There might be a new way to fight the opioid epidemic.
Encourage drug manufacturers to stop promoting the use of some prescription painkillers. In particular, those with higher dosage levels.
Cigna Health Insurance has taken a step in that direction. At least with one drug.
Instead, it’ll switch to Collegium Pharmaceutical’s Xtampza ER. It’s another oxycodone-derived drug with safeguards against potential abuse.
Cigna said it has signed a deal with Collegium intended to encourage physicians to prescribe lower doses of Xtampza ER.
“Cigna is intentionally aligning with stakeholders — including doctors, national and local organizations, and drug manufacturers — who share our mission to reduce the inappropriate and unnecessary overuse of opioids,” Karen Eldred, a Cigna spokesperson, told Healthline.
Last year, Cigna announced a goal of reducing its customers’ opioid use by 25 percent in three years.
“Our focus is on helping customers get the most value from their medications — this means obtaining effective pain relief while also guarding against opioid misuse,” Jon Maesner, PharmD, Cigna’s chief pharmacy officer, said in a press release.
No longer a ‘preferred drug’
OxyContin will be dropped from Cigna’s list of preferred drugs as of Jan. 1.
Patients who’ve already started taking the drug for hospice care or cancer treatment will still be able to continue taking OxyContin throughout 2018.
“As with other medications that are not on covered drug lists, Cigna will consider approving coverage for OxyContin if a customer’s doctor feels that treatment using OxyContin is medically necessary,” Cigna said in the press release.
In most cases, OxyContin can be taken less frequently than Xtampza. However, OxyContin's stronger formulation makes it more likely to be misused, experts told CNN.
For example, crushing or melting some extended-release pills can be one day’s worth of dosage in just one pill.
Cigna officials say Xtampza ER is formulated to resist attempts to cut, crush, or chew the pills to obtain a higher, immediate dose of oxycodone.
“Under the terms of the contract, Collegium is financially accountable if the average daily dosage strengths of Xtampza ER prescribed for Cigna customers exceed a specific threshold,” Cigna stated. “If the threshold is exceeded, Collegium will reduce the cost of the medication for many of Cigna’s benefit plans.”
Cigna believes that linking financial terms to dosage metrics will help prevent overprescribing, Eldred explained.
“While drug companies don’t control prescriptions, they can help influence patient and doctor conversations by educating people about their medications,” said Maesner.
In a statement last week, Purdue Pharma, the manufacturer of OxyContin, said that “Cigna’s decision limits the tools prescribers can use to help address the opioid crisis as both products are formulated with properties designed to deter abuse. Unfortunately, this decision appears to be more about pharmaceutical rebates.”
A different approach
Dr. Andrew Kolodny, director of opioid policy research at the Heller School of Social Policy and Management at Brandeis University in Massachusetts, said that Cigna’s approach with Xtampza ER runs contrary to common industry practices.
“Typically, the higher the dose, the more the company makes,” Kolodny told Healthline.
Kolodny has called for the U.S. Food and Drug Administration (FDA) to ban all ultra-high-dose opioid drugs.
Kolodny said that getting doctors to prescribe lower doses of oxycodone-based medication “would be helpful” in reducing the risk of opioid dependence.
Dr. Michael Lowenstein, medical director of the rapid opioid-detoxification program called the Waismann Method, said that Collegium could use enticements like “copay cards.”
These would be used to reduce or eliminate the amount that patients have to pay out of pocket for Xtampza ER. This could encourage physicians to prescribe the lower-dose drug.
Experts point out that while legal opioids like OxyContin and Xtampza ER can be a gateway to addiction, the reformulations made in recent years make it less likely that they’ll be directly misused.
However, long-term users of these legal pharmaceuticals can become dependent on them. Some slide into severe addiction and turn to the illicit market for other opioid drugs, including heroin.
Part of a trend
Lowenstein told Healthline that Cigna’s new approach to opioid-drug management is reflective of a general trend among pain management specialists to prescribe lower doses of opioid drugs to patients.
When OxyContin first came on the market, for example, it wasn’t uncommon to see patients get prescriptions for 80 mg of the drug to be taken three times daily, he said.
Now, the Centers for Disease Control and Prevention (CDC) generally recommends that the daily dose of opioids not exceed 90 morphine milligram equivalents (MME). This works out to about 60 mg of oxycodone total in a day.
“You can’t get in as much trouble with 20 milligram [pills] of oxycodone as you can with 80 milligram,” said Lowenstein. “There’s less abuse potential.”
Stacey E. Grant, PharmD, director of clinical consult services at axialHealthcare, commended Cigna for recognizing “the inherent risks of providing extensive coverage for opioids” while “also taking steps to curb the epidemic facing tens of millions of Americans.”
However, Grant told Healthline, “We believe that the potential short-term negative consequences of removing a prescription therapy from patients’ care plans outweigh the long-term benefits of mitigating opioid misuse.”
Addressing health insurers, Grant added: “While a prescription drug like OxyContin may lead to opioid use disorder, the best possible measure to take would be to cover more addiction treatment options while working closely with physicians to prevent more patients from suffering from or being at risk of opioid use disorder.”