While the opioid crisis deepened in Maine over the past three years, drug companies selling opioids increasingly showed up on the doorsteps of physicians’ offices – offering free food and beverages, consulting or speaking fees, discount coupons for drugs and other freebies. The total payments to doctors related to opioids doubled from 2014 to 2015.

The increased payments, documented in recently released federal data, occurred while the opioid crisis accelerated, and overdose deaths from prescription opioids and related illicit drugs such as heroin soared to record rates.

One physician – Dr. Doug Jorgensen of Manchester – stands out for both prescribing opioids for pain relief and for seeing patients at a recovery center for people with opioid addictions. He is facing criticism from other doctors for accepting thousands of dollars from drug companies because of the conflicts that creates with prescribing medicine.

Jorgensen received 60 percent of all pharmaceutical company payments to doctors in Maine related to opioids, or $42,522 from August 2013 through December 2015, the period for which data are available. He was paid $28,519 in 2015 alone.

Overall, opioid industry spending on Maine doctors increased from $21,654 in 2014 to $42,550 in 2015. The data reporting requirement went into effect in August 2013, and for the August-through-December period of that year, payments from opiate manufacturers to Maine doctors totaled $6,298.

These numbers pale in comparison to the total payments to Maine doctors by all drug companies and manufacturers of medical devices. For 2013-2015, that grand total was $11.9 million, ranking Maine behind 42 other states and the District of Columbia.

But while the amount spent by opioid drug makers represents a fraction of total payments to doctors, the impact of opioid abuse has staggered the nation, emerging as one of the country’s – and Maine’s – major public health threats. And research shows even small amounts of money can have large effects on doctors’ prescribing practices, experts say.

In Maine, the number of visits to doctors by pharmaceutical sales representatives for opioids like OxyContin, Subsys, Butrans and Hysingla ER has increased – from 440 visits to 125 doctors in 2014 to 569 visits to 117 doctors in 2015.

SOURCE: Centers for Medicare & Medicaid Services | CHART: Christian MilNeil

This is happening at the same time Maine is passing laws and trying to persuade doctors to minimize opioid prescribing in an attempt to alleviate the public health epidemic of addiction. Fueled by the opioid crisis, overdose deaths from heroin and other opioids jumped from 176 in 2013 to 272 in 2015 to 286 through the first nine months of this year.

Jorgensen is a physician at New England Sport and Spine in Manchester, which advertises pain relief for a number of maladies. At the same location, he’s a doctor at the Maine Recovery Center to treat drug addiction. He’s treating patients at the recovery center who may have become addicted to opioids he prescribed to them at the pain clinic.

In the spring, Jorgensen spoke out against what was then a proposed law that would make Maine one of the strictest states in the nation for prescribing opioids. The law passed.

Two other Maine physicians – Dr. Stephen Hull of Mercy Hospital in Portland and Dr. Noah Nesin of Penobscot Community Health Center in Bangor – question Jorgensen’s ethical decisions in accepting the money.

They say for Jorgensen to take thousands of dollars in drug company money at the same time he was prescribing opioids is a dubious practice and an inherent conflict.

“There’s no way to reconcile the acceptance of money from the industry in these types of circumstances,” Nesin said, referring specifically to Jorgensen. “It’s inconsistent with the most important role a physician has, to advocate for their patients’ best interests.”

‘PROFESSIONALLY IRRESPONSIBLE’

Nesin said doctors should never have a financial interest in prescribing a certain drug.

In one event recorded in the database and labeled as either a speaking fee or other promotional service, Jorgensen received $7,220 on Nov. 21, 2015, from Purdue Pharma related to Hysingla, an extended-release opioid used to control severe pain, as well as opioids Butrans and OxyContin. The payment was categorized as a speaking, training and education engagement.

There were 10 additional payments of more than $1,000 each to Jorgensen for opioids and 49 overall interactions or visits between Jorgensen and opioid pharmaceutical companies, according to the database, which is compiled by the U.S. Centers for Medicare and Medicaid Services. The data can be searched at openpaymentsdata.cms.gov. ProPublica, an independent, nonprofit journalism website, sorts and analyzes the federal data and offers its own search tool at ProPublica.org.

Hull said Jorgensen – who obtained a medical license in Maine in 1997 – is setting a bad example for other physicians.

“It’s unfortunate to see doctors who are prescribing opioids in large quantities also benefiting from fees from these same pharmaceutical companies,” said Hull, referring to Jorgensen. “It raises questions about conflict of interest.”

It’s rare for doctors to openly question the judgments other physicians make in practicing medicine, especially in the same state. The Maine Medical Association, which represents physicians, discourages such payments to doctors, although they are legal.

“This is pretty vexing,” said Dr. Eric Campbell, a medical ethics expert at Harvard Medical School, speaking broadly about the practice. “To be accepting payments for opioids in the face of the opioid epidemic in many ways can be viewed as professionally irresponsible.”

Jorgensen did not respond to multiple requests for comment from the Maine Sunday Telegram, including phone calls and emails.

In April, he wrote an op-ed for the Portland Press Herald opposing a strict new opioid prescribing law. Jorgensen’s efforts failed, as the law was approved and doctors will now have to reduce opioid dosages for some patients and cap the length of prescriptions. They are also required to report opioid prescriptions to the state’s Prescription Monitoring Program as a way to prevent “doctor shopping.”

Nesin questioned whether Jorgensen’s attempts to defeat the bill were influenced by the payments he was receiving from the drug companies, which include Purdue Pharma, the maker of opioids OxyContin and Hysingla.

“That looks like self-interest,” Nesin said of Jorgensen’s lobbying efforts. “He’s representing the interests of the people who are paying him money.”

But one Maine doctor who accepted drug company money for opioids defended the practice.

EFFECTIVENESS OF EVEN MODEST GIFTS

Dr. Gianelia Guernelli, a Brunswick pain specialist for Mid Coast Hospital, was paid $13,863 from August 2013 through December 2015, including $6,667 in 2015. His total payments were second only to Jorgensen’s.

Guernelli, in an interview with the Telegram, said two large payments he received in 2015 – $3,960 for consulting and $2,475 for training – were justified. The payments were from Purdue Pharma, for training at the pharmaceutical giant’s headquarters in Connecticut and for marketing purposes with other physicians about Hysingla Extended Release, an abuse-deterrent opioid that prevents patients from abusing the pills by crushing them and snorting the powder.

“They paid me for my training at Purdue Pharma and so I could do marketing talks for other doctors,” Guernelli said, explaining the marketing talks were to promote Hysingla. He said that in general, the drug company training helps him keep up with “cutting edge” drugs and the latest technology.

SOURCE: Centers for Medicare & Medicaid Services | CHART: Christian MilNeil

Guernelli said he sees nothing wrong with accepting money from pharmaceutical companies as long as it serves a useful purpose, and he said it does not affect how he prescribes medication.

“I do not see a direct correlation,” Guernelli said.

But Campbell, the Harvard Medical School professor who has studied industry payments to doctors, said studies point to a correlation between doctors accepting money and the types of drugs they prescribe.

“It’s a form of self-delusion if they believe they’re not being affected,” Campbell said. “The drug companies do this because it works. It’s a way to pay doctors for prescribing.”

Campbell said it’s not so much the dollar amount that influences doctors – even small gifts or free food can change the way doctors prescribe medicine.

He said it may seem counterintuitive to believe modest gifts or a dozen pastries make a difference, but they do. The small dollar value of the gifts makes it insidious. Because the gifts are modest, the doctors’ guards are down and they may not realize they are being influenced, he said.

“At the most basic level, it’s unreasonable to believe the drug companies are throwing their money away,” Campbell said.

Top 10 doctors with the most “food and beverage” payments from opioid manufacturers, Aug. 2013 – Dec. 2015:

CHART: Christian MilNeil | SOURCE: Centers for Medicare & Medicaid Services

For all drugs and medical devices across the United States, drug companies spent $6.2 billion on 810,000 doctors, according to the federal data.

Nesin and Hull are part of a contingent of doctors trying to reduce the frequency with which Maine doctors prescribe opioids for pain – especially chronic pain – but their efforts are hindered by the one-on-one conversations between pharmaceutical reps and physicians. They are joined by the Maine Medical Association, which supported the new law and is trying to persuade doctors to prescribe fewer opioids, especially for chronic pain. There is no proof that opioids are effective in treating chronic pain, according to the U.S. Centers for Disease Control and Prevention. They do work in treating acute pain, such as immediately after surgery.

‘DANGER IN THE STATUS QUO’

Gordon Smith, executive vice president of the Maine Medical Association, is criss-crossing the state touting the benefits of complying with the law and reducing or eliminating opioid prescribing, especially for chronic pain.

But also increasingly criss-crossing the state are pharmaceutical reps selling what they claim is the effectiveness of opioids to doctors.

Hull said there’s no doubt that the salespeople are exaggerating the benefits of opioids while downplaying the risks.

People are much more likely to become addicted to opioids and die of a drug overdose if they are prescribed opioids, according to the CDC.

“There is danger in the status quo. The status quo is killing people,” said Dr. Elisabeth Fowlie Mock, a Holden doctor who is also working to reduce Maine doctors’ reliance on opioid prescribing.

Campbell said a financial incentive is likely a reason why the pharmaceutical reps were showing up in Maine in 2015 in much greater numbers than in 2013.

In 2015, Maine passed a law that required insurance companies to reimburse for abuse-deterrent drugs the same way that they reimburse for opioids that do not have abuse-deterrent formulations.

The abuse-deterrent drugs cost far more than regular opioids and produce more income for manufacturers.

When the law changed, the profit motive appeared, and so did the pharmaceutical reps touting abuse-deterrent opioids in Maine, Campbell said.

Hysingla, for instance, is an abuse-deterrent opioid, and Jorgensen and Guernelli were paid thousands of dollars related to Hysingla.

The opioids – whether they are abuse-deterrent or not – still contain the same addictive properties. The difference is they can’t be abused in ways other than taking them orally.

The data are collected by the U.S. Centers for Medicare and Medicaid Services and easily searched on the ProPublica.org website, but there’s no way to track payments over a long period because the data have only been collected and made public since 2013, as one of the requirements of the Affordable Care Act.

Campbell said several studies show a clear correlation between doctors’ willingness to prescribe certain drugs and receiving free food or other gifts from drug companies.

Campbell said he doesn’t fault the drug companies, who are “merely doing what is in their best interest, to sell drugs,” but he blames the medical profession for failing to have strong policies in place to stop the practice.

“The blame lies entirely with the medical profession,” Campbell said.

Nesin said there is no value in the free food, speaking or consulting fees offered to doctors, nor in the drug company clinical trials in which doctors are paid to participate. Nesin said it’s all designed to stroke the ego of the doctors, and none of it is beneficial or used for credible research.

For instance, he said the “clinical trials” might show up in a marketing brochure – similar to “nine out of 10 dentists recommend a brand of toothpaste” – or never be used at all. It’s all an excuse to pay doctors to prescribe.

Nesin said even meeting with the sales reps to talk about the drug doesn’t have any value because better, independent information on when and how to prescribe is available online.

“There’s no reasonable excuse to have them in your practice at all,” Nesin said. “There is no value to it. The only reason to have them there is because you like what they’re giving to you.”

Fowlie Mock, the Holden doctor working to reduce opioid prescribing, runs a $150,000-per-year state program that offers doctors neutral, academically based research on common prescribing topics. She said some doctors have naively been thinking that the sales techniques don’t work on them and don’t realize the extent to which they are being sold or marketed to.

“What makes a successful salesperson? You don’t learn that in medical school,” Fowlie Mock said.

She noted that the program she runs providing research and training on prescribing practices is now focusing on opioids.

“We don’t pay for lunch. If they want lunch, they can pay for their own lunch,” she said.

HOW IT WORKS

Many of the contacts between Maine doctors and drug companies are simply pharmaceutical sales representatives dropping off food and beverages – pastries, muffins, doughnuts or lunch.

Such hospitality may not seem egregious – how could two dozen pastries influence a doctor who earns a comfortable upper middle-class or better lifestyle? But the free lunches have a subtle way of psychologically influencing prescribing practices, experts say.

“There’s no such thing as a free lunch. It might not cost you any money, but it comes with strings attached,” Fowlie Mock said.

Fowlie Mock said the free food is pleasurable and opens the doctors up to conversations with the salespeople.

Nesin said he’s managed different practices over the past 10 years, and every time he switches jobs, he bans pharmaceutical reps from even entering the door. Nesin said there’s always some pushback from fellow doctors and employees, and he has to explain why it’s a bad idea to let them drop off the doughnuts.

“One doctor, when I refuted every last reason he gave me for allowing pharmaceutical reps in the practice, admitted to me that the real reason was he liked the sandwiches that they give you. I told him if that’s what it would take, I would buy him sandwiches every week,” Nesin said.

Campbell said research he conducted shows that doctors who receive free food and beverages from pharmaceutical companies are more likely to prescribe drugs from those companies than the generic equivalents, which are just as effective and less costly.

Nesin said something happens to the brain when you can get something for free, even if it’s not of great value and even if you earn a comfortable living.

Nesin said he remembers attending a conference several years ago and he checked out a vendor room and watched as doctors would go to every table and get a card punched so they would qualify for a free Blu-ray player.

“You would see these highly compensated physicians scurrying around like lab rats for a free Blu-ray player that they could easily afford back home. It’s ludicrous,” Nesin said.

Hull said about 10 years ago, pharmaceutical reps were permitted to show up at the Mercy Pain Clinic he operates, and often they would drop off muffins or pastries. As time went on, he became uncomfortable even with accepting food or discount coupons for drugs, so he banned the practice.

“What they do influences you in very subtle ways,” Hull said.

Hull said at the time he was prescribing opioids more often – before he shifted the entire practice about three years ago to use opioids as little as possible to control chronic pain. The U.S. CDC says there’s “insufficient evidence” that opioids help with chronic pain, and Hull said based on his extensive research and experiences helping patients with chronic pain, opioids are not useful for such pain.

STRICTER LAWS MAY BE NEEDED

Guernelli, the No. 2 recipient of drug company money for opioids in Maine, however, said that even though the evidence does not prove opioids are effective for chronic pain, doctors such as himself still prescribe opioids. He said the “science is evolving.”

“In the pain world, there is still a role for opioids to control chronic pain, as long as it’s done in a cautious and reasonable way,” said Guernelli, noting that the severity of chronic pain can vary widely depending on the condition of the patient.

Hull said opioids should be prescribed as little as possible because of their inherent risks, but that’s not what he heard from pharmaceutical reps, who would tout the drugs as effective in a number of pain control strategies.

Hull said pharmaceutical representatives do not give “unbiased, evidence-based information” and would never say that opioids are not effective for chronic pain. He said as a more frequent prescriber of opioids several years ago, he was targeted by the drug companies and offered all-expense-paid junkets, but he always refused.

“There would often be offers to fly you someplace warm in the winter, often next to a golf course, where you would be asked to give your professional advice,” Hull said. “I considered it to be a very thinly veiled strategy to convince me to prescribe their drugs.”

Campbell said ideally the solution would come from within the medical community, but stricter laws regulating drug companies at doctors’ offices may be needed.

“The medical field has not proven to be willing or able to self-regulate on this issue,” Campbell said.