Combating the opioid crisis one doctor at a time

https://www.washingtonpost.com/national/health-science/combating-the-opioid-crisis-one-doctor-at-a-time/2019/02/01/9d11c1a0-1a71-11e9-8813-cb9dec761e73_story.html

GLENSIDE, Pa. — Sandeep “Sonny” Bains pulled up to Lyons Family Medicine in the pre-dawn dark armed with coffee, doughnuts and glossy brochures about pain treatments.

“What can I help you with for acute pain?” he inquired of ­father-and-son primary-care doctors Michael and Zachary Lyons as he was ushered into a wood-paneled back office.

Bains’s quick drop-ins are modeled on those used by pharmaceutical sales reps to pump up sales. The similarity ends there, though: Bains, a pharmacist, is part of a fledgling movement co-opting the drug industry’s tactics to deliver a different message to doctors — that narcotics are not only addictive but also often no better at managing pain than safer, over-the-counter medicines.

“I’m cold-calling them, picking up the phone: ‘I’m Sonny . . . a pharmacist providing free education,’” Bains said. “It does sound like a drug rep’s pitch.”

The opioid crisis and a series of high-profile lawsuits against drugmakers, including Purdue Pharma and Insys, have put a national spotlight on aggressive pharmaceutical marketing campaigns to persuade doctors to prescribe their drugs, sometimes with scant attention to safety issues — a $20 billion-a-year effort for all drugs sold in the United States, according to a recent study. It has also given new energy to a countermovement that borrows the style, if not the substance, of that outreach.

Late last year, Aetna invested nearly $7 million in the counterprogramming strategy, partnering with a nonprofit, Alosa Health, to bring its pain treatment education to doctors in Pennsylvania, Maine, Illinois, Ohio and West Virginia — states hit hard by opioid overdose deaths. The health system Kaiser Permanente and the Department of Veterans Affairs also use the approach.

Bains is one of about 30 trained academic detailers, as they call themselves, who will be knocking on doctors’ doors for the next year, deploying their knowledge about drugs and their people skills to provide the best evidence about how to treat pain. Aetna will measure how well the intervention works and could expand it to other states — or to other health problems, such as overuse of antibiotics.

“What’s fascinating about this program is that . . . the cause of the opioid epidemic was inappropriate and aggressive marketing of opioids by these sales reps,” said Daniel Knecht, vice president of clinical strategy and policy at Aetna.

Holly Campbell, a spokeswoman for PhRMA, a lobby for the drug industry, said that ethical relationships between drugmakers and health care professionals were beneficial for patients and aided in the development of new medicines.

“An important part of achieving this mission is ensuring that health care professionals have the latest, most accurate information available regarding medicines,” Campbell said.

Policymakers often favor top-down approaches to change how doctors practice: Some states, for instance, set limits on pain prescriptions, or send doctors report cards on their prescribing habits in hopes of quelling a crisis that now kills more Americans each year than AIDS at the height of the HIV epidemic.

Bains’s approach, in contrast, adopts the very method of building relationships with doctors that helped seed the opioid crisis.

“The message is not: ‘Don’t use opioids,’ ” Bains said, after quizzing Michael Lyons on when he would consider using narcotics to treat pain. “It’s . . . be cautious. Use immediate-release and not necessarily long-acting drugs. Short course of treatment.”

He sees himself as peddling evidence, often championing treatments that may be too old or too unconventional, like Advil and Tylenol or acupuncture, to have a sales force dropping by to remind doctors to use them.

“The drug company is frankly much smarter about how to get into people’s heads,” said Jerry Avorn, a Harvard Medical School professor and critic of the drug industry’s influence. As a primary-care doctor, “I would definitely have sales reps trying to get to see me to talk about this amazing medication, [to] tell me that pain is undertreated, it’s the fifth vital sign and every patient should be asked if they are in pain.”

The idea of using the drug companies’ own playbook is familiar to Avorn, who first showed the strategy could work nearly four decades ago in a research project. But only recently has Avorn seen broader embrace of the idea that the drug industry’s outreach may drive up the use of expensive medicines and push physicians to use them inappropriately.

Bains makes these visits not just for opioids, but also to help physicians manage dementia, lung diseases, diabetes and other conditions, through an Alosa Health program supported by the Pennsylvania Department of Aging. In brief meetings that often take place off-hours, he builds relationships with doctors, listening to their questions and challenges.

The interactions are collaborative and respectful, even if doctors practice in ways that don’t conform with evidence. Bains said doctors are often dismissive when confronted with a new idea or evidence, but then they bring it up with greater interest next time he sees them.

These unconventional education efforts have often started as one-off contracts or experiments, but they are growing as studies show they work. Michael Courtney, director of physician engagement at the Capital District Physicians’ Health Plan, now deploys his experience as a pharmaceutical sales rep for companies such as Pfizer and Johnson & Johnson to dissuade doctors from unnecessary use of expensive drugs, drawing on relationships built over time.

“Even in the pharmaceutical industry, it wasn’t a one-time call,” Courtney said. “You were going in there because the data said you have to hear something six to eight times to make it change or resonate.”

A recent study in JAMA Network Open found a possible link between the number of office visits that drug reps made, building trust over time, and the number of overdose deaths — although the research couldn’t show that the visits caused the deaths.

For doctors, these visits amount to a different way to stay abreast of research in their fields. Normally, physicians learn about new findings piecemeal, at best, when they have time to read medical journals or to sit in darkened hotel rooms watching slides flash by. Or they get a highly selective version of the data from drug company representatives, along with free samples.

Bains, by contrast, comes with prescription pads already filled out for treatments like Tylenol or rest, ice and compression — and with warnings about risks and side effects of opioids.

“Being in primary practice, it would be very easy to be in isolation — to take the medical knowledge from the time you finish residency, really not bulk it up, or update it, and really veer off of what is the current evidence-based medicine,” said Zachary Lyons, the son.

The Lyonses, trained three decades apart, were both aware of the risks of opioids, but they debated with Bains about when to turn to steroids, which are not recommended for short-term pain relief for acute low-back pain.

“The wonderful thing about doing what we do is — you and I can disagree, but we’re all on the same side. We all want the patient to get better,” Michael Lyons said of their chats with Bains. “Drug salesmen come, but they have motivation — they’re trying to sell.”

Filed under: General Problems