Abstract
This study examines the number and dollar amount of payments to physicians from companies marketing prescription stimulant medications.
Use of prescription stimulants doubled from 2006 to 2016 in the United States1 and, as of 2013, it resulted in more pharmaceutical expenditures for children than any other medication class.2 Although the rise in stimulant use parallels increasing attention-deficit/hyperactivity disorder diagnosis rates, stimulants, even when appropriately prescribed, are commonly diverted and used nonmedically.3 It is important to consider factors that may contribute to a potential oversupply of stimulants. Pharmaceutical company marketing is associated with increased prescribing.4 The extent to which physicians receive marketing for stimulants is not well described.
All US industry-physician marketing interactions are compiled by the Centers for Medicare & Medicaid Services (CMS). Using these data, we characterized stimulant marketing to physicians.
Methods
Data were extracted on industry-physician marketing interactions (termed payments) occurring between January 1, 2014, and December 31, 2018, from the Open Payments database.5 We extracted data on nonresearch payments for stimulants listed by generic or brand name. Payments were tabulated with regard to the products marketed; the type, number, and dollar value of payments (inflation adjusted using the Consumer Price Index); and the number of unique physicians receiving payments overall and by medical specialty. Unique physicians were identified by CMS based on name, medical license number, and National Provider Identifier number. The 5-year prevalence of marketing among physicians was estimated using as a denominator the number of active physicians between 2014 and 2018 in each specialty per historical National Provider Identifier data.6 Medical specialties were defined by CMS in the Open Payments and National Provider Identifier databases. The study was not considered human subjects research by the Boston University School of Medicine institutional review board and was thus exempt from ethical review and informed consent procedures. Analyses were undertaken with Stata version 15.1 (StataCorp).
Results
Between 2014 and 2018, there were 591 907 payments to physicians totaling $20 101 250 (Table 1) in the Open Payments database. The median value of payments was $14 (interquartile range [IQR], $12-18). Payments for food and beverage were the most common types (578 105 [97.7%]) and made up the greatest percentage of dollars spent ($9 988 670 [49.7%]). Median payments were highest for consulting fees ($3045 [IQR, $1920-$3750]). The most commonly marketed stimulant was Vyvanse (lisdexamfetamine), which made up 274 502 payments (46.4%) and $7 076 729 (35.2% of all dollars spent).
Table 1. Marketing to Physicians Involving Stimulant Products, per the Open Payment Program Database (January 1, 2014, to December 31, 2018).
| Characteristic | Payments, No. (%) | Total Payment Amount, $ | Payment, Median (IQR), $ |
|---|---|---|---|
| Total | 591 907 (100.0) | 20 101 250 (100.0) | 14 (12-18) |
| Type of marketing | |||
| Food and beverage | 578 105 (97.7) | 9 988 670 (49.7) | 14 (12-18) |
| Travel and lodging | 7142 (1.2) | 2 049 398 (10.2) | 178 (53-361) |
| Speaking fees | 1806 (0.3) | 3 834 205 (19.1) | 2000 (950-2570) |
| Honoraria | 1579 (0.3) | 2 454 854 (12.2) | 1500 (1000-2025) |
| Consulting fees | 438 (0.1) | 1 563 676 (7.8) | 3045 (1920-3750) |
| Other paymentsa | 2837 (0.5) | 210 446 (1.0) | 38 (20-91) |
| Stimulant productb | |||
| Vyvanse | 274 502 (46.4) | 7 076 729 (35.2) | 14 (12-17) |
| Quillivant | 80 086 (13.5) | 2 250 682 (11.2) | 15 (13-19) |
| Mydayis | 65 356 (11.0) | 3 085 987 (15.4) | 15 (12-19) |
| Evekeo | 60 969 (10.3) | 1 739 565 (8.7) | 13 (11-15) |
| Adzenys | 51 269 (8.7) | 2 199 064 (10.9) | 15 (13-19) |
| Dyanavel | 28 817 (4.9) | 1 948 762 (9.7) | 15 (12-19) |
| Aptensio | 19 925 (3.4) | 1 469 859 (7.3) | 16 (13-20) |
| Other stimulantsc | 30 490 (5.2) | 851 566 (4.2) | 15 (12-18) |
Abbreviation: IQR, interquartile range.
Includes payments labeled as education or other gifts.
Some payments involved multiple stimulant products; totals may add to more than 100%.
Includes Cotempla, Daytrana, Quillichew, Zenzedi, Focalin, Precentra, Adderall, Ritalin, and Concerta.
Annual marketing was $2 429 626 in 2014, increased to a peak of $4 817 619 in 2016, and decreased to $3 861 186 in 2018. Annually, physicians received a median of 2 payments (IQR, 1-4 payments; maximum, 286 payments) and $35 (IQR, $17-$81; maximum, $22 248) in marketing.
Overall, 55 105 physicians received payments, resulting in an estimated 5.6% five-year prevalence among 989 789 physicians. Pediatricians received the most payments (239 217 payments [40.4%]), and psychiatrists received the most marketing in dollars ($11 392 037 [56.7%]; Table 2). Pediatrics had the highest percentage of physicians receiving marketing (5-year prevalence, 19.2%).
Table 2. Marketing of Stimulant Products According to Medical Specialty, per the Open Payment Program Database (January 1, 2014, to December 31, 2018).
| Physician Specialty | Payments, No. (%) | Total Payment Amount, $ (%) | Payment, Median (IQR), $ | Unique Physicians, No. (%)a | Total Active Physicians, No. (%)b | Estimated 5-y Prevalence, % |
|---|---|---|---|---|---|---|
| Pediatrics | 239 217 (40.4) | 5 003 379 (24.9) | 14 (12-18) | 17 427 (31.6) | 90 766 (9.2) | 19.2 |
| Psychiatry | 188 076 (31.8) | 11 392 037 (56.7) | 15 (12-19) | 9660 (17.5) | 54 895 (5.5) | 17.6 |
| Family medicine | 106 615 (18.0) | 2 138 459 (10.6) | 14 (12-16) | 17 048 (30.9) | 136 604 (13.8) | 12.5 |
| Internal medicine | 32 531 (5.5) | 825 003 (4.1) | 14 (12-17) | 7213 (13.1) | 272 060 (27.4) | 2.7 |
| Neurology | 20 077 (3.4) | 637 634 (3.2) | 15 (12-19) | 1235 (2.2) | 20 974 (2.1) | 5.9 |
| Otherc | 5391 (0.9) | 104 738 (0.5) | 14 (12-17) | 2522 (4.6) | 416 440 (42.0) | 0.6 |
Abbreviation: IQR, interquartile range.
Overall, 55 105 unique physicians received marketing.
Estimated using National Provider Identifier data from 2014 to 2018.6
Includes anesthesiology, dermatology, emergency medicine, general surgery and subspecialties, obstetrics and gynecology, orthopedic surgery, otorhinolaryngology, pain medicine, physical medicine and rehabilitation, and physicians from other specialties.
Discussion
During the 5-year study period, 1 in 18 physicians appear to have received marketing for stimulants. Payments were most typically high-frequency, low–dollar value marketing in the form of food or beverage. Pediatricians, psychiatrists, and family physicians (ie, clinicians who often care for children and adolescents) received the greatest share of marketing.
Pharmaceutical industry marketing may be partly contributing to rising stimulant-prescribing rates.4 The most heavily marketed product was Vyvanse (lisdexamfetamine), which is not available as a generic drug and costs more than other stimulant drugs.2 Despite a misuse-deterrent formulation that prevents intranasal and injection use, Vyvanse can be used nonmedically.
Limitations of this study include its descriptive nature; associations between marketing and prescribing cannot be established. Some marketing may have been educational and served to mitigate potential underprescribing. Some physicians receiving marketing may not have had active National Provider Identifier numbers. Information on nonphysician prescribers was excluded.
In the context of rising stimulant prescribing, examining the potential role of pharmaceutical industry marketing is warranted. In particular, since prescription medication misuse commonly begins during adolescence and young adulthood, the intensity of marketing to clinicians who care for individuals at these developmental stages may deserve scrutiny.
References
- 1.Piper BJ, Ogden CL, Simoyan OM, et al. . Trends in use of prescription stimulants in the United States and territories, 2006 to 2016. PLoS One. 2018;13(11):e0206100. doi: 10.1371/journal.pone.0206100 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Cohen E, Hall M, Lopert R, et al. . High-expenditure pharmaceutical use among children in Medicaid. Pediatrics. 2017;140(3):e20171095. doi: 10.1542/peds.2017-1095 [DOI] [PubMed] [Google Scholar]
- 3.McCabe SE, Veliz PT, Boyd CJ, Schepis TS, McCabe VV, Schulenberg JE. A prospective study of nonmedical use of prescription opioids during adolescence and subsequent substance use disorder symptoms in early midlife. Drug Alcohol Depend. 2019;194:377-385. doi: 10.1016/j.drugalcdep.2018.10.027 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.DeJong C, Aguilar T, Tseng C-W, Lin GA, Boscardin WJ, Dudley RA. Pharmaceutical industry-sponsored meals and physician prescribing patterns for Medicare beneficiaries. JAMA Intern Med. 2016;176(8):1114-1122. doi: 10.1001/jamainternmed.2016.2765 [DOI] [PubMed] [Google Scholar]
- 5.US Centers for Medicare & Medicaid Services Dataset downloads. https://www.cms.gov/openpayments/explore-the-data/dataset-downloads.html. Published 2019. Accessed July 1, 2019.
- 6.National Bureau of Economic Research NPI data. https://www.nber.org/data/npi.html. Published 2019. Accessed September 24, 2019.