The announcement on Friday last week that pregabalin (Lyrica) had made it onto the PBS is a huge relief for sufferers of chronic nerve pain.
It also means that the true cost of providing appropriate care to chronic pain sufferers can be better measured. Too many GPs and other doctors are forced to prescribe opioids for nerve pain when the evidence for their usefulness is known to be unconvincing. As previously mentioned in this column, long-term opioid therapy for non-cancer pain has limited benefits compared to the potential for reduced quality of life, even if the generally overstated risk of abuse and addiction is discounted. This is especially true for nerve pain, also known as neuropathic pain. The pain is simply generated in a way that opioid drugs don’t really influence.
In choosing to accept the PBAC recommendation to list pregabalin, we are finally seeing some movement on the issue of the scandalous undertreatment of chronic pain in Australia.
But Minister Plibersek and her bureaucrats have missed a big trick.
Gabapentin is an older drug with the same basic mechanism of action as pregabalin. It is out of patent and is manufactured by a number of generic manufacturers, including some Australian ones. Gabapentin will never be listed on the PBS despite its proven effectiveness because the company which originally held the patent is Pfizer. Pfizer also developed pregabalin, and will be the beneficiary of essentially all of the half a billion dollars that this listing will generate for it. There is no commercial imperative for them to reapply for gabapentin, which is what the current listing process demands.
However, if the Minister had insisted that gabapentin be listed alongside pregabalin, there would have been a cheaper alternative drug with the same mechanism of action, and which most experts agree is equally effective. Moreover, the financial rewards for treating neuropathic pain would not then all go to Pfizer, but would be split to include some home-grown generics.
It would have been a win all round. Doctors would have access to two first-line drugs instead of one to treat neuropathic pain. The PBAC could specify that gabapentin must be tried prior to pregabalin via the Authority system. Patients would have had the option of trying a different agent if they can’t tolerate the side effects of pregabalin (in our experience over the last four years of prescribing both drugs this happens a lot.) And finally the local generic drug manufacturers would get a share of the profit from treating locals more effectively. The total cost of treating neuropathic pain more effectively would arguably also be less, as for lower doses gabapentin is more cost-effective and better tolerated than pregabalin. The only losers from all this would be the Pfizer executives and shareholders.
So while I welcome with relief the news that pregablin will be available on the PBS, I can’t help thinking that we could have done better all around. We need both drugs to be available.