Putting crushable Oxycodone back on the streets – what is the PBAC thinking?

Australia’s oxycodone problem has thankfully not risen to the heights of the public health disaster that the USA is dealing with, but it’s been bad enough. Mundipharma, the company that makes OxyContin, the most popularly abused form of oxycodone, quietly brought out a new formulation of abuse-deterrent OxyContin in the middle of this year. The new Oxycontin tablets form a gel when crushed, thereby rendering it unsuitable for injection. This has not gone down well with the injecting drug community.

It has dramatically reduced the abuse of OxyContin according to figures from the Sydney Medically Supervised Injecting Centre and other anecdotal reports I have heard from addiction medicine colleagues. There is some concern that addicts are returning to more potent opioids such as fentanyl and heroin which are more unsafe in overdose, but the fact remains that the new formulation has been a success in the role for which it was intended.

This makes the recent introduction of a generic controlled-release oxycodone formulation onto the PBS hard to understand. The new generic formulations are not tamper-proof, and can be crushed and injected like the old OxyContin. Is this a good or bad thing?

The arguments in favour of the new formulation that I have seen in print are unconvincing. Price is the usual justification for introducing generics on the the PBS. If Mundipharma follows the usual practice of manufacturers, it will drop its list price so the savings will be less than perhaps the PBAC modelling might suggest. And what about the increase in costs associated with the doctor-shopping and dealing that such a drug will facilitate? There is no advantage that I know of to going back to old formulation as far as efficacy goes.

Unfortunately, the details of the November meeting of the Pharmaceutical Benefits Advisory Committee (PBAC) are not yet available publicly, but it will be fascinating to see what benefits they believe outweigh the obvious risk of public harm that this approval will cause.

It is also interesting from an ethical point of view, for doctors and pharmacists in the field. I am aware that many community and hospital pharmacies in my area will refuse to stock the generic oxycodone pills. I will certainly be ticking the ‘Brand Substitution Not Permitted’ box on all my scripts from now on (though I tend to prescribe OxyContin less and less these days due to better alternatives being available). I will also be encouraging GPs and hospital docs to forbid the brand swap. I feel a little uncomfortable insisting on one company’s brand but in this case, the rationale is compelling.

GPs will not be happy, since they have had a few months break from dodgy oxycodone demands, and will now be swamped with a rising tide of sob stories from people whose opioid receptors are apparently not OxyContin-shaped but seem to only respond to the generic brand.

I applaud the pharmacies which have made this decision, as it will likely cost them some money. There is a little bonus payment that pharmacists get from the PBS every time they substitute a cheaper generic for a more expensive brand. Not all manufacturers’ products are equivalent, so the prescribing doctor has the option to specify a certain brand on the prescription. Sticking to the OxyContin brand will potentially mean some pharmacies will have to forego this bit of extra income, and I salute them for having the public spirit to do the right thing.

Increasing abuse of fentanyl and heroin is undoubtedly more dangerous than crushing oxycodone tablets. It may be that the community is better off overall with fewer deaths and serious overdoses among opioid-addicted people if tamper-friendly oxycodone makes it back onto the streets. I can’t quite believe that this is what the PBAC has in mind, though.

So I’ll keep scratching my head at this piece of seeming folly and hoping that they know something I don’t. Putting large-dose, injectable oxycodone tablets back on the streets doesn’t seem a step in the right direction to me.

Disclosure Statement. Dr Vagg has received honoraria from Mundipharma for speaking at educational meetings. For the last 2 financial years, this has comprised approximately 0.05% of his total income