This is the Reason Harvard Business Review Got Opioids Wrong

This is the Reason Harvard Business Review Got Opioids Wrong, Lynn R Webster, The Painful Truth

When a publication of Harvard Business Review’s caliber prints something, it stands as fact unless an authoritative voice corrects it. Therefore, I feel obligated to comment on Christopher Bowe’s recent HBR article, “Fixing Pharma’s Incentives Problem in the Wake of the U.S. Opioid Crisis.”

I’m disappointed in (although hardly surprised by) the misleading content of the HBR article. If we’re going to solve the opioid crisis, then we have to get our facts straight. So let’s begin.

Harvard Business Review: Opioids

Bowe’s article opens with an often-quoted CDC opioids-related statistic: Since 1999, three years after Purdue Pharmaceuticals introduced OxyContin, drug overdoses in the United States have quadrupled. It continues with another CDC assertion: “Nearly half a million people have died, a number driven mainly by prescription opioid overdoses. In 2014, more people died in the U.S. from drug overdoses than in any year on record at the agency, and at least half of those deaths were caused by prescription opioids.”

Then, having left those CDC statistics unchallenged, Bowe goes on to blame “the incentive compensation structure in the pharmaceutical industry” for the opioids problem. Bowe summarizes the compensation problem this way.

Purdue doubled its sales force when it launched OxyContin, Bowe explains (citing an LA Times article, ” ‘You Want a Description of Hell?’ Oxycontin’s 12-Hour Problem”). Sales reps were encouraged to increase dosages of the painkiller so that one dose would work for 12 hours, the LA Times article explains. Their commissions and performance evaluations were based on how much Oxycontin they sold, and higher dosages meant higher sales.

Yes, I agree that Pharma has perverse incentives, just as the entire healthcare industry does. Bowe is correct about that. There definitely needs to be a change in the sales-based income/compensation that’s paid to pharmaceutical employees.

But, beyond that, Bowe got almost everything about opioids wrong.

Pharma is only a small piece of the problem. To end the opioid crisis, the focus must be on those who are holding the purse strings (in other words, payers) and the entities who are managing the care (that is, hospitals and providers).

Financial incentives are the basis of the problem, but it is the payer/insurer incentives to limit options — not the marketing by Pharma — that has been the primary driver for using opioids.

Treating Opioid Addiction: A Multidisciplinary Approach

The most effective way to treat severe chronic pain is with a multidisciplinary approach, but there has been a continual decline in the number of these clinics over that the past 20 years. The reason we have fewer multidisciplinary pain clinics per capita than any other country in the world is because payers don’t reimburse for them. It is simpler to pay for inexpensive opioids like methadone (which is associated with about 1/3 of all overdose deaths but represents only 5% of the opioids prescribed).

Secondly, most overdose deaths are due to polysubstance abuse, not just the abuse of one drug. Most deaths are not “caused” by opioids but, rather, associated with opioids. The actual causation is much more complicated than to attribute deaths to one drug. Moreover, it appears that many, if not most, overdose deaths do not occur in patients recently prescribed opioids, but in non-medical users or people had once been prescribed opioids but are still considered patients.

Thirdly, Bowe states that opioid prescribing has quadrupled despite no increase in the amount of reported pain. That is simply not true.

Opioids: Reality Vs. Spin

Here are the realities about why we’re treating more people in pain now than we did in 1999:

  • More than half of all adults older than 65 experience arthritic pain of the spine and other joints. This age group is growing. If you’re interested in seeing more age-related statistics regarding arthritis (the facts are sobering), click on this U.S. government’s PubMed abstract, another U.S. government PubMed abstract, the CDC’s own arthritis information page, and the Arthritis Foundation site.
  • Overall, the incidence of chronic pain after major surgery is estimated to lie in the range between 20% and 50%; relatively minor operations, such as inguinal hernia repair or a C-section, seem to lead to this problem in around 10% of patients. This is an annuity that will keep growing as more operations occur every year.
  • Many cancer survivors experience treatment-related severe chronic pain. There are more cancer survivors today due to better treatments (in fact, more than 40% of cancer survivors now live longer than 10 years), which is good, but the number of people with chemotherapy- and radiation-induced pain is increasing.
  • The U.S. has an obesity epidemic (according to the CDC and the Journal of the American Medical Association) which can lead to diabetes. Diabetes causes increased load on the joints and chronic pain. In addition, there is more peripheral neuropathy due to more people having diabetes.

So, not only is there an increased prevalence of chronic pain, but historically, there hasn’t been the recognition that pain deserves to be treated. Thus, it has been under treated.

When we are aware that patients have pain, and that their pain can be debilitating, then we use the tools at our disposal — which, at this point, are largely limited to opioids — to treat it.

So, the compensation structure of salespeople for pharmaceutical companies is not the main reason for the opioid epidemic. I’d say the problem is far more complicated than that, and to understand it, we must first know the difference between facts and spin.


Purchase my book The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us (available on Amazon) or read a free excerpt here.

the painful truth, lynn webster, md, chronic pain

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Copyright 2016, Lynn Webster, MD


  1. Judith Bruno on June 19, 2016 at 3:21 pm

    . Please start asking some real questions like are any drug addicts no longer abusing drugs with these policies because we know that Prohibition does not work? The country is so concerned over the raise in heroin addiction and you will find, if you really look, that the raise is directly connected to these policies because if a drug addict can’t get the pills they want, they will and are turning to heroin and now our government is supporting the Drug Cartels who will get a drug addict anything they want just as the “Mob’s” did for alcohol. Did we learn nothing from history?

    Why is the life of a drug addict more important than the lives of those who are in pain? Why are politicians acting as doctors in the decisions of what is the best way to treat us?

    Mothers can no longer care for their children and bread winners no longer able to support their families. Who is going to pay for that care and where will that money come from? Who is going to care for those like myself who strive to stay independent and live within the boundaries of our disabilities but can no longer do so without the pain relief we need?

    Health Care in this country is going to fail under these policies and it must when doctors refuse to take on patients who are in pain, clinic are closing and good doctors can no longer treat their patients in the way they know is best without fear of prosecution? Who are they going to blame for this? Obama Care? Someone must be blamed for the failure of our health care system to deal with those who are in pain.

    Chronic Pain is a disability and we are being discriminated against because of those who will and do abuse drugs just like any religion or race who is discriminated against because of the actions of a few. We need someone to stand for us, talk about us, do something for us in this losing war on drugs.

    We are told that 13% of Veteran’s abuse drugs but what about the 87% who need relief from pain and now can’t get that relief? Chronic Pain can and does kill and those who can no longer deal with a life in pain 24/7 will take their own lives and Veterans are the most vulnerable after the horrors of war. America makes these Veterans and makes the pain they now live with and yet we are turning our backs on them and telling them there is nothing we can do for the pain they are in.

    Why aren’t pain patients given the same rights as others to decide what is the best care for their problems? Politics needs to stay out of our relationship between our doctors and the care we need.

    Please do your jobs, do it right, look into the problems these policies are making that no one will talk about because of the fear of supporting drug addicts but we are NOT drug addicts, we are patients who need help.

    Please look into the politics of all of this as we know the reasons behind this attack on pain medications after losing the war on Marijuana, which will become legal in this country, in order to validate their existence and the billions of dollars wasted in this losing war on drugs are now attacking those who are in pain. Look into the big pharmacies and the fight against them and yes, they need to be held responsible for never finding cures but only drugs that mask the symptoms to make more money but taking all of this out on those who’s only sin is that they are in pain, is not the right way to fight any of these injustices.

    Please, think of the quality of life of those who are suffering in pain and think of your families, your parents, your children and how you would feel if they were suffering in pain and told there is nothing that can be done.

    Help us, help the millions of American’s both Veterans and civilians alike who are actually being tortured because of these policies. Please look at all sides of this war on drugs and the dangers of drug abuse but remember, there are millions of us who need relief from our pain. They can’t fix the problems, can’t give us what we need to live with any kind of quality of life without the pain medications that are available so why are they torturing us?

  2. Wayne S. Swanson II on June 19, 2016 at 4:44 pm

    I have taken this opportunity to share my heartbreaking story in hopes these witch hunting Opiate ill informed skeptics will read and understand that I would have no life without Medically prescribed Opiates by a physicians care and strictly monitored monthly urine and blood test. Please remember that An Opinion Before A Thorough Investigation Is The Epitome Of Ignorance! And that a little more compassion from the Medical Field and its representatives could have saved my beautiful Stepdaughters life. Let me say this! A person who has a addictive personality will abuse anything that helps them feel better. I have taken Oxycontin for 12 years , I have had 20 major surgery’s in 9 years. I have so much physical pain I can not even get out of bed with ouit pain meds and when I run out I run out and just lay in bed praying the Lord relieve me of this horrible condition and I pray God you pain med skeptics never go through what I go through everyday of my life when the only thing you have to do is threaten what help I get, Shame on you! There will always be drug abuse and as the so called war on drugs has failed all this will! All you do is stoke and aid the drug pushers business to knew heights in the Black Market of Heroin while depriving folks as me to this horrible movement! My Stepdaughter committed suicide 4 years ago because of being treated like a drug addict by her family and doctors when all along she suffered from Lupus and Fibro which I believe was brought on by a deadly car crash at 18 , she told me between that which I was being put through and what they were putting her through she was not going to live her life in such a hell brought on by people like you that are on a witch hunt to out law Opiates and pain meds that give us some sort of a life . As a retired Police officer and worked indirectly close to the DEA, you people do not have a clue how thrilled you are making the illegal opiate trade and think of my Late Stepdaughter as you continue on with this untrue propaganda movement to outlaw opiates! Just like the slaughter of children at Sandy Hook if there would have just been gun laws , my God they were Gun Laws , the guns that murdered all those 20 children were all registered and owned by a school teacher! You fight Drug Addiction in Elementary education by teaching all children the dangers of Booze and Tobacco which if these witch hunters want for us to know the real truth but they do not. I miss my Stepdaughter a so much and some of us will continue on the fight to protect our right to feel better and function without fear of these witch hunters trying to convince us to commit suicide . And they are trying to do exactly THAT!
    The under line real truth is THESE witch hunters would rather us Chronic Pain sufferers commit suicide are and DRINK all the BOOZE we can drink! The Federals legalized it ( ALCOHOL) knowing its a more deadly drug than Strychnine. And just because the DEA has miserably failed with their propaganda war on drugs why do they deprive us sick people of our Constitutional Rights to be Happy in that pursuit of with Professional Physicians to take meds that give us relief of this horrible malady of Chronic Pain ! May God have mercy on their miserable souls they that seek to destroy us Chronic Pain Sufferers only and little hope of temporary relief of this horrible sickness.
    Wayne S. Swanson II

  3. richard on June 13, 2017 at 12:11 pm

    I am getting sick and tired of reading about our governments war on opiate addiction. I continue to read about children who are dying from taking strong opiates and the media Uses this as a weapon. Fact is if a child gets opiates he is getting them from a friend at school or from their parents. Additionally, doctors are being targeted as the ” gateway to opiate addiction”. There is all this disinformation being circulated and the craziest thing is that I am hearing about people becoming addicted in 1 week. Such information is harmful simply because it’s just not true. Lies are dangerous if we really want to fix the problem because we need people (especially kids) to believe what we say . For the last 50 years as a pain patient I can tell you that I don’t use illicit drugs, I am physically dependent on opiates, I am retired and 68 years old. If they took my pain meds away I would be unable to get out of bed – however because I was able to get the meds I needed I spent the bulk of my life running a very successful business for aver 20 years i NYC. My point is simple and my message to the powers that be is also simple: Stop disseminating incorrect information about opiate addiction. If you’d like some real information you may contact me.

  4. BobT on October 16, 2017 at 2:51 am

    First of all, no one would ever prescribe opiates to a child. So, the idea that a doctor is responsible for a child’s addiction or death from opiates is absurd. Secondly, everyone seems to be ignoring the fact that another drug that is LEGAL, namely alcohol, is probably responsible for far more deaths than the “opiate epidemic”, bar none. When you consider the number of people who die not only from alcohol poisoning (yes, it does exist!), but from violent behavior by people under its influence and people driving recklessly under its influence, then the number of deaths from alcohol probably dwarfs the number from opiate addiction/overdose. Probably by a huge margin! Nevertheless, no action akin to the drastic restriction of doctor’s ability to prescribe pain medicine is proposed for alcohol abuse. In fact, “alcohol epidemic” is not even a coined saying. Yet! At some point we have to accept that the world is imperfect; that people will die from things like alcohol, guns, opiate pain pills, and you name it. Sensible precautions need to be taken and, after that, we need to accept that life is what it is. The death rate will never be 0. From anything.

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