US$572m for igniting the state’s opioid crisis.
The company also invests in poppy farms in Tasmania that produce 60% of the raw ingredient for opioids. The state alleged that the company developed and carried out a plan to directly influence and convince doctors to prescribe opioids despite being aware of their propensity to cause abuse, addiction, death and crime.
What particularly rang true to me is the mention of reluctant and “the least knowledgeable” physicians, against whom the company mounted an aggressive misinformation campaign to increase prescribing.
Medicine needs to turn its attention to educating a new generation of doctors about the insidious influence of drug companies
I was a newly minted doctor in the early 2000s when opioids started being promoted for uses beyond postoperative pain, trauma and end-of-life care. Back then, pharmaceutical representatives mingled easily and frequently with doctors and I couldn’t believe it when one told me she’d take care of my subscription to a medical journal. The offer was so genuine, so smooth and so without fanfare that I didn’t think twice, especially because it allowed me to spend my own money on filling my library with novels.
This is how easily I came under the influence of the opioid industry. I can’t faithfully recall how many times I met that representative – perhaps four times in all, but enough to be reminded that she represented a particular opioid, which she blithely promoted as being safe and appropriate for use in a variety of situations. I don’t remember how many times I repeated that advice to patients. I can only hope it wasn’t often. Patients who expressed doubts about opioids were being casually reassured by doctors that they had no reason to worry – it would be disingenuous for me to say that I never passed on the misinformation.
I was once flown to an overseas conference. There I was allocated a pharmaceutical representative to ensure my comfort. The height of this came when I bought a bowl of soup and the representative insisted on paying the $10 bill. I was bemused, perhaps even flattered, that a doctor who knew so little mattered so much. As I slurped my soup, the representative benignly talked about his product. Did it make me prescribe that product over and above others? I’d like to say no but the evidence is against me. Spending as little as $13 on a doctor encourages preferential prescription of a drug for three months.
Now, my more discerning self is appalled at the naivety that may have harmed patients I really cared about. And while people don’t need an excuse, they deserve an explanation.
I graduated from medical school knowing the causes of chest pain, how to recognise a stroke and why diabetics could go into a coma. I knew the names of hundreds of drugs and what to administer during a resuscitation. But on the subject of medical ethics, my education had been silent.
What constituted lobbying? How did one distinguish marketing from evidence? How did one learn that a free lunch was in fact very costly to patients? I had to find out on my own.
Dismayed patients may ask how such things could go unscrutinised but those were the days of extraordinary largesse and no visible governance. A specialist used to joke to nonplussed trainees that a successful conference was measured by the number of free flights and meals one could extract from drug companies. My resident accepted a free drink while envying his cardiologist father who had been flown with his wife to a Scottish castle to discuss coronary artery stents, which were making their entry around the same time. In this loose environment, a journal subscription here, a bowl of soup there was small fry.
Times are changing and the pharmaceutical industry faces greater restrictions on its interactions with doctors. There are those who deem these restrictions insufficient, while many doctors continue to believe they are impermeable to drug company influence. “I can’t be bought by a pen” is a common refrain among doctors but institutional rules should be tightened to drive out this disproven sentiment. It is not the pen, it’s the bias it comes with.
But most importantly, medicine needs to turn its attention to educating a new generation of doctors about the insidious influence of drug companies and give them a toolkit for conducting themselves carefully and ethically in an increasingly loud, competitive and stretched environment where there is even less time to critically evaluate information.
A grounding in ethical behaviour isn’t just for philosophers but for everyday doctors who hold the lives of patients in their hands and change those lives with the stroke of a pen. This is what I did each time I told a patient that opioids were safe. Experts fear that the crisis may take decades to correct and many patients will be unsalvageable. All this reminds me of my contribution to the malady – and I am not alone.
With what we know now, we must prevent another generation of patients from enduring harm. This will require funding health literacy and medical education and not simply taking away opioids but adopting a holistic approach to pain. All this, and a dose of humility, to concede that when doctors use pharmaceutical opinion as a trusted source of education, society stands to lose.
• Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death
Source: The Guardian Australia