EpiPens and Opioids: Common Ground
EpiPen’s astronomical price increase from $100 in 2007 to $600 today has caused quite a furor among parents and advocacy groups. The price hike sounds like a lot, but Heather Bresch, chief executive officer of Mylan Pharmaceuticals, explained that a lot of other drugs have increased their retail prices by an even larger percentage over the same time period.1 [As of press time, Mylan has announced that it will release a generic version of its EpiPen—at a cost of $300 for a 2-pack carton.2
We in the pain business can attest to that. The huge price increases of many opioid medications in recent years are now causing some pain practitioners to spend as much time justifying the high cost of opioids (known as a “medical necessity”) as they are spending to treat patients. Sadly, there is no end in sight. The public is outraged because EpiPen provides both children and adults who have severe allergies with a lifesaving medicine, but don’t expect the same public outcry to bring pain-related drug prices into a reasonable price range.
This is partly due to the current climate of prescription drug reform, which is in response to the dramatic rise in the number of people with opioid and heroin addiction, and a spike in accidental overdoses. Lost in the public discourse are those patients with chronic, unrelenting pain (cancer and noncancer chronic pain) who require strong pain medication (as a last resort) to be able to function on a daily basis.
Please recall that a great deal of the opioid cost is not the opioid. Just as with the EpiPen, reformulation and new delivery systems have been the rationale for the higher price of these medications. Plain, cheap opioids are now available at a much higher cost as patches, lollipops, troches, films, sprays, slow dissolving matrixes, high-potency tablets, and intrathecal delivery, among other formulations. In addition, the Food and Drug Administration has recommended that all new opioids, including generics, be made with abuse-deterrent technology to reduce the risk of misuse and abuse, which also will increase cost.
The idea, of course, has been to deliver the opioid in a manner that makes it work faster and last longer, while avoiding the inconvenience of frequent administration and the time it takes to educate patients in a safe, effective, disciplined self-help regimen.
EpiPen is similar. A simple epinephrine injection, which has been around since 1901, is conveniently packaged in an auto-injector, mostly for children who may develop a severe, possibly fatal, reaction to a peanut, bee sting, or other allergen. Before the advent of the EpiPen, some clinicians issued syringes filled with epinephrine to the family and child. Admittedly, it took some time to educate—and patience to equip—patients and families, but it did the job at a cost of pennies on the dollar. Put another way, the EpiPen is a safe, effective convenience for patient and practitioner. But is the cost worth the convenience?
Americans seem to be in love with expensive convenience. Has anyone seen a slide rule, pay phone, map, or rabbit ears lately? In some places you might have to budget time to find a fax machine or a yellow cab! I’m even being led to believe that I can give up my car’s inconvenient steering wheel for a price.
It’s time to ask a basic question: Has the drive for convenience brought us a price tag that is now unsustainable? Have things gotten so bad that it appears that the only way to make opioids available is by going back in time and returning to old-fashioned multiple injections, or by adding older and thus cheaper other medications, which may not improve patient safety or comfort?
When I started my clinic in 1975, available opioids were few and consisted of: morphine (10 mg); hydromorphone (1, 2, 3, and 4 mg); and meperidine (50 and 100 mg). We had never heard of long-acting opioids. We also had a different attitude. Opioids (called “narcotics” at the time) were considered a medication of last resort. Nonsteroidal anti-inflammatory drugs, corticosteroids, muscle relaxants, topical analgesics, physical exercise, heat, and ultrasound were our first-line therapies.
When the World Health Organization came out with its 3-step analgesic ladder for cancer pain in 1982, it received little publicity simply because it was the ho-hum, standard order of the day. Every patient referred for pain management, in those days, was actively using a number of nonopioid measures. Today, I see patients who are being referred because their insurance plan won’t pay for the desired amount of fentanyl or oxycodone.
Quite frankly, no one was more excited about the development of oral transmucosal fentanyl (Actiq lollipops) in the late 1990s than me. When Actiq hit the market, I recognized its convenience, and its ability to replace opioid injections and suppositories. I even wrote a paper about its virtue in keeping pain patients with flare-ups out of emergency rooms.4 The cost of each dose was only a couple of bucks. So what happened? The price escalation of Actiq, and the other short-acting fentanyl products, was the precursor to an EpiPen-type price trajectory.
Today the cost of opioids and some other pharmaceuticals is so high that further yearly escalation seems unsustainable. Reduction in pharmaceutical prices seems elusive. Consequently, we’re stuck with undertreating legitimate patients, like children who can’t afford EpiPens.
My bet: Some bright, innovative, and practical physician, in a poor rural county, is probably putting a little epinephrine in a TB syringe today and sending it home as “EpiPractical.”