1.
Letters
RESEARCH LETTER
Analysis of Pharmaceutical Industry Marketing
of Stimulants, 2014 Through 2018
Use of prescription stimulants doubled from 2006 to 2016 in
the United States1
and, as of 2013, it resulted in more pharma-
ceutical expenditures for children than any other medication
class.2
Although the rise in stimulant use parallels increasing
attention-deficit/hyperactivitydisorderdiagnosisrates,stimu-
lants, even when appropriately prescribed, are commonly di-
verted and used nonmedically.3
It is important to consider fac-
torsthatmaycontributetoapotentialoversupplyofstimulants.
Pharmaceutical company marketing is associated with in-
creased prescribing.4
The extent to which physicians receive
marketing for stimulants is not well described.
All US industry-physician marketing interactions are com-
piled by the Centers for Medicare & Medicaid Services (CMS).
Using these data, we characterized stimulant marketing to
physicians.
Methods | Data were extracted on industry-physician market-
ing interactions (termed payments) occurring between Janu-
ary 1, 2014, and December 31, 2018, from the Open Payments
database.5
We extracted data on nonresearch payments for
stimulants listed by generic or brand name. Payments were
tabulatedwithregardtotheproductsmarketed;thetype,num-
ber, and dollar value of payments (inflation adjusted using the
Consumer Price Index); and the number of unique physi-
cians receiving payments overall and by medical specialty.
Unique physicians were identified by CMS based on name,
medicallicensenumber,andNationalProviderIdentifiernum-
ber. The 5-year prevalence of marketing among physicians was
estimated using as a denominator the number of active phy-
sicians between 2014 and 2018 in each specialty per histori-
cal National Provider Identifier data.6
Medical specialties were
defined by CMS in the Open Payments and National Provider
Identifierdatabases.Thestudywasnotconsideredhumansub-
jects research by the Boston University School of Medicine in-
stitutional review board and was thus exempt from ethical re-
view and informed consent procedures. Analyses were
undertaken with Stata version 15.1 (StataCorp).
Results | Between 2014 and 2018, there were 591 907 payments
tophysicianstotaling$20101250(Table1)intheOpenPayments
database. The median value of payments was $14 (interquartile
range [IQR], $12-18). Payments for food and beverage were the
most common types (578 105 [97.7%]) and made up the great-
estpercentageofdollarsspent($9988670[49.7%]).Medianpay-
ments were highest for consulting fees ($3045 [IQR, $1920-
$3750]).ThemostcommonlymarketedstimulantwasVyvanse
(lisdexamfetamine),whichmadeup274 502payments(46.4%)
and $7 076 729 (35.2% of all dollars spent).
Annual marketing was $2 429 626 in 2014, increased to a
peak of $4 817 619 in 2016, and decreased to $3 861 186 in 2018.
Annually, physicians received a median of 2 payments (IQR,
1-4 payments; maximum, 286 payments) and $35 (IQR,
$17-$81; maximum, $22 248) in marketing.
Overall, 55 105 physicians received payments, resulting in
an estimated 5.6% five-year prevalence among 989 789
physicians. Pediatricians received the most payments (239 217
Table 1. Marketing to Physicians Involving Stimulant Products, per the Open Payment Program Database
(January 1, 2014, to December 31, 2018)
Characteristic Payments, No. (%) Total Payment Amount, $ Payment, Median (IQR), $
Total 591 907 (100.0) 20 101 250 (100.0) 14 (12-18)
Type of marketing
Food and beverage 578 105 (97.7) 9 988 670 (49.7) 14 (12-18)
Travel and lodging 7142 (1.2) 2 049 398 (10.2) 178 (53-361)
Speaking fees 1806 (0.3) 3 834 205 (19.1) 2000 (950-2570)
Honoraria 1579 (0.3) 2 454 854 (12.2) 1500 (1000-2025)
Consulting fees 438 (0.1) 1 563 676 (7.8) 3045 (1920-3750)
Other paymentsa
2837 (0.5) 210 446 (1.0) 38 (20-91)
Stimulant productb
Vyvanse 274 502 (46.4) 7 076 729 (35.2) 14 (12-17)
Quillivant 80 086 (13.5) 2 250 682 (11.2) 15 (13-19)
Mydayis 65 356 (11.0) 3 085 987 (15.4) 15 (12-19)
Evekeo 60 969 (10.3) 1 739 565 (8.7) 13 (11-15)
Adzenys 51 269 (8.7) 2 199 064 (10.9) 15 (13-19)
Dyanavel 28 817 (4.9) 1 948 762 (9.7) 15 (12-19)
Aptensio 19 925 (3.4) 1 469 859 (7.3) 16 (13-20)
Other stimulantsc
30 490 (5.2) 851 566 (4.2) 15 (12-18)
Abbreviation: IQR, interquartile
range.
a
Includes payments labeled as
education or other gifts.
b
Some payments involved multiple
stimulant products; totals may add
to more than 100%.
c
Includes Cotempla, Daytrana,
Quillichew, Zenzedi, Focalin,
Precentra, Adderall, Ritalin, and
Concerta.
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2.
payments [40.4%]), and psychiatrists received the most mar-
keting in dollars ($11 392 037 [56.7%]; Table 2). Pediatrics had
the highest percentage of physicians receiving marketing (5-
year prevalence, 19.2%).
Discussion| Duringthe5-yearstudyperiod,1in18physiciansap-
peartohavereceivedmarketingforstimulants.Paymentswere
mosttypicallyhigh-frequency,low–dollarvaluemarketinginthe
form of food or beverage. Pediatricians, psychiatrists, and fam-
ilyphysicians(ie,clinicianswhooftencareforchildrenandado-
lescents) received the greatest share of marketing.
Pharmaceutical industry marketing may be partly con-
tributing to rising stimulant-prescribing rates.4
The most heav-
ily marketed product was Vyvanse (lisdexamfetamine), which
is not available as a generic drug and costs more than other
stimulant drugs.2
Despite a misuse-deterrent formulation that
prevents intranasal and injection use, Vyvanse can be used
nonmedically.
Limitations of this study include its descriptive nature; as-
sociations between marketing and prescribing cannot be es-
tablished. Some marketing may have been educational and
served to mitigate potential underprescribing. Some physi-
cians receiving marketing may not have had active National
ProviderIdentifiernumbers.Informationonnonphysicianpre-
scribers was excluded.
In the context of rising stimulant prescribing, examining
thepotentialroleofpharmaceuticalindustrymarketingiswar-
ranted. In particular, since prescription medication misuse
commonly begins during adolescence and young adulthood,
the intensity of marketing to clinicians who care for individu-
als at these developmental stages may deserve scrutiny.
Scott E. Hadland, MD, MPH, MS
Magdalena Cerdá, DrPH, MPH
Joel J. Earlywine, BA
Maxwell S. Krieger, BS
Timothy S. Anderson, MD, MAS, MA
Brandon D. L. Marshall, PhD
Author Affiliations: Grayken Center for Addiction and Department of
Pediatrics, Boston Medical Center, Boston, Massachusetts (Hadland); Division
of General Pediatrics, Department of Pediatrics, Boston University School of
Medicine, Boston, Massachusetts (Hadland); Department of Pediatrics, Boston
Medical Center, Boston, Massachusetts (Hadland); Center for Opioid
Epidemiology & Policy, Department of Population Health, New York University
School of Medicine, New York (Cerdá); Department of Health Law, Policy, and
Management, Boston University School of Public Health, Boston,
Massachusetts (Earlywine); Department of Epidemiology, Brown University
School of Public Health, Providence, Rhode Island (Krieger, Marshall); Division
of General Internal Medicine, University of California, San Francisco,
San Francisco (Anderson).
Accepted for Publication: October 8, 2019.
Corresponding Author: Scott E. Hadland, MD, MPH, MS, Grayken Center for
Addiction, Boston Medical Center, 801 Albany St, Room 2055, Boston, MA
02119 (scott.hadland@bmc.org).
Published Online: January 21, 2020. doi:10.1001/jamapediatrics.2019.5526
Author Contributions: Dr Hadland had full access to all of the data in the study
and takes responsibility for the integrity of the data and the accuracy of the data
analysis.
Concept and design: Hadland, Cerdá, Marshall.
Acquisition, analysis, or interpretation of data: Hadland, Earlywine, Krieger,
Anderson, Marshall.
Drafting of the manuscript: Hadland.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Hadland, Earlywine, Krieger.
Obtained funding: Hadland.
Administrative, technical, or material support: Earlywine, Krieger, Marshall.
Supervision: Hadland, Cerdá, Marshall.
Conflict of Interest Disclosures: None reported.
Funding/Support: Dr Hadland is supported by the National Institute on Drug
Abuse (grant K23DA045085), Thrasher Research Fund (Early Career Award), and
the Academic Pediatric Association (Young Investigator Award). Dr Cerdá is
supported by the National Institute on Drug Abuse (grant R01DA039962).
Dr Marshall is supported in part by National Institute of General Medical Sciences
(grant P20GM125507).
Role of the Funder/Sponsor: The funders had no role in the design and conduct
of the study; collection, management, analysis, and interpretation of the data;
preparation, review, or approval of the manuscript; and decision to submit the
manuscript for publication.
1. Piper BJ, Ogden CL, Simoyan OM, et al. Trends in use of prescription stimulants
intheUnitedStatesandterritories,2006to2016.PLoSOne.2018;13(11):e0206100.
doi:10.1371/journal.pone.0206100
2. Cohen E, Hall M, Lopert R, et al. High-expenditure pharmaceutical use among
childreninMedicaid.Pediatrics.2017;140(3):e20171095.doi:10.1542/peds.2017-1095
3. McCabe SE, Veliz PT, Boyd CJ, Schepis TS, McCabe VV, Schulenberg JE.
A prospective study of nonmedical use of prescription opioids during adolescence
and subsequent substance use disorder symptoms in early midlife. Drug Alcohol
Depend. 2019;194:377-385. doi:10.1016/j.drugalcdep.2018.10.027
4. DeJong C, Aguilar T, Tseng C-W, Lin GA, Boscardin WJ, Dudley RA.
Pharmaceutical industry-sponsored meals and physician prescribing patterns for
Medicare beneficiaries. JAMA Intern Med. 2016;176(8):1114-1122. doi:10.1001/
jamainternmed.2016.2765
5. US Centers for Medicare & Medicaid Services. Dataset downloads. https://www.
cms.gov/openpayments/explore-the-data/dataset-downloads.html. Published
2019. Accessed July 1, 2019.
6. National Bureau of Economic Research. NPI data. https://www.nber.org/
data/npi.html. Published 2019. Accessed September 24, 2019.
Table 2. Marketing of Stimulant Products According to Medical Specialty, per the Open Payment Program Database
(January 1, 2014, to December 31, 2018)
Physician Specialty Payments, No. (%)
Total Payment Amount,
$ (%)
Payment, Median
(IQR), $
Unique Physicians,
No. (%)a
Total Active
Physicians, No. (%)b
Estimated 5-y
Prevalence, %
Pediatrics 239 217 (40.4) 5 003 379 (24.9) 14 (12-18) 17 427 (31.6) 90 766 (9.2) 19.2
Psychiatry 188 076 (31.8) 11 392 037 (56.7) 15 (12-19) 9660 (17.5) 54 895 (5.5) 17.6
Family medicine 106 615 (18.0) 2 138 459 (10.6) 14 (12-16) 17 048 (30.9) 136 604 (13.8) 12.5
Internal medicine 32 531 (5.5) 825 003 (4.1) 14 (12-17) 7213 (13.1) 272 060 (27.4) 2.7
Neurology 20 077 (3.4) 637 634 (3.2) 15 (12-19) 1235 (2.2) 20 974 (2.1) 5.9
Otherc
5391 (0.9) 104 738 (0.5) 14 (12-17) 2522 (4.6) 416 440 (42.0) 0.6
Abbreviation: IQR, interquartile range.
a
Overall, 55 105 unique physicians received marketing.
b
Estimated using National Provider Identifier data from 2014 to 2018.6
c
Includes anesthesiology, dermatology, emergency medicine, general surgery
and subspecialties, obstetrics and gynecology, orthopedic surgery,
otorhinolaryngology, pain medicine, physical medicine and rehabilitation, and
physicians from other specialties.
Letters
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