Monday, Sep 24, 2018
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Medicaid patients need options in opioid fight


In the sad geography of America’s opioid-overdose crisis, Ohio is at the center of the map. In 2015, 2,700 of its people died from prescription and illicit opioids, a number far higher than any other state and one that shot up by 28 percent in one year.

In response, Gov. John Kasich signed a bill this month to expand access to the treatment drug naloxone, therapy, and social supports.


Governor John Kasich and other have made strides in curbing Ohio's epidemic of opioid-overdose deaths.


Why more than 50,000 Americans died from drug overdoses in 2015, and why Ohio — or Massachusetts, for that matter — has opioid death rates 12 times that of California or Texas are critical questions. But just as critical is preventing and treating the nation’s 2.6 million opioid addicts and other users, reducing the availability of illicit drugs like heroin, reversing the prescription frenzy that now results in about one opioid prescription per year for every adult American, and fighting the lobbying behemoth of pharmaceutical companies making prescription painkillers like OxyContin and fentanyl.

While Governor Kasich and former President Barack Obama are to be applauded for expanding treatment to the millions who need it, not all pharmacological treatments are created equal. 

The maker of the principal treatment drug Suboxone — a combination of buprenorphine and naloxone — is the target of a massive antitrust lawsuit by 42 state attorneys general (including Ohio’s Mike DeWine), and the drug’s current form has become a contraband substance in prisons and on the streets.

Suboxone, approved by the FDA in 2002 to reduce cravings and withdrawal symptoms, is more profitable than Viagra. It has yielded more than $1.5 billion a year for its British manufacturer, Reckitt Benckiser, including $857 million from Medicaid over three years. More than a million Americans are treated with the drug, a number that could double under a new expanded-treatment rule. 

Having cornered 85 percent of this tragically lucrative market, Benckiser played hardball when its patent expired in 2009.

The company quickly created a new firm called Indivior and partnered with another company to sell a new version dispensed as a dissolvable film. While approved by the FDA in 2010, this so-called “product hopping” coincided with Indivior’s aggressive efforts to fight FDA approval of generics, shameless arguments that its original product was dangerous, and lawsuits against potential competitors.

The FDA rejected the company’s bizarre argument that its own drug was hazardous — one belied by Indivior’s increased marketing of Suboxone tablets overseas.

In 2013, the Federal Trade Commission opened an investigation and the Department of Justice launched a criminal probe. The FDA subsequently approved generics and three other forms of buprenorphine. 

However, Suboxone maintained its overwhelming market share, in part thanks to its top spot on states’ Medicaid preferred drug lists. With Medicaid’s imprimatur, private insurers generally follow.

Then came last fall’s multistate suit alleging that Indivior had “employed an unlawful, multi-pronged scheme designed to prevent or delay less-expensive generic versions of Suboxone from entering the market to preserve their monopoly profits.” The attorneys general called the company’s actions “deceptive and unconscionable,” forcing patients and taxpayers to pay much more than necessary.

Because Suboxone sheets are small, easily cut, and hidden, police report a sharp increase in illegally sold Suboxone bought at cash-only clinics. Easily smuggled into prisons, it has been called “prison heroin.”

Last year, with support from police, corrections officers, and public-health leaders, Maryland became the first state to take action by demoting Suboxone to “nonpreferred” status for Medicaid coverage of opioid treatment, making another, more efficient drug preferred. Prison smuggling has plummeted.

Maryland’s action has drawn some criticism, but as Dr. Stuart Gitlow, past president of the American Society of Addiction Medicine said: “If I were a clinician and was told you must switch all your patients, I’d say, ‘Hell, no.’ But if it’s cheaper and bioequivalent, then as a society, we have to make that choice.”

Ohio and other states should follow Maryland’s lead to move alternatives onto their preferred drug lists. Given Suboxone’s many problems, changing state Medicaid formularies would be a wise move.

The goal should be to solve the suffering of millions from opioid addiction most effectively, at the least expense, and without the potential for abuse. Broadening options can accomplish this and bring a freer market in which treatment drugs compete more fairly on quality and price.

Andrew L. Yarrow is a freelance writer who writes frequently on economic, health care, education, and other policy issues, as well as on American culture and politics. He is the author of four books and a senior fellow with the Progressive Policy Institute.

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