A major insurer’s move to drop the brand drug OxyContin for a lesser known abuse-deterrent opioid has been touted by the company as a way to curb opioid abuse. But experts question the actual effects of the decision—and suggest it may have had more to do with saving money.
Drug makers are combating allegations that they are partly responsible for the opioid crisis as policymakers and advocates search for solutions to curb prescription-drug abuse. President Trump said he would make a national-emergency declaration related to the opioid crisis this week.
Amid this, Cigna earlier this month announced that it would stop covering OxyContin on its group commercial drug lists and simultaneously signed a value-based contract with Collegium Pharmaceutical, maker of the opioid drug Xtampza ER. “Under the terms of the contract, Collegium is financially accountable if the average daily dosage strengths of Xtampza ER prescribed for Cigna customers exceed a specific threshold,” Cigna stated.
This is a unique contract that Cigna says is its first with a company regarding opioids. “What you’re seeing is a recognition that pharma companies have tremendous influence over how doctors prescribe [opioids],” said Andrew Kolodny, codirector of opioid-policy research at Brandeis University. “Cigna is betting on this … that the company will encourage lower-dose prescribing.”
Experts, though, questioned the effect of the contract on the opioid crisis, and Kolodny said that as opioid doses trend down, it will be hard to tell whether it was because of agreements like this or broader initiatives to combat the crisis.
Purdue Pharma, which makes OxyContin, immediately denounced the deal. “Cigna’s decision limits prescribers’ options to help address the opioid crisis,” the company said. “Further, while both products are formulated with properties designed to deter intranasal (snorting) and intravenous (injection) abuse, neither is abuse proof. Unfortunately, this decision appears to be more about pharmaceutical rebates.”
Other experts echoed that suggestion. “Let’s not be fooled; this was a business decision as well as a clinical one,” said Caleb Alexander, codirector of the Johns Hopkins Center for Drug Safety and Effectiveness. He said coverage policies for safer alternatives are just as important to evaluate.
“There are much more effective ways to modify policies to prevent opioid overuse than this one,” Alexander added.
To persuade other insurers not to head in the same direction, Purdue may draw parallels between OxyContin and Xtampza to argue they are essentially the same—or possibly that OxyContin is better, said Michael Rea, founder and CEO of Rx Savings Solutions.
Purdue in fact sent National Journal more background on the abuse-deterrent form of OxyContin, insisting that only real-world studies can adequately demonstrate whether using a product with abuse-deterrent properties results in meaningful reductions in abuse, misuse, and related adverse outcomes.
“These data do not yet exist for Xtampza ER,” the company asserted.
During the approval process for Xtampza, Collegium did include some data comparing abuse deterrence of the two medications. The company claimed that crushing its opioid product does not alter the oxycodone exposure, whereas crushing OxyContin can overcome the time-release mechanism.
Purdue has the additional challenge of dealing with a bad public image associated with its extended-release opioid drug. “It has been blamed in the media and by policymakers as a reason for the opioid crisis,” said Dania Palanker, assistant research professor at the Center on Health Insurance Reforms at Georgetown University. “There is a certain PR standpoint for an insurance company that is trying to say they are making efforts to reduce the opioid epidemic.”
Purdue has been at the center of several lawsuits brought by cities and states over its marketing of OxyContin. And in 2015, the company was in the spotlight after it received approval to market OxyContin for pediatric use, prompting a group of senators to call for an investigation into the decision.
Peter Pitts, president and cofounder of the Center for Medicine in the Public Interest, described OxyContin as “the poster child for opioids,” though he added that the reformulated drug with abuse-deterrent properties is not widely abused.
“But the name is out there; the name carries a lot of baggage,” Pitts said.
And the general opioid crisis could provide insurers some leverage to negotiate for better deals; Rea said insurers could ask for data from manufacturers proving their drugs are not being abused. “The focus gives payers leverage to demand more,” he said.
But Cigna’s moves could come with the unintended consequence of limiting access to medications for patients who really need the therapy. “I find it concerning that the penalty is so separate from the medical provider that is doing the prescribing and the patient in this instance,” Palanker said. “That could have a negative effect on that person with pain.”