The drug fentanyl — which is up to 50 times stronger than heroin — is available in generic form. It is also a highly addictive street drug, manufactured in back-alley labs and laced in heroin to boost its potency. Fentanyl is used to treat extreme chronic pain that is unresponsive to other opioid pain relievers, such as breakthrough pain cancer patients often suffer. A fentanyl transdermal patch costs from $5 to $12 depending on the dose per hour. A 12 micrograms (mcg) per hour patch retails for about $5 and offers 72 hours of pain relief, whereas the 100 microgram per hour patch is about $12 with GoodRx coupon. Sounds like a bargain; pain-free bliss for $2 to $4 a day. That works out to about $50 to $125 per month.
An article in the Wall Street Journal discusses a recently approved (2012) opioid pain reliever also made from fentanyl. Insys Therapeutics created a way to speed the delivery of generic fentanyl into a fast-acting mouth spray. Subsys spray is a fentanyl sublingual spray for breakthrough pain. A month’s supply of the lowest dose (100 mcg) retails for $930. The 800 mcg applicator costs more than $4,000 per month. Some physicians have written prescriptions for up to four doses per day. At the highest dose (1,600 mcg), the cost exceeds $500 per day for four daily doses.
Keep in mind, fentanyl is highly addictive. It binds to opioid receptors in the brain much better than heroin. A fast-acting mouth spray is even more addictive than a transdermal patch. The fast-acting product was intended to be used by cancer patients, whose prognosis meant they would not live long enough to worry about potential addiction. The U.S. Food and Drug Administration only approved Subsys spray for cancer patients who are already on around-the-clock pain killers, but continued to suffer breakthrough pain.
Sales have shot up. Soon the drug was being prescribed “off-label” to people who did not have cancer. In 2014, only about 1 percent of the prescriptions were written by cancer specialists). How the drug maker began marketing the drug is the subject of much controversy. The drug maker hired 250 drug sales reps to convince roughly 1,700 doctors to prescribe the drug. The reps earned base pay of only $40,000 per year but could get up to 10 percent commission off sales. The sales reps were also paid a commission that rose with the dosage the doctor prescribed. If the physician had patients on lower doses, the rep would work to convince doctors to up the dose of those patients. With those kind of incentives, top sales reps earned from $350,000 to $500,000 annually.
Part of the drug sales reps’ jobs were to also convince drug plans to reimburse for the drug. Because the drug was only approved for cancer, reps would sometimes go as far as to call the pharmacy benefit manager (PBM) and pretend to be from the doctor’s office and claim the patient had cancer whether they did or not.
How could a sales rep hope to convince a doctor to change prescribing behavior? By offering highly-paid speaking engagements and bogus consulting gigs. Doctors who prescribed huge amounts might be offered speaking fee worth, say, $1,000 a speech or given retainers for “consulting” with the firm on pain management. The Justice Department believes these were basically bribes to reward high prescribers.
This is an example where mandatory electronic prescribing of controlled substances might have identified offending doctors sooner. Also, it might have allowed drug plans to verify that inappropriate patients were not receiving the drugs. It also shows how firms look for way to take old cheap drugs and sell them for huge markups by patenting delivery systems when cheaper version exist.