Wednesday, June 17, 2015

The Pen, the Price, the Panacea?

The Washington Post attempted to capture America's drug overdose epidemic in four charts/maps. I'm not sure they pulled it off, but I certainly appreciate the attempt to highlight the issue in a way people can easily understand it.

Of the four charts/maps, the last one highlights an issue about which all of us in work comp need to be aware.  This map captures the mix of nalaxone access and "Good Samaritan" laws throughout the country.  Essentially, "Good Samaritan" laws protect drug abusers and those that might assist them (i.e., calling 9-1-1 or driving them to the emergency room in light of an overdose) from criminal prosecution.  All states and local jurisdictions should pass such laws. It makes no sense for people to die because someone else is afraid of getting in trouble.

The nalaxone access issue is also important.  But it's more complicated.

Yes, emergency responders and others on the front lines of the drug abuse epidemic should have access to this potentially life-saving drug.  But there are two challenges with respect to nalaxone that we're not openly discussing, mostly because its uncomfortable to do so.  And the two challenges happen to be the critical questions we should ask of any new medication:

1) Cost.  Nalaxone itself is an old drug and long off patent.  A simple syringe filled with a single dose would cost about $3.  But last year, the FDA approved EVZIO, a portable nalaxone injector.  This device is costing payers about $500 for two doses packaged together.  We see EVZIO being paid for in our payer data and we've seen fees closer to $800 for EVZIO.  This drug is a critical public health tool, but does Kaleo Pharma (the makers of EVZIO) deserve patent protection for putting a drug originally approved in 1971 into an injector pen?  Is that really the type of innovation we want our patent system to protect?  

2) Utilization. We just heard from a prescribing physician during a PRIUM follow up call to a peer-to-peer review that he was prescribing EVZIO for the injured worker in question.  We further learned that he was being encouraged by the "drug rep" to prescribe EVZIO to all of his patients being prescribed opioids.  Just in case they overdose.

The answer to the epidemic of opioid misuse and abuse shouldn't be layering on another $800 prescription for a nalaxone injector for every patient on opioids.  Are there instances where such a prescription will make sense?  Certainly.  But why not focus our efforts on eliminating the possibility of overdose completely by focusing on non-pharmacological pain management and non-opioid medications?  We need to focus physician education efforts on the lack of evidence for the effectiveness of opioids among chronic, non-cancer pain patients... and not allow a nalaxone injector to be perceived as the panacea it will never be.

On Twitter @PRIUM1

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