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Senior Director Clinical Research and Development Endo Pharmaceuticals, Inc. 100 Endo Boulevard Chadds Ford, Pennsylvania 19317 fax 610/558-4162 Ahdieh.Harry{at}Endo.com
Senior Director Pharmacoeconomics and Outcomes Research Endo Pharmaceuticals, Inc.
Published Online, October 30, 2007. www.theannals.com, DOI 10.1345/aph.1H451a
We believe that adding oxymorphone to a formulary is appropriate because the similar clinical responses to opioids observed in broad populations do not translate into similar efficacy and tolerability for individual patients. It is widely recognized by pain specialists that individual patients vary in their responses to different opioids, and this variability is likely attributable to genetic, metabolic, or other patient-specific factors.2,3 Some patients will respond to one drug but not another, other patients may have the opposite profile, some may respond to both drugs, and the remainder respond to neither. Studies have documented that patients who do not respond to one opioid or have intolerable adverse effects achieve improved outcomes when therapy is changed to a second opioid; some patients may require a third, fourth, or even fifth opioid trial.2,4,5 Therefore, the addition of a new opioid analgesic provides needed options to patients.
We also suggest that formularies should consider the issue of drug acquisition costs within the context of the total costs associated with managing pain. In an analysis of 3 years of claims data on approximately 600,000 insured lives from 7 large employers, both direct and indirect costs per employee were up to 3.5-fold higher for employees with painful conditions compared with other employees.6 Medication costs accounted for only 9.6–18.6% of direct costs for these employees. The largest proportion of direct costs (58–67%) was associated with hospital outpatient and inpatient care. Indirect costs for disability and absenteeism from work were also substantial (35–44% of total costs). These data suggest that a modest increase in medication expenditures can be justified if it helps control pain and thereby reduces some of the larger direct and indirect costs associated with poorly controlled pain.
We also note that with the impending removal of generic controlled-release oxycodone from the market, controlled-release morphine will be the only generic long-acting oral opioid available. Because no single opioid is sufficient to address every patient's analgesic requirements, formularies will need to consider including branded long-acting opioids. The cost differences between a 60 mg dose of generic controlled-release morphine and equipotent doses of branded extended-release oxymorphone 20 mg or controlled-release oxycodone 40 mg are similar ($2.34 and $2.23, respectively). At all equipotent dose levels, only small (<2%) cost differences are observed between branded extended-release oxymorphone and branded controlled-release oxycodone.
Given this modest price difference, the pivotal issue is not whether oxymorphone is superior to other opioids, but whether patients with poorly controlled pain can be treated effectively by switching to oxymorphone. If so, it would seem reasonable to provide this option. We therefore hope that managed care formularies will consider oxymorphone as an additional valuable option for patients with chronic pain.
References
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