Last year, a week before Christmas in Kernville, Pa., 5-month-old Summer Chambers died in her crib from dehydration and starvation. Her parents — Jason Chambers, 27, and Chelsea Cardaro, 19 — had died about four days earlier from a non-abuse-deterrent opioid overdose. Thousands of other children are now in foster care because their parents are either dead or too addicted to raise them.
An October 2016 report by the Pew Charitable Trusts found that “children also are staying in foster care longer, and more children are entering the system because of a parent’s substance abuse.” Foster care systems are in crisis as well. “In Ohio, where more than 9,900 children are in foster care and nearly half of those taken into custody last year had a parent using drugs, case workers are having a hard time placing children with relatives. By the time the children get to foster care, they report, many of the adults in their extended family are addicted to opiates, too.”
There are no easy solutions to this crisis — so you’d think if there were medicines that helped prevent the scourge of opioid addiction it would be valued. But you’d be wrong. Many large insurers and pharmacy benefits managers are reluctant to pay for these new abuse-deterrent technologies.
Last week, this pattern of denial was endorsed by the Institute for Clinical and Economic Review. ICER is a private organization that recommends what drugs it feels should be covered and at what price based on the value of a new medicine. ICER and its funders — which include the largest health plans and PBMs — claim to use “transparent” methods to produce independent and objective recommendations.
The ICER report claims that abuse-deterrent opioids — designed to deprive users of a high when cooked or snorted — provide neither financial nor societal benefits, despite the fact they (ICER) were provided data demonstrating that over five years using abuse-deterrent Oxycontin prevented 4,300 cases of abuses, avoided 12,000 abuse years and saved $300 million in medical costs for $387 million in drug costs.
ICER confirmed those results, but tossed them aside.
ICER ignored research that demonstrated abuse deterrent Oxy reduced abuse by 20 percent and reduced the average daily dose of OxyContin from 80mg to 60mg. Perhaps even more important, it reduced sharing and selling of the drug for getting high (“diversion”) by nearly 90 percent. The diversion of generic painkillers is responsible for as many as 63 percent of fatal prescription drug overdoses. ICER consciously decided to ignore the human cost of this deadly behavior.
What the ICER report ignores entirely is that one of the factors driving abuse and addiction is the inappropriate use of generic opioids for conditions that have non-opioid, on-label options. Fifty-two percent of patients diagnosed with osteoarthritis receive an opioid pain medicine as first-line treatment, as do 43 percent of patients diagnosed with fibromyalgia and 42 percent of patients with diabetic peripheral neuropathy.
ICER had promised to consider the societal impact of reducing the use of opioids. But it never considered the $50 billion in lost productivity, early death, increased crime, and more incarceration due to inappropriate opioid use. And they were silent on the explosion in the number of infants abandoned by addicted parents or, like Summer, left to die alone.
Instead, ICER states that abuse deterring pain killers are only valuable if they don’t cost health plans more than widely available non-abuse deterrent generic options, with value to patients not entering the equation. Rather, ICER determines the patient value based price by estimating what rebate manufacturers must pay PBMs and health plans. In other words, ICER focuses on how much money PBMs and health plans can pocket even as it ignores the very human pain and suffering these new formulations help avoid.
According to Harvard health economist David Cutler, virtually every study of medical innovation suggests that changes in the nature of medical care over time are clearly worth the cost. But, as Aldous Huxley reminds us, “Most human beings have an almost infinite capacity for taking things for granted.”
ICER does this knowing full well that payers also limit access to new abuse-deterrent opioid formulations by forcing people to try generic forms first.
Furthermore, ICER recommends the use of prior authorizations, the “Mother-May-I” process insurers use to limit what they pay for. In fact, PBMs and health plans regularly use prior authorizations more often with mental health and addiction treatments than for anything else.
The harsh truth is that our health system systematically discriminates against those at risk of addiction. Now, armed with ICER’s blessings, PBMs and health plans will continue to maximize the use of cheap non-abuse-deterrent opioids (the mother’s milk of abuse and addiction) to demand more rebates and steer patients to those painkillers that maximize profit.
Vermont Gov. Peter Shumlin said, “We’re losing the battle, not winning it. The children are the biggest victims. We’ve lost babies to parents who beat them, strangle them, bang their heads against the floor, sexually abuse them. And it’s happening because of opioid addiction.”
The new ICER analysis enables cost-containment practices that will perpetuate this crisis. It justifies leaving infants like Summer Chambers to die alone.
Correction: A previous version of this story misspelled Kernville, Pa.
Robert Goldberg and Peter Pitts are the vice president and president of the Center for Medicine in the Public Interest.
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