Transcript A Policy Analysis

DSHS Formulary Restriction of
OxyContin® – A Proposed
Policy Analysis.
John Pedey-Braswell and Greta
Sweney.
Washington Medical Assistance
Administration’s Formulary Restriction
of OxyContin® – A Policy Analysis
• As of 11/1/2003, D.S.H.S. will no longer fill OxyContin® prescriptions
without prior authorization. Expedited P.A. is available for those
patients with chronic cancer pain.
• Pharmacies received updated prior authorization lists in mid-October
without any accompanying explanation of restriction.
• Health care providers sent/delivered list of patients whom they
prescribed OxyContin® along with a conversion table for methadone
and morphine SR.
• Currently, D.S.H.S. is allowing prescriptions to be processed without
P.A. due to deluge of phone calls and insufficient staffing –
approximate wait time for P.A. was 5 days during first week of
November.
Why is this restriction necessary?
OxyContin®
Dose
Price/30
days
Approximate
Morpine SR
Dose
Price/30
days
Approximate
Methadone
Dose
Price/30
days
10mg bid
$50.89
15mg bid
$25.21
2.5 mg tid to
5mg bid
$5.97 or
$6.55
20mg bid
$93.84
30mg bid
$44.11
5mg tid to 10mg
bid
$7.71 or
$7.80
40mg bid
$162.00
60mg bid
$82.06
5mg qid or
10mg bid
$8.88 or
$7.80
60mg bid
(1x20mg,
1x40mg)
$255.84
90mg bid
(3x30mg)
$123.90
5mg qid or
10mg tid
$8.88 or
$9.58
80mg bid
$294.42
100mg bid or
120mg bid
(2x60mg)
$119.47
or
$159.90
10mg tid to
10mg qid
$9.58 or
$11.37
160mg bid
$457.18
200mg bid
(2x100mg) or
240mg
(4x60mg)
$234.72
or
$315.57
10mg qid to
10mg 5 times
daily
$11.37
or
$13.16
Issues Surrounding Opioid Conversion
• HMC prescribers long-familiar with using oxycodone 5mg prn.
OxyContin® was well-marketed to provide around-the-clock pain
relief.
• Oxycodone easy to work with: predictable bioavailability and
pharmacokinetic profile. No toxic metabolites to worry about in renal
failure.
• Morphine is more likely to cause excessive-itching due to histamine
release, and 6-glucuronide metabolite worrisome in patients with
renal disease.
• Many prescribers uncomfortable with dosing methadone due to long
elimination half-life, and comparatively short duration of analgesic
effect. Initial drug accumulation creates opportunities for adverse
effects. Potential for drug interactions due to CYP3A4 Ndemethylation. Women may metabolize methadone more quickly
than men.
• Methadone is stigmatized as maintenance medication for addicts.
Methodology
•
•
•
•
•
N=110 HMC Adult Medicine Clinic (AMC) patients with chronic, nonmalignant pain controlled on OxyContin®. Payor blend of D.S.H.S., other
third-party insurers and uninsured – clinic pharmacists recommended
switching pain regimens for all patients. All patients fill prescriptions at HMC
pharmacy.
Confidentiality agreement to be filed with UW HSD. Data from PCSI
pharmacy database and chart-review.
Primary analysis of patient charge data for analgesics from 4/1/03 – 9/30/03
paired with those from 12/1/03 – 5/31/04.
Representative search of chronic long-term pain medications including
opiates, NSAIDs, non-acetylated salicylates, TCAs, gabapentin, muscle
relaxants, lidocaine patches, diazepam and clonazepam used during the
two periods. All charges will be adjusted to 4/1/2003 prices.
Secondary analyses: clinic, ER, and UCC visits coded for pain during study
periods, pain scales administered during AMC visits, SEs, breakthrough
pain medication use, patients successfully converted to other therapies,
patients willing to pay cash for OxyContin®, and patients lost to follow-up.
Attempting to track AMC pharmacist time during November and December
2003.
Limitations
• Literature suggests equipotent dosing is possible with narcotic
analgesics, however the possibility of side-effects, temporary
discomfort, and inconvenience to all involved make a CMA
impractical.
• No warning of policy change. Ideally, we would like to track
pharmacy and clinic staff time spent on conversion issues to ensure
accurate costing. What expenses does DSHS accrue to implement
this change?
• Study is not designed to track costs resulting from side-effects
(hospitalizations, time off work, etc.).
• No time to find and administer quality of life batteries to clinic
patients. Retrospective questionnaires will be prone to bias. We
cannot determine accurately determine effectiveness or utility of
program.
• Also, how do we account for stress to pharmacy staff from irate
patients?
A Possible Measure of Program
Success?
• OxyContin® billed to DSHS (All HMC Ambulatory Prescriptions):
– September 2003 = $11603.25
– November 2003 = $1555.10
• Would like a chance to “fully” analyze a DSHS formulary decision to
determine the impact of DSHS’s cost-silo mentality on state
pharmacies.
• Pharmacy paid $4.22/prescription no matter how much time and
effort it takes to fill it. Are we losing money?
Questions? Let the Grilling
Commence