Opioid Abuse Takes Back Seat to Cost at Medicare

By Pat Anson, Editor

The U.S. Food and Drug Administration calls the development of abuse deterrent opioids a “priority” in combatting the so-called epidemic of prescription painkiller overdoses.

But when it comes to Medicare coverage of opioids, new research shows that lowering the cost of painkillers is a bigger priority for the federal government than discouraging abuse.

The study by Avalere, a health analytics research firm, found that Medicare Part D coverage of abuse deterrent OxyContin is falling rapidly. From 2012 to 2015, OxyContin coverage fell from 61% to 33% of Medicare Part D plans. In addition, one quarter of Part D plans now require prior authorization for OxyContin. 

In contrast, a generic version of OxyContin (oxycodone hydrochloride) that has no abuse-deterrent properties is covered by all Medicare Part D plans – and prior approval for it is only needed in 0.3% of Part D plans.

“While prescription opioid abuse continues to be a priority for public health experts and lawmakers, coverage for these products by Part D plans is limited and plans are increasingly favoring lower-cost generic products on their formularies,” said Caroline Pearson, senior vice president at Avalere.

“Policymakers seeking to limit opioid abuse will have to balance the desire for greater access to abuse-deterrent opioids with the increased costs of such medications to public programs and private payers.”

OxyConin was reformulated by Purdue Pharma in 2010 to make it harder for addicts to crush or liquefy for snorting and injecting. In 2014, the FDA approved three other opioids with abuse deterrent properties and in April of this year issued guidance to drug makers strongly encouraging them to develop more.  

“The science of abuse-deterrent medication is rapidly evolving, and the FDA is eager to engage with manufacturers to help make these medications available to patients who need them,” said FDA Commissioner Margaret Hamburg, MD. “We feel this is a key part of combating opioid abuse.”

But combating opioid abuse apparently takes a back seat to price, not only for Medicare but private insurers and the drug makers that developed abuse deterrent formulations.

According to the Healthcare Bluebook, a website that estimates the market price of medications, the “fair price” for a 60-day supply of OxyContin 20mg is $316.

A 60-day generic version of oxycodone -- without abuse deterrence -- retails for just $78.

“It will be important for policymakers to monitor and consider the implications of these trends,” the Avalere study says, warning that abuse-deterrence formulations may be pricing themselves out of the market.

“The potential increase in costs due to new innovations may be a barrier to policies that increase the coverage of abuse-deterrent opioids, especially in public programs, despite potential long-term public health savings associated with lower levels of opioid abuse. While the greater number and quality of abuse-deterrent options—both brand and generic—can support competition, reduce cost, and increase plan coverage, the potential of abuse-deterrent technologies may not be fully realized as long as non–abuse deterrent alternatives have less restrictive insurance coverage.”

Funding for the Avalere study came from Pfizer. Avalere says it maintained “full editorial control” over its content.

Over 16,500 deaths in the U.S. were linked to opioid overdoses in 2010, according to the CDC. The government estimates that over 400,000 seniors are  “misusing” pain medication.

According to the National Institutes of Health, only about 5% of patients taking opioids as directed for a year end up with an addiction problem.