Scrimping on pain drugs is bad medicine and worse economics

The government has made a mistake by not listing pain drug Targin on the PBS. J Hawk

In an attempt to contain growing health costs, the Australian Government has resisted recommendations to subsidise the pain medication Targin on the Pharmaceutical Benefits Schedule.

Not only is this a missed opportunity to improve treatment options for the growing number of Australians who have long-term pain – it overlooks a potential solution to the nation’s growing illicit market for prescription pain killers, which may end up costing the health system more in the longer term.

Pain relief

Chronic pain affects around 20% of Australians at any given time. According to the Australian Institute of Health and Welfare, long-term musculoskeletal pain is the most common cause of disability in Australia, with an economic and human burden comparable to mental illness or type 2 diabetes.

A 2007 Access Economics report estimated a yearly cost of $34 billion to the economy due to lost productivity and direct healthcare costs.

In the last 15 years, a whole raft of new formulations of opioid-based painkillers have become available to treat long-term pain. The increased availability of a variety of prescription opioids has led to a huge increase in prescribing – and not just for those in need.

More and more PBS-funded prescriptions for sustained-release opioid drugs such as Oxycontin (or hillbilly heroin, as it’s sometimes named), are making their way into the illicit market.

While prescription opioids might be the right choice for some patients with long-term pain (cancer pain, for instance), there are real risks with dependence and addiction.

Limits of opioid-based medicines

Prescription opioids such as Oxycontin come with serious side effects including nausea, itchiness, sedation and especially constipation. So additional medications are needed to prevent constipation, which adds to the cost and complexity of care.

Reducing the side-effects of prescription opioids is an important development to increase chronic pain sufferers’ tolerability of this type of pain-relief.

The idea of adding a small dose of an opioid-blocking drug (naloxone) to the same tablet as the painkiller has been around since the early 1990s, and is thought to have two possible advantages:

1) The opioid-blocking naloxone can’t make its way into the bloodstream from the gut and will therefore block the gastrointestinal side-effects of the painkiller, without reducing its overall effect.

2) If the tablet is crushed to be injected by an abuser, the two ingredients become mixed and the addictive effects of the opioid are reduced or prevented.

That’s why pain management and palliative care specialists have been eagerly awaiting the arrival of a drug such as Targin, which combines opioids with naloxone.

It was the first drug in its category to be recommended for inclusion on the PBS by the Pharmaceutical Benefits Advisory Committee (PBAC) – and this came late last year.

Usually, medicines are listed on the PBS after recommendation from PBAC, but because of the tight economic climate, all recommendations are going to Cabinet for another layer of approval.

So Targin remains available in Australia but patients have to foot the entire bill, which can be around $100 a month. If you’re a pensioner with advanced cancer, the cost may well be prohibitive.

Cost-saving?

It’s likely Targin was blocked because of fears of a cost blowout for the PBS. But the Gillard Government seems oblivious to the potential economic benefits of listing the drug.

On its own, Targin is more expensive than Oxycontin, but Oxycontin itself is not a cheap drug, and given current levels of (over) prescribing, the collective cost of the drug is enormous.

In 2009-10 nearly 5000 warnings were issued to doctors suspected of prescribing opioids and benzodiazepenes to doctor-shoppers. And in March 2011, the Minister for Human Services announced an investigation of 50 doctors for similar irregular prescribing practices.

Listing a drug such as Targin, which is unpalatable to abusers, is very likely to cut the market for doctor-shoppers and reduce the prescribing rates of Oxycontin.

In fact, if Oxycontin and Targin were both listed on the PBS, there would be no reason for doctors or genuine patients to prefer Oxycontin.

The size of this shift is hard to calculate, but the replacement of Oxycontin with a drug that is equally effective, more tolerable for genuine users and much harder (and less rewarding) to abuse, seems a no-brainer.

It makes little sense for the Health Minister to cry poor on this issue. PBAC has estimated the worst-case cost scenario was less than $10 million over five years.

Besides, how do you cost the ongoing epidemic of prescription opioid addiction, and the criminal subculture it supports?

A painful situation

The wider issue is the disgraceful state of the PBS in supporting the treatment of persistent pain.

Of the five first-line drugs for neuropathic pain recommended by the International Association for the Study of Pain (IASP), none are available for pain-relief on the PBS.

Gabapentin and pregabalin are available for Veterans, and through most compensation providers, but every other individual with nerve-related pain has to find a GP or specialist willing to lie to the PBS or pay thousands of dollars a year out of their own pockets.

The Government thinks it’s expensive to treat persistent pain sufferers with the best available drugs, but treating them with drugs that don’t work or that have severe side-effects isn’t a solution.

The Health Minister and the Government she represents need to get serious about a long-term plan for pain management. Statistically speaking, every fifth one of them will have reason to be grateful for it someday.

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