Here are the different ways drug companies are influencing your doctor’s prescription pad — and what you can do about it.

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It’s not just money. There are a number of ways drug companies are influencing doctors to prescribe patients specific drugs. Illustrations by Ruth Basagoitia

In May, a federal jury found top executives of the opioid manufacturer Insys Therapeutics guilty of racketeering charges related to the opioid epidemic.

The criminal charges and guilty verdicts were a rarity, as it held high-ranking corporate officials responsible for bribing doctors to prescribe their fentanyl-based Subsys and intentionally misleading insurers of patients’ needs for the potent and addictive pain reliever, as reported by The New York Times.

Subsys was approved for use in cancer patients, but was soon prescribed for people with other problems like back pain, opening them up to potentially life-altering or life-ending opioid addictions. Medical experts, as well as federal authorities, say top-down pressure from executives at opioid-making drug companies helped fuel the opioid epidemic.

According to the U.S. Centers for Disease Control and Prevention (CDC), the first wave of the opioid crisis — which kills an average of 130 people daily in the United States — first started in the 1990s when doctors began prescribing more opioids.

The next wave was heroin, which pill-addicted opioid users turned to because it was cheaper. The latest wave is fentanyl, which Insys executives pushed company representatives to promote in predominantly rural counties across the United States.

They used tactics like showing up at medical offices before they’re even open to reach doctors early in the day to hype up their products and offer free trials and samples — all to reach sales goals on an addictive and potentially lethal product.

Those practices have come under increasing scrutiny, which is why more medical offices — from small offices to large research universities — have created policies to stop allowing drug representatives free access to their offices.

Dr. Charles Rosen is a clinical professor of orthopedic surgery and spine surgeon at the University of California, Irvine, where drug reps are only allowed in by appointment, and they can’t leave samples, or buy lunch for staff.

As the co-founder of the Association for Medical Ethics, Rosen says there’s more than enough evidence to know that these seemingly nice gestures can directly impact a doctor’s prescription pad.

“The psychology of it is anytime you’re given a mug, a pen, a meal, there’s a subconscious expectation to reciprocate,” Rosen told Healthline.

In the midst of these corporate profits, shareholder expectations, compromised medical ethics, and payments to doctors are patients who generally trust their doctors to make the best decisions on their behalf in the United States’ for-profit healthcare system.

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In 2010, President Barack Obama signed into law the Physician Payments Sunshine Act, which required disclosure of any payment over $10 to medical professionals from pharmaceutical, insurance, or other providers seeking reimbursements under Medicare, Medicaid, and Children’s Health Insurance Program (CHIP).

The first batch of disclosures involved 2012, which quickly illuminated the amount of money that was being paid to medical professionals for a variety of reasons, whether royalties for devices they invented to speakers fees and accommodations to attend conferences.

Those records are searchable for free on several websites:

The payment data made available by the Sunshine Act, coupled with reimbursement claims from federal healthcare coffers, helped authorities see prescription patterns, some of which showed the more a doctor is paid, the more often he or she would prescribe drugs pushed by those visiting their offices or paying consulting fees.

Or, as the nonprofit investigative reporting organization ProPublica found, “doctors who received industry payments were two to three times as likely to prescribe brand-name drugs at exceptionally high rates as others in their specialty.”

Caitlin Hoff, a consumer advocate with ConsumerSafety.org, says doctors paid by the medical industry may still be prescribing medications they believe are best for their patients, but even the smallest gifts can have an impact on a physician’s prescribing behavior.

“There are clearly some actions that are illegal, like prescribing medications to patients who don’t need them,” Hoff told Healthline. “However, some doctors may not realize that things like office visits, catered lunches, and consulting gigs can subtly influence them.”

Research published in JAMA suggests when medical centers create policies that restrict drug company representatives’ access to doctors — in an effort to thwart off accusations of and prevent real-life cases of conflicts of interest — there are “modest but significant changes in prescribing behavior” at some of those centers.

That study examined 2,126 physicians at 19 academic medical centers involving more than 16 million prescriptions. Noting several limitations on their research and data, the researchers from across the globe concluded that, overall, it’s cheaper to prescribe generic drugs, and limiting a drug company representative’s access to prescriber created a noticeable difference in fewer branded, and more expensive, drugs from being prescribed.

Also, two of the JAMA study’s authors were employees of CVS Caremark, one of the United States’ largest managers of pharmacy benefits, involving thousands of large healthcare plans, including contracts with the federal government.

They were David Hutchins, CVS Caremark’s senior strategic research advisor, and Dr. Troyen Brennan, chief medical officer and executive vice president of CVS Health (of which CVS Caremark is a subsidiary), who provides oversight for the company’s “clinical and medical affairs and health care strategy.”

While the Insys trial opened a window into some of the more egregious forms of money’s influence in medicine, it and events before it have shown the extent at which some healthcare-focused companies will chase the bottom line that investors want to see rise every day.

“While consumers hold companies within the healthcare space to higher standards, they are still for-profit businesses expected to make money,” Hoff said. “It may be unrealistic to hope that these companies put people before profits, however, as with any business, we can hold these companies accountable for illegal or dangerous activities.”

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Testimony and evidence in the Insys trials — along with information gleaned from investigations from various state attorneys general into the Sackler family, Purdue Pharma, and OxyContin — show the sales tactics common in the United States’ for-profit medical system.

One of these are drug and device makers regularly dropping by doctors’ offices.

It’s a practice that Jeff Moffett, a family nurse practitioner in Laurel, Mississippi, has ended after years of being part of the system that meshed people with medical degrees and those with bonuses on the line.

He says drug or insurance company representatives would forward along his credentials if they were interested in having him give compensated speeches about their medications to doctors who had heard it before, but were given free lunches to hear it again.

“It’s what it looks like,” he told Healthline. “You get manipulated to remember that drug.”

In return, Moffett said he was paid up to $300 for 15- to 20-minute speeches while also “looking behind the scene of the insurance industry.”

He learned how many tests doctors were pushed to order and found out about pharmaceutical companies that shared their not-so-public goals to improve reimbursements from federal programs like Medicare and Medicaid.

Now, he’s sworn it off, saying his patient care has improved because he’s no longer taking time out of his day to hear from or speak for someone seeking profit from his decisions. It’s also given him an increased feeling of autonomy in his practice because he’s more focused on patients, not his or drug and insurance companies’ profits.

“And that’s not possible when you have a price,” he said. “If they’re going to pay you to do something, then who are you working for?”

Rosen — who testified before Congress to help pass the Sunshine Act and make money in medicine more transparent — says that 90 percent of medical professionals want to do the right thing and hold true to the Hippocratic Oath. The rest, he says, “have sold their souls for money.”

It can start with a complimentary branded pen or a comped meal and possibly end under the jurisdiction of federal law enforcement like the Insys executives.

But Rosen says when doctors change the way they treat patients because of financial incentives from those who profit from their prescription pads, they’re breaking the oath they took when they graduate medical school.

“Because you’re getting paid,” Rosen said, “that’s unethical.”