The family trying to escape blame for the opioid crisis

In the years since OxyContin came to market, the industry has implemented rules that forbid the most egregious forms of gift-giving. As early as 1991, the American Medical Association had issued recommendations: Ideally, gifts would benefit patients (free samples for those who otherwise couldn’t afford them), but gifts to doctors were generally aboveboard as long as they were of “minimal value”—notepads and pens.

As the methods of Purdue’s detailers make clear, the AMA’s recommendations were honored in the breach through much of the ’90s—and Purdue reps were hardly alone in using such methods to their advantage. In 2009, amid intensified government scrutiny of the industry, Big Pharma instituted a code that banned gifts large (tickets to sporting events or the theater) and small (coffee mugs).

Still, that code was itself full of loopholes. Pens were prohibited, but meals—most often casual, in-office affairs—were still permissible. A 2017 article in the Journal of the American Medical Association found that in a single year (2015), nearly half the doctors in America received a payment from a drug rep. Close to 90 percent of those payments came in the form of free food and beverages.

You might reasonably ask whether a modest meal with a pharmaceutical sales rep matters all that much. You might also be surprised by what a small gift can buy. In recent years, social psychologists and marketers have demonstrated that the pull of reciprocity is exceedingly powerful in human beings, often acting on us in ways we may not consciously appreciate. Perhaps it’s too much to suggest that free pens were responsible for the opioid epidemic. But it’s become more and more clear that a gift, even from a salesperson, can make the receiver feel obliged to give something in return.

The potential conflicts of interest created by detailers’ gifts have been recognized for as long as the money’s been flowing. Doctors tend to prescribe drugs from companies that give them gifts—but there could be harmless reasons for the pattern. Doctors who believe that Prozac is an effective drug might prescribe it a lot and also spend time with reps from Prozac’s manufacturer, Eli Lilly, to learn about the latest research on how best to use it in treating patients.

Another 2017 study in jama, however, suggests that even small gifts can cause doctors to change their script-writing behavior. It looked at what happened to the market share of brand-name drugs sold by reps at 19 academic medical centers from 2006 to 2012. Each institution in the study banned small gifts and regulated pharma reps’ visits more strictly at some point during this time; the first enacted its prohibitions in October 2006, the last in May 2011. This staggered timeline allowed the researchers to examine how the rate of prescriptions for the repped drugs changed when the policies went into effect. They found that these drugs lost 1.67 percent in market share to cheap generics and drugs without a dedicated sales force. If that doesn’t sound like a lot, think of it as a percentage of $60 billion, the 2010 sales revenue for the drugs covered by the study. It works out to a pretty handsome payback for some turkey sandwiches.