Trends in Industry Marketing of Stimulants to Physicians and Advanced Practice Clinicians

Abstract

This cross-sectional study examines pharmaceutical marketing of stimulants to physicians and advanced practice clinicians and its influence on stimulant use after the COVID-19 pandemic.

Stimulant prescribing has increased sharply since the COVID-19 pandemic and remains elevated.¹ Although stimulants are an effective treatment for attention-deficit/hyperactivity disorder (ADHD), rising use has raised concerns about overprescribing and misuse.² Postpandemic telehealth expansions might partly explain these trends by reducing barriers to obtaining ADHD medications,³ but pharmaceutical marketing is another potential contributor. The relationship between pharmaceutical marketing and prescribing behavior is well established.⁴ Previous research documented substantial stimulant marketing to physicians from 2014 to 2018, peaking in 2016,⁵ but how these practices have changed postpandemic remains unclear. We examined trends in stimulant marketing from 2021 to 2023, including newly available data on marketing to advanced practice clinicians (APCs), a group of growing importance given recent state laws expanding their authority to prescribe controlled substances (eg, stimulants).⁶

Methods

Data on pharmaceutical industry stimulant marketing payments (eg, meals and speaking fees) were obtained from the Centers for Medicare & Medicaid Open Payments Program from 2021 (the first year APCs were included) to 2023 (eMethods in Supplement 1). Payments were identified as related to at least 1 stimulant medication (eTable 1 in Supplement 1). We quantified the annual total value of payments separately for physicians and APCs, by specialty and by drug annually from 2021 to 2023. We also quantified the overall percentage (number of active clinicians receiving any payment), number of clinicians receiving payments exceeding $5000 in any year, total payments, and average individual payment for each specialty or subspecialty from 2021 to 2023. Numbers of active clinicians by specialty or subspecialty were obtained from the December 2023 National Plan and Provider Enumeration System. We converted all payments to 2023 US dollars using a consumer price index (eTable 2 in Supplement 1).

Analyses were performed using Stata 18 (StataCorp LLC). This study of publicly available data was exempt from review and informed consent per the Common Rule (US 45 CFR part 46) and followed the STROBE reporting guideline for cross-sectional studies.

Results

Among physicians, total stimulant marketing payments doubled from $1.8 million in 2021 to $3.6 million in 2023 (Figure, A). Among APCs, payments tripled from $0.5 million in 2021 to $1.6 million in 2023. These trends were largely driven by growth in marketing to psychiatrists (by $1.2 million from 2021 to 2023, representing a 250% increase) and nurse practitioners (by $0.8 million from 2021 to 2023, representing a 300% increase; Figure, B). By product, marketing growth was highest for Azstarys (serdexmethylphenidate/dexmethylphenidate) (increased by $2.4 million, or 580%; Figure, C).

Figure. Growth in Annual Stimulant Marketing Payments Overall, by Clinical Specialty, and by Stimulant Product, 2021 to 2023.

Data are from the Centers for Medicare & Medicaid Open Payments and in constant 2023 US dollars. In panel B, psychiatry includes adolescent psychiatry, and pediatrics includes adolescent medicine. Other clinicians include family medicine, neurology, internal medicine, and physician assistants, as well as all other clinician types listed under the “other physicians” and “other advanced practice clinicians” categories listed in the footnotes to the Table. In panel C, payments might be related to multiple stimulant products. Generic drug names for each of the branded products listed are as follows: Azstarys (serdexmethylphenidate/dexmethylphenidate), Jornay (methylphenidate), Dyanavel (amphetamine), and Vyvanse (lisdexamfetamine).

Psychiatrists and pediatricians—including those in adolescent-focused subspecialties—were the specialties with the highest percentage of clinicians in their respective specialties receiving any payment (5.9% to 10.5%) (Table). However, nurse practitioners accounted for the highest number of unique clinicians receiving payments (18 676). The frequency of clinicians receiving payments exceeding $5000 annually, total payments, and average individual payments were highest for adolescent psychiatrists and psychiatrists.

Table. Stimulant Marketing by Specialty and Subspecialty, 2021 to 2023^a.

Specialty	Clinicians			Payments, $
	Receiving payments		No. paid>$5000 in any year	Total	Mean (SD)
	% Active	No.
Physicians	1.1	25 339	155	8 473 374	42.1 (248.1)
Adolescent medicine	10.5	476	3	204 581	42.9 (198.2)
Adolescent psychiatry	9.9	927	42	1 083 567	84.1 (445.7)
Pediatrics	8.2	9716	20	2 358 004	25.8 (125.8)
Psychiatry	5.9	4086	71	3 362 307	72.9 (373.0)
Family medicine	3.0	6224	1	482 652	19.5 (52.2)
Neurology	1.8	602	11	408 344	49.3 (304.7)
Internal medicine	0.6	2210	4	198 563	27.8 (169.2)
Otherb	0.1	1098	3	375 356	61.8 (322.8)
Advanced practice clinicians	3.2	23 731	7	3 055 999	20.0 (37.6)
Nurse practitioner	4.1	18 676	5	2 360 360	20.3 (39.3)
Physician assistant	2.4	4665	0	628 323	18.7 (23.8)
Otherc	0.4	390	2	67 316	24.6 (79.7)

^a Data are from the Centers for Medicare & Medicaid Open Payments, 2021 to 2023, and in constant 2023 US dollars. Data on the number of active clinicians of each specialty (the denominator in column 2) is from the National Plan and Provider Enumeration System.

^b Includes allergy and immunology, anesthesiology, dermatology, emergency medicine, nuclear medicine, obstetrics and gynecology, ophthalmology, preventive medicine, surgery, and other specialties.

^c Includes anesthesiology assistants, certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists.

Discussion

Stimulant marketing to clinicians rose sharply from 2021 to 2023. Although payments to physicians remain roughly 40% below the 2016 peak reported in previous research,⁵ the decline has sharply reversed, with payments to physicians more than doubling from 2021 to 2023. Payments to APCs, particularly nurse practitioners, are also rising and at an even faster rate. This latter marketing pattern mirrors national prescribing data: since the pandemic, nurse practitioners have become the fastest-growing group of stimulant prescribers, surpassing psychiatrists in 2022 by number of prescriptions written.¹

These findings suggest a notable shift in pharmaceutical marketing strategy and raise concerns about its potential role in rising stimulant use. Future research correlating stimulant marketing with prescribing behavior is needed to examine how marketing influences clinical decision-making, prescribing appropriateness, and health outcomes. Study limitations included reliance on industry-reported payments, inability to identify APCs with pediatric or psychiatric subspecialties, and lack of data on free medication samples.

Supplement 1.

eMethods.

eTable 1. Stimulant products (generic drug names) included in the analysis

eTable 2. Consumer price index (CPI) used for inflation adjustment

eReferences.

Supplement 2.

Data Sharing Statement