Treatment crisis

Action is needed now to stop the spiralling costs of buprenorphine, says Roz Gittins.

Read the full article in DDN Magazine

We want to offer high quality, safe, cost-effective services to as many people as we can – that’s why we all go to work in the morning. That’s our passion and our goal. Over the past few months, the spiralling costs of buprenorphine are threatening the vital work of all of us in this sector and more importantly the treatment plans of thousands of clients.

Roz Gittins
Roz Gittins: Director of pharmacy at Addaction

Currently, clients are given the choice to decide whether to use medications, mostly methadone or buprenorphine, as part of their treatment for opioid dependency. They make their own decision about their future, based on their own personal needs. They are empowered to steer their own recovery.

And let’s not forget, there can be a considerable difference in the effects and patient experience between the two medications. Buprenorphine may be associated with a reduced risk of overdose compared to methadone because it partially blocks other opioids. So if an individual takes heroin on top, they won’t experience the usual effects associated with it, and are usually put off doing so.  

Buprenorphine can also make people more clear-headed than methadone so may be preferred by some people who are working. Often parents also prefer it because the risks from unintended ingestion are far lower because buprenorphine tablets don’t work if they are swallowed (they should be dissolved under the tongue).

Just six months ago, the cost of buprenorphine was about £15 for a month’s supply. Now it’s closer to £130. In one of our services, the prescribing bill for buprenorphine shot up from nearly £3,000 to over £21,000 in just two months.

While we’re continuing to support clients prescribed buprenorphine, the long-term sustainability of this will be put in jeopardy if prices remain this high. In normal practice the option of switching from buprenorphine over to methadone would only be considered if clinically appropriate and if the client makes an informed choice to make the change.

Transferring someone for cost or supply reasons could generate significant anxiety and have a serious impact on the trust between the client and the provider, which in turn could damage their future engagement.

Changing to methadone may also destabilise clients or make them feel that they have been ‘put’ on treatment where they have previously ‘failed’.  At a time when drug-related deaths are higher than ever before do we really want service providers and commissioners to be forced into that position?

The importance of a client’s confidence in their treatment cannot be underestimated. Yet because the cost of this medication increased by more than 700 per cent for some of our services, we have worried clients and frustrated staff, who while knowing the life-saving benefits of buprenorphine are being forced to think about the costs.

It’s estimated there are around 30,000 people in England using buprenorphine as part of their recovery plans. That’s 30,000 parents, brothers, sisters, sons, daughters and friends, who are already doing the best they can with their recovery, experiencing extra anxiety.

It’s not in our control. It’s not sustainable. It’s not OK.

At Addaction, we’re calling for the government to do more. More should be done to monitor the price and supply of this crucial drug within the UK and we want to see adequate contingency mechanisms in place to ensure sudden shortages and price increases do not happen or are quickly dealt with.

Paying the price

The rising cost of buprenorphine has caused serious concern in the treatment field. DDN looks at the issues behind it.

The generic drug market can be a volatile one, with companies ceasing supply or switching production of drugs at little notice and with consequent shortages in supply. While government pricing control mechanisms to manage these shortages rarely affect the treatment field – as it prescribes far fewer drugs than wider health services – in the case of buprenorphine the impact has undoubtedly been felt.

The drugs recommended by NICE and the Drug misuse and dependence ‘orange book’ guidelines as maintenance for people with opioid problems are methadone and buprenorphine. However, as Addaction’s article opposite states, while the latter is the preferred option for many clients, a shortage has led to the price of generic buprenorphine sublingual tablets rising sharply in recent months. This has hit parts of the treatment sector – already struggling with shrinking budgets – hard.

Drug pricing mechanisms can seem complicated and opaque. The UK pharmaceutical sector is strictly regulated, with prices agreed via the Department of Health and Social Care (DHSC). NCSO (No Cheaper Stock Obtainable) is a special concessionary pricing status negotiated by the Pharmaceutical Services Negotiating Committee (PSNC), enabling a set number of drugs above the drug tariff price to be reimbursed at a higher level than that price. The tariff is produced every month by NHS Prescription Services on behalf of DHSC, and then supplied to pharmacists and other bodies.

In May, Public Health England (PHE) wrote to directors of public health in response to concerns from some pharmacists and treatment providers about the availability of generic 2mg buprenorphine tablets. The letter explained that while branded buprenorphine is more expensive than the generic product used by many services, pharmacists are paid a standard price as set out in the tariff for ‘whichever product they dispense against a prescription for generic buprenorphine’, adding that the reimbursement price can change according to market conditions. While the NHS is used to managing these fluctuations and temporary concessionary prices, as PHE’s letter pointed out the limited range of medicines used in drug treatment means less scope to do that.

A further briefing in September stated that the agency recognised the ‘severe financial problems’; that continuing supply issues and raised prices were causing, and in late October PHE once again wrote to directors of public health explaining that the concessionary price had remained higher than the reimbursement price, and stressing that PHE had continued to work closely with DHSC and treatment providers to ‘understand the issues and their impact, and what can be done to mitigate any resulting problems’.

This most recent letter states that while the original supply issue has been resolved, supplies of generic buprenorphine remain limited and pharmacists have continued to rely on more expensive branded products, meaning that treatment services and commissioners will ‘see increased drugs bills for most, if not all, of 2018 and potentially beyond that’.

The letter ends with a statement that local authorities may need to ‘reflect on the medicines element in their budget for drug treatment’. Given this, what is a realistic timescale until the situation might be resolved? ‘The bottom line is that no one knows,’ Pete Burkinshaw, alcohol and drug treatment and recovery lead at PHE, tells DDN.

Pete Burkinshaw: Alcohol and drug treatment and recovery lead at PHE.

‘The price is determined by the market conditions, and they can change rapidly. Essentially the old tariff price was the market price for buprenorphine in this country and it was low for a long time, particularly in comparison to other countries in Europe. Perhaps it was unsustainably low and the recent changes may be to some extent a natural correction, or competition may increase again and the price would then fall.’

What PHE was communicating in its recent letter to local authorities was that their planning needs to be done ‘in the context that the recent changes may well be long term and not a temporary blip’, he adds. ‘The medicines market is fluid and all we can say with any confidence is the market conditions have changed, and that no one can predict them with any absolute certainty.’

On calls for the government to put contingencies in place he states that PHE is ‘raising questions within government persistently, and making the relevant people aware of the unique set of circumstances and the impact on drug treatment. However, it is very difficult and unprecedented for government to intervene in markets. This is a very complex issue and no centralised solution or mitigation is likely or perhaps even possible in the immediate future. We have explored many options with colleagues but none have been possible.’

Fluctuations in the medicines market are common and appear to be ‘particularly frequent at the moment’, he states. ‘The NHS and DHSC regularly have to deal with these issues but on a far larger scale than the current buprenorphine issue. However, we have gone to great lengths to point out that this is being felt particularly acutely by the drug and alcohol treatment sector and that there are – and will be increasingly – direct and immediate consequences. This is largely because of the very small number of medicines used by the sector which are funded from discrete budgets, which means that any peak cannot be absorbed by reductions in the price of other medicines.

‘This is further compounded by the financial pressures local authorities and services are currently under. We are confident that message is now understood, and we will continue to do everything we possibly can.’

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