Prescription drugs are back in the news again, particularly EpiPen and OxyContin. Although EpiPen is a generic medication, the EpiPen’s manufactuer, Mylan, has been steadily raising the price by over 400 percent over the past ten years, so that each EpiPen now costs over $500. Over the last twenty years, OxyContin prescriptions grew rapidly due to an outrageous campaign by its manufacturers, and a new trove of documents unsealed by a federal court have revealed more details about the campaign.
Obviously, both of these are yet more examples of the depths to which drug companies will sink to increase their profits. But in all the media attention these stories are getting, one part is conspicuously absent: the responsibility doctors bear for these problems.
Let’s start with the EpiPen. Many articles have focused on how, although there are eight epinephrine-injecting devices available in Europe, there’s just two available in the United States, the EpiPen and Adrenaclick. Part of this problem is because the maker of EpiPen has repeatedly sued competitors for patent infringement (even though epinephrine itself is no longer under patent), and part of it is because the FDA has rejected competing devices. But that’s not the only problem.
Doctors often prescribe “EpiPen,” because it’s easier to remember, but, when a doctor does that, the pharmacist must fill the prescription with the Mylan-branded EpiPen. The pharmacist can’t just substitute Adrenaclick or syringes filled with epinephrine, both of which work just as well. A doctor could easily write “Adrenaclick” or “epinephrine injection,” thereby making those other options available, but doctors don’t bother. They’ve always written “EpiPen” in the past and they don’t care about staying up to date with other medicines, so they keep writing “EpiPen,” and we all suffer as a result.
The same goes for OxyContin. As just one example noticed in the documents that were recently unsealed, one orthopedic surgeon long held out on prescribing OxyContin, until Abbott Laboratories found out he liked junk food, and so they delivered him a box filled with doughnuts and snacks arranged to spell out “OxyContin.” The silly and offensive marketing tactic worked, and he changed his prescribing habits.
Truth is, many doctors are so cavalier about prescribing opioid pain relievers — despite countless news stories and medical journal articles about the damage caused by over-prescription of opioids — that the Surgeon General, the Department of Health & Human Services, and a variety of medical groups have launched the “Turn The Tide” initiative. “Turn The Tide” is a good idea, but it’s also an embarrassment to the medical community: how have medical standards fallen so low that doctors need a “checklist” and a “pocket card” to figure out whether or not to give opioid pain relievers?
The solution to this problem can’t be found in medical malpractice law. At the core of every medical malpractice case is the simple question, “did the doctor’s care and treatment meet the standard of care?” Unfortunately, all of this haphazard prescribing nonsense is so common that it is part of the standard of care.
Some have proposed improving this situation by limiting insurance or Medicare coverage for these prescribing decisions. There’s some merit in that suggestion, but it’s also like using a chainsaw to make a cut that should be done with a scalpel, and I’m always wary of limiting doctors and patients’ ability to get insurance coverage for their decisions. The problem here is that doctors aren’t really “deciding” to use EpiPens or to prescribe OxyContin, they’re thoughtlessly doing it out of habit, or because of a drug company’s marketing push. Until we can find some better way of structuring our prescription drug and medical device industry in general, I think change has to start with simple shame. Doctors need to be told, in public, that they are part of the problem, and that they need to think more carefully about their prescribing decisions.