Even Small Interactions Between Marketers and Doctors Contributed to Opioid Mortality, a Study Reports

A new study looking across the United States county by county reports that it took only a few extra dollars in marketing for pharmaceutical companies to effect an increase in opioid prescribing. The study demonstrated a link between mortality from opioids and marketing by pharmaceutical companies directly to physicians. The study and a commentary are both published in the Journal of the American Medical Association's JAMA Network Open and available for free. (See Hadland SE, Rivera-Aguirre A, Marshall BDL, et al. Association of pharmaceutical industry marketing of opioid products with mortality from opioid-related overdoses. JAMA Netw Open. 2019;2(1):e186007. doi:10.1001/jamanetworkopen.2018.6007; Trecki J. A perspective regarding the current state of the opioid epidemic. JAMA Netw Open. 2019;2(1):e187104. doi:10.1001/jamanetworkopen.2018.7104.)

"In this study, across US counties, marketing of opioid products to physicians was associated with increased opioid prescribing and, subsequently, with elevated mortality from overdoses," the authors wrote in their conclusion. "Amid a national opioid overdose crisis, reexamining the influence of the pharmaceutical industry may be warranted."

The study demonstrated that, even by increasing their marketing budgets by $5.29 per 1000 population, the number of opioid prescriptions written by doctors went up by 82% and the opioid death rate was 9% higher a year later.

"It really doesn't take much marketing to increase the number of deaths," lead author Scott Hadland, MD, MPH, MS, a pediatrician and researcher at Boston Medical Center's Grayken Center for Addiction, told Reuters Health by phone. (See Emery G. Study links opioid epidemic to painkiller marketing. Medscape, Reuters Health, January 22, 2019. https://www.medscape.com/viewarticle/907985?src=wnl_edit_tpal&uac=178501SR&impID.)

The study demonstrated that the key was not the amount of money paid to individual physicians, but rather the number of smaller interactions, "such as repeatedly bringing lunch to the office staff or treating the physician to a dinner" that had the most effect.

But now that the problem has grown, with illicitly produced fentanyl products that are now adulterating typical street drugs such as heroin, even if the root cause was the targeting of physicians by marketers, wrote Jordan Trecki, PhD, in a separate commentary also published by JAMA Network Open. Trecki is employed in the Drug & Chemical Evaluation Section, Diversion Control Division, of the US Drug Enforcement Administration in Springfield, Virginia.

"The data covering the period of 2013 to 2015 analyzed by Hadland and colleagues do support an association between pharmaceutical marketing to physicians, physician prescribing, and prescription opioid abuse," wrote Trecki in the conclusion. "However, as the opioid epidemic grows, it is evolving beyond prescription medications and heroin to involve illicitly produced fentanyl, fentanyl-related substances, and other opioids either alone or in combination. It is clear that a variety of approaches will be necessary to control this epidemic."

Cardiac Arrest Reported With Complication of Epidural Analgesia

A published case report describes 2 unrelated instances of 2 female patients suffering cardiac arrest a little more than an hour after receiving epidural analgesia. The women, ages 78 and 69 years, were rescued with cardiopulmonary resuscitation, and tests later revealed pneumocephalus in one of the patients, and pneumorrhachis in the other.

"If cardiac arrest occurs after epidural analgesia, pneumocephalus and pneumorrhachis should be considered as its cause," the authors wrote. "Although epidural analgesia is a common procedure, caution is warranted during this procedure."

The authors report that pneumorrhachis and pneumocephalus are rare complications of unintentional dural puncture allowing air to be injected into the subarachnoid or subdural space. They report that no cases of cardiac arrest associated with these complications have been reported in the literature previously, but that clinicians should be aware of the possibility of this complication being a cause in the event of cardiac arrest soon after epidural injection.

The 6 authors are associated with departments of emergency medicine at Hanyang University Guri Hospital and Hanyang University Seoul Hospital. (See Shin H, Choi HJ, Kim C, et al. Cardiac arrest associated with pneumorrhachis and pneumocephalus after epidural analgesia: two case reports. J Med Case Rep. 2019;12(1):387.)