Monday, May 6, 2013

Abuse-Deterrent Opioids: Great Solution, Wrong Problem

I was asked recently what PRIUM's plan will be when the "opioid crisis" passes.  My first thought was that I'll probably be dead and gone by then (I'm not that old, mind you).  The answer I gave (and which I wholeheartedly believe) is that workers' compensation is the ultimate tail claim business and whether it's opioids or something else entirely, the need for medical expertise on complex claims isn't going away.  Nevertheless, the question got me thinking about the fact that this particular medical management crisis is, in fact, different from past waves of over-utilization exhibited by providers treating injured workers. 

One of the significant factors perpetuating the current struggle with opioid over-utilization is the source of the pills themselves: giant, multi-national pharmaceutical companies with huge marketing budgets and armies of sales reps.  Pain meds are a $7.3 billion market projected to grow 15% by 2017 to $8.4 billion (according to Cowen & Co).  These companies are not inherently evil - in fact, any discussion regarding pain management medications must begin with the fact that there exists a legitimate need for these drugs in the world today.  There is little doubt, however, that our society is experiencing a public health crisis related to the misuse and abuse of these medications.  The pharmaceutical companies themselves, while perhaps suffering from a public relations fiasco, are nonetheless generating incredible economic profit driven, at least in part, by the inappropriate and medically unnecessary use of their products.  (Anticipating objection, let me point out that I am aware of the efforts being made by Purdue, Endo, Pfizer and others to stem misuse and abuse of opioid medications.  I find the effort laudable, albeit largely ineffective). 

This 15% projected market growth is driven by a simple equation that relies on two variables, price and utilization.   How much do the pills cost?  How many of the pills are sold?  If you know both variables, it's easy to arrive at the dollars at stake.  Billions of them, in this case.  In the world of pharmaceuticals, price is a function of patents.  And as Timothy Martin of the Wall Street Journal points out, those patents are being extended in the interests of medication abuse-deterrence. 

I wish to be perfectly clear on this point: I am 100% supportive of abuse-deterrent formulations of prescription opioids.  These formulations are effective in combating abuse and diversion (at least in the short-term - it seems drug addicts often find a way to crack the code of each newly formulated medication.  But that doesn't mean we should stop trying, nor does it mean we should eliminate the economic incentive for the pharmaceutical companies to develop such technology).  There is legitimate debate on this point.  I know several well respected clinicians who believe the work comp system would derive greater benefit from the drop in price of the drugs driven by generic conversion than from the protection of patents for branded drugs less likely to be abused by patients. 

To me, though, this conversation is a distraction.  While eliminating abuse and diversion would be great for the work comp system, these aberrant behaviors are not driving the bulk of the problem.  The vast majority of cases in which PRIUM intervenes involve legitimate prescriptions being taken as prescribed.  Very little pill crushing.  Very little intravenous injections.  Very little drug dealing. 

The problem as we see it is lack of medical necessity.  In most cases, it doesn't matter if the patient's opioid is abuse-deterrent or not.  If it's medically unnecessary, if it's leading to loss of function, if it's leading to dependence and addiction... it needs to go away.  The doctor will be better educated.  The patient will get better.  The cost of care will go down.  Everyone wins. 

Abuse deterrent technology is great, but if we focus on technology over medical necessity, we will have missed the mark and the crisis will continue. 

On Twitter @PRIUM1