June 4, 2010

Most Prescribed Drugs 2009: Post 1, JFK to SFO

crying indian litter ad.jpg
I'm sure we have a pill for that

(The Air Tran challenge: they offer Wifi on my flight, so how well can I use it?  Post 1.)


In 2006 I offered you the Top 25 psychiatric prescriptions.

Want to see what's changed in 2009?

The decade long WMD that was Depakote?   Does anyone want to apologize for that?  Hello?

II.

You have to dig a little bit.  Look at Wellbutrin XL, at 2M, down by 73% from 11M.  But bupropion (generic Wellbutrin) is up, at 8M.  Add the two together, and you're back to 11M.  This doesn't even account for generic bupropion SR + Wellbutrin SR.  So in this case, the company isn't marketing the branded drug, but doctors still want to use the chemical.

This makes it hard to argue that it's Pharma that is pushing the "overprescription" of Wellbutrin (in contrast to Prozac, which has fallen.)

Meanwhile, Risperdal is up-- but it's generic now.  So why up?  Because many insurance plans ask for it first.  Same with Celexa, which is the "generic" of Lexapro (I know, I know).  Add the two together, not much change.

But what is evident here are three trends:

  • SSRI/SNRIs are on the way out, except for Cymbalta.
  • antipsychotics are up, probably taking over for antidepressants
  • antiepileptics appear to have been a terrible, embarrassing fad.
  • either more people are on medications than in the past, or the same number of people are getting more medications.

III.

In 2008, drugs sales rose only 1.8%. in 2009, by 5%.  Those are both low.  Very low.

Yet:

  • number of generics exploded to 75% of prescriptions in 2009, up from 57% in 2004
  • number of branded drugs fell by 8%
  • total drug sales climbed to $300B (more spending on drugs).
  • But generics only accounted for $75B. 

In other words, even though we are using way more generics, we are either: using more medications than ever before (as above); or the few branded ones we are using are even more expensive than ever.

That turns out to be the case:  specialty drugs (e.g. Avastin) for chronic illnesses jumped to  21% of the sales. 

If you couple post-Obama American medicine's (and I'm not blaming him) focus on preventative medicine and long term maintenance-- where Big Clinics and Big Insurance will be the winners; with Big Pharma's move away from expensive acute treatments to really expensive long term treatments, you almost have to wonder if that's more than a coincidence?



III.

Here's the punchline: there's a little over $100B in waste (pdf) due to outright noncompliance, according to Express Scripts.  This number is undoubtedly high, because it is based on monthly refills-- for example, if it takes you 40 days to use up a 30 tablet supply, then you'll use only 9 scripts a year.  Based on this, they estimate a compliance with antidepressants of 83% (i.e. 10 scripts a year).  However, psychiatrists (unlike most other specialties) ask you to come back every month or two months at which point you'll get a new script-  regardless of how many you actually have left.  No one says to their psychiatrist, "you know, I still have a lot of Cymbalta left over from the last script."  So the actual noncompliance is likely much higher.

In other words, while prescriptions may cost a lot, the real budget killer is waste, thrown in garbage cans or flushed down toilets.

IV.

And I'll say what no one dares say: how many times does a patient agree to "take" Zyprexa and Effexor just to get the Klonopin?   Or Lipitor and glucophage, just to get Percocet?  True story: there's a pharmacy I walk by on the way to the sketchy city movie theatre, and every time I pass it I see guys tossing full pill bottles into the outside trash can.   

V. 

The solution: have Pharma pay for the first 30 days of any treatment (e.g. vouchers.)  Only after a patient has been on it for at least a month should the insurance cover the rest; this cuts out the wasted one or two or three first attempts at medications ("I didn't like the Cymbalta, so I stopped it.")

Copays, hated by all, are a necessity: free medications are not valued by patients/humans; nor should the copay be subsidized by medicaid or other plans.  Five dollars is enough.

And, finally, the most hated of all (choose a or b):

a) all prescriptions should require a prior authorization by the doctor, and a supplemental one every six months.  The easier it is for docs to prescribe, the more they will prescribe.  Now you'll think twice before you add on the Buspar.

b) you make all medications full access, and priced however Pharma wants, but you give each doctor a pharmacy budget, e.g. $20/patient per month. 

Another reality no one wants to hear: doctors will have to accept managed care at the treatment level (e.g. formularies) or they will have to accept managed care at their reimbursement level.  Or both.

http://twitter.com/thelastpsych












Comments

Last time I was on Air Tran... (Below threshold)

June 4, 2010 6:50 PM | Posted by Lou Natick: | Reply

Last time I was on Air Tran, the WiFi was down. Believe it or not, this was actually more fun. If it ever happens to you, just do what I did: browse around your cached webpages, pretending like you're online, and watch all the 40-year-old MBA's around you get increasingly furious.

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Wellbutrin changed my life.... (Below threshold)

June 4, 2010 7:51 PM | Posted by Chiara: | Reply

Wellbutrin changed my life. Actually, it was bupropion :)

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Wellbutrin + talk therapy h... (Below threshold)

June 4, 2010 8:31 PM | Posted by Anonymous: | Reply

Wellbutrin + talk therapy have been so effective that it breaks my heart to have not had access to such things much earlier in life. And yes, I used to scoff at the very idea of meds.

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I have psoriasis and Crohns... (Below threshold)

June 5, 2010 1:19 AM | Posted by Carol: | Reply

I have psoriasis and Crohns, as well as depression (hey there's a reason!) I was prescribed buproprion by my family practice doctor and since then have not had a flare of the psoriasis and the Crohns is under control. My father used buproprion to stop smoking and it was successful for him. A cousin with MS has had success with it too.
My point being is that there are many, some off label uses for buproprion that are not related to depression (as in the study of folks with psoriasis that were not depressed.) So it is within the realm of possibility that it is not being over-prescribed.

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Me too, Anon. I did everyth... (Below threshold)

June 5, 2010 3:40 AM | Posted, in reply to Anonymous's comment, by Chiara: | Reply

Me too, Anon. I did everything humanly possible to overcome my issues without meds. After 10 years I hit a brick wall. Was 37 before I even considered meds, and the Wellbutrin helped bring to fruition everything I'd been working on. I'm currently surviving a situation that I'm sure would have broken me had I not found the meds.

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Are Elavil and Depakote off... (Below threshold)

June 5, 2010 9:52 AM | Posted by acute_mania: | Reply

Are Elavil and Depakote off the list because they aren't as widely prescibed as much as they had been, or is it that they are no longer are considered primarily psychiatric?

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I think I read in the last ... (Below threshold)

June 5, 2010 11:06 AM | Posted by Anonymous: | Reply

I think I read in the last 6 months that GSK was repackaging bupropion with another drug.

Wellbutrin almost killed me. Instead of helping with depression and quitting smoking, it made me extremely anxious, high-strung, and want to smoke more. I swelled up like a water balloon and broke out. I wasn't able to quit smoking until I'd been off of it for 6 months. I was on it one year.

Their drugs may help some people but God help you if you are in the "small" percentage that suffer the side effects.

GlaxoSmithKline has a history of harmful drugs, poor quality control, and denial. Alli is only one of the latest.

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1) though it is undoubted d... (Below threshold)

June 5, 2010 2:18 PM | Posted by Anonymous: | Reply

1) though it is undoubted depakote is overprescribed (was, rather), this is actually only because bipolar disorder was overdiagnosed. In real mania, depakote actually helps, and it may be better tolerated than antipsychotics for some patients. Depakote is really only going to help certain manias, it is not really going to help agitation and distress and emotionality (i.e. generalized poor coping often labeled "bipolar"). AAPs are on the rise because AAPs are general sedatives (i.e. major tranquilizers) w/o the addiction and abuse potential of benzodiazepines. Depakote is not going to help a non-manic fake bipolar person that much, but risperidal is going to help anyone who is pissed off, extremely distressed, chaotically unhappy, agitated, regardless of whether or not the etiology is manic. ANY type of craziness responds to an AAP, because they shut off your brain and make you a zombie if you take enough of it.


2) Your idea for a preauth for every script sounds like a nightmare on wheels. This would be terrible for patients. Thre has to be a better way to cut down on reckless prescribing.

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Same anon above, posted ear... (Below threshold)

June 5, 2010 2:28 PM | Posted by Anonymous: | Reply

Same anon above, posted early.

(cont) Perhaps a better way would be to just target the doctors financially... rather than individual patients. Some patients are more sick and unstable than others and require more emergency scripts. What I see a lot are relatively functional normal people on benzos PRN and SSRIs and a small dose of an AAP when the problem really isn't even psychiatric! The patient usually has a lot of coping/social issues and unresolved health problems (I feel angry every time a woman with PCOS is taking lots of psych drugs because it is well documented that when this hormonal disorder is not controlled it WILL produce psychiatric symptoms, and psych drugs usually make PCOS worse)... or, like, a patient who is probably low thyroid is receiving inadequate thyroid treatment, or NO thyroid treatment, and they are diagnosed with atypical depression or some crap. That's dumb.

THe problem is too many people are not being treated hollistically, a lot of physical problems cause psych symptoms, and yes a lot of the time the patient just needs to be told that the problem is a thinking/coping issue (eventually, anyway). Psychiatrist often do the opposite, they encourage the patient to view themselves as hopelessly sick and to look for a drug cure, so that they take zero accountability for their nonfunctionality, when in reality if they just put in the effort to DEAL with the distress they might make progress with their anxieties.

I think people in real psychiatric episodes should have access to emergency meds... they need to cut down on people with anxiety and other nonserious illnesses being on meds.

And people with real psych illnesses also need to be told that some of their crap is just lack f effort. Bipolar people in remission who don't work, for example. Taking benzos whenever they feel uncomfortable. Yea, that's gotta stop, IMO.

But then again people in distress should receive immediate help.

FIne balance, friends... I doubt there is an adequate solution, other than perhaps fixing shit so that these companies charge less or offer some kind of charity care.

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Nice post on this subject. ... (Below threshold)

June 5, 2010 6:52 PM | Posted by David: | Reply

Nice post on this subject. I particularly like your general reviews of medication and your views on how medications attain prominence or decline. It takes the "godhood" out of prescribers and highlights the myriad non-scientific factors which distort the issue.

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Elavil is off the list caus... (Below threshold)

June 5, 2010 7:20 PM | Posted, in reply to acute_mania's comment, by Anonymous: | Reply

Elavil is off the list cause the side effects suck. Docs used to RX it for depression and the side effects caused a lot of noncompliance and pt bitching "Well doc I'm feeling better now but every time I stand up I faint and my mouth feels like sand paper. I'm also really tired..." and then for neuralgias (esp. diabetic) until Cymbalta came along (and Gabapentin but Cymbalta has really replaced that too is doing well against Lyrica for that) and replaced it for the same reasons.

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Who the hell still prescrib... (Below threshold)

June 5, 2010 7:45 PM | Posted by Anonymous: | Reply

Who the hell still prescribes Vistaril? That's just a waste of money and should come right out of the doc's pay. That would immediately stop that nonsense.

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Unfortunately many people a... (Below threshold)

June 6, 2010 4:18 AM | Posted by Whatever: | Reply

Unfortunately many people are forced to become non-compliant, because many institutions and services demand that you're on meds, whether they work or not, to prove that you're doing the best you can. Eff the side-effects, eff the long term consequences.

What I'd like to know is how to get rid of the stuff in an environmentally safe manner. I'm certainly not going to use my intestine or my family's intestines to do their dirty work.

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Thanks for sharing your rev... (Below threshold)

June 6, 2010 3:22 PM | Posted by P. Samuel: | Reply

Thanks for sharing your reviews on certain medications. I would highly recommend this post to everyone taking drugs regularly.

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I'm aware the the side effe... (Below threshold)

June 6, 2010 9:22 PM | Posted, in reply to Anonymous's comment, by acute_mania: | Reply

I'm aware the the side effects of Elavil are awful, even compared with the other tricyclics. I also see that the increase in Cymbalta just about makes up for the 14 million Elavil prescriptions that are no longer there, at least in numbers. But I have trouble believing that prescribing would have dropped off so quickly, especially since psychiatry had long considered Elavil obsolete in 2005.
I think what actually happened is that IMS health figured out that Elavil is prescribed by everyone except psychiatrists and moved it to a different category.

The same thing same happened with Klonopin. Yes the increase in Xanax and Ativan makes up for the Klonopin no longer being on the list, but why would doctors stop prescribing it, in favor of mostly Xanax, which has the worst reputation out of all the benzos as far as abuse goes (which evidently doesn't stop all that many docs from Rxing it)? My guess is that IMS decided that Klonopin was an antiepileptic, and in the 2009 report, IMS no longer considers anticonvulsants to be psychiatric, which is why Depakote and Lamictal aren't there either.

my suspicion is that the biggest change in these rankings is a result of changes in the way the data is presented. Of course I'll never know because IMS doesn't let you see this stuff for free.

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....antiepileptics appea... (Below threshold)

June 7, 2010 8:19 AM | Posted by Jack Coupal: | Reply

....antiepileptics appear to have been a terrible, embarrassing fad.

This may be a good time to ask Alone for his/her/their view on combining a GABAergic and a serotoninergic med for anxious depression.

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Whatever says: "many instit... (Below threshold)

June 7, 2010 9:52 AM | Posted by medsvstherapy: | Reply

Whatever says: "many institutions and services demand that you're on meds, whether they work or not, to prove that you're doing the best you can."

-Whatever, can you give an example? What kinds of institutions? What do they do if you are not compliant? Do any of these institutions validate your self-report? Are you in jail? Prison? A long-term psych hospital?

Or are you forced to take psych meds somewhere to keep your job? Or keep some government benefits?

I don't get this, but am curious abt who is forced to take psych meds.

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medsvstherapy:It a... (Below threshold)

June 8, 2010 1:47 AM | Posted by Whatever: | Reply

medsvstherapy:

It actually starts with the doctor - in most cases he won't even hand you a written diagnosis (which is necessary for receiving services) if you say no to the meds.

And many institutions have learned to expect them - won't force you but won't cooperate with you either and will peg you as a troublemaker. This is understandable perhaps in cases where meds would be of help - but oppressive in cases that rarely benefit from them. (like autism)

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whatever: i serously don't ... (Below threshold)

June 8, 2010 9:21 AM | Posted by medsvstherapy: | Reply

whatever: i serously don't get it. a doc will not hand you a diagnosis unless you agree to take meds: what is the diagnosis needed for?

if i get another parataxical answer, I am gonna give up on this puzzle.

Are you trying to get disability benefits for a mental illness?

Are you trying to prove you are attending psych treamtent as a stipulation of parole?

it sounds like you want to play the game, but not play the game.

if you want "services" to be given to you by someone, you are gonna have to recognize the golden rule: he who has the gold makes the rules.

you want gold from them, you go by their rules.

you might be free to step out of their matrix whenever you want. you just have to accept that you will give up whatever they are holding out to you, that you seem interested in.

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you want gold fro... (Below threshold)

June 8, 2010 2:08 PM | Posted by SusanC: | Reply

you want gold from them, you go by their rules

... or rather, it goes some way to explaining why there might be an economic incentive for patients to get prescriptions for drugs they have no intention to take. (More details of the example would make it clearer, but I appreciate the poster might want to keep some details confidential).

I've never taken or been prescribed psychiatric drugs. For ordinary medical conditions, my doctor is sometimes a bit enthusiastic about writing a prescription for several drugs where just one of them might have done the job. There's a possible trade-off between the cost of the drugs and the cost of the doctor's time: "Here's a prescription for X and Y. Try X and if that doesn't work, try Y" saves the patient from having to go back when X doesn't work.

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Having read the report you ... (Below threshold)

June 8, 2010 2:52 PM | Posted by SusanC: | Reply

Having read the report you linked to.

I don't agree with the way they've put anti-depressants under the heading "sporadic forgetter".

Sure, patients with depression are sometimes too depressed to take their anti-depressants. But this is rather different from simple forgetting: the patient's inability to take their medication is caused by the condition the medication is intended to alleviate, and there is a positive feedback effect. (Failure to take medication increases depression, which increases the chance the patient will be unable to take medication the next day as well...)

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Not everyone is a lazy bum ... (Below threshold)

June 9, 2010 9:29 AM | Posted by Whatever: | Reply

Not everyone is a lazy bum trying to get services so they won't have to work. Nor is everyone who needs services an adult or has disabilities which can be helped by mental medications. But institutions need "something to shut them up" and docs need to pay off their university debt and pharma needs to make shareholders happy.

So yes, there is a game where everyone involved wants something so they must accept the rules.

Not everyone has a choice in the matter.

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Whatever @09:29,I ... (Below threshold)

June 9, 2010 10:31 AM | Posted, in reply to Whatever's comment, by Jack Coupal: | Reply

Whatever @09:29,

I agree with most of your post.

But, "Not everyone has a choice in the matter", is wrong. People always have "a choice in the matter". That's what makes us different from animals.

The choices often aren't easy, pleasant, convenient, rewarding, or ego-stroking; they're sometime the exact opposite.

"The Government" tells you that you don't have choices, and that you need government (or lawyers) to eliminate those messy decisions giving you something that soothes you directly. Beware of Grecians bearing gifts.

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In response to (June5@2:18)... (Below threshold)

June 13, 2010 5:38 AM | Posted, in reply to Anonymous's comment, by Vince: | Reply

In response to (June5@2:18), I wholeheartedly agree with your comment on depakote's effectiveness and bipolar's over-diagnosis.

Because of the classification problem, the mapping of a molecule to underlying problem is becoming even harder to ensure. As the subset labeled "BP" expands beyond it's true size by virtue of being en vogue, the relative effectiveness of a depakote drops quite fast relative to a seroquel which it seems will have 'some' effect over *any* population; something is afoot when Seroquel is found to be an effective antidepressant at 50mg; saturating H1 can be done for a fraction of the cost by Benadryl.

Then again, I never did see an article here explaining the distaste for depakote in detail.

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Actually, I do say to my ps... (Below threshold)

July 7, 2010 1:49 AM | Posted by somebodynobody: | Reply

Actually, I do say to my psychiatrist, "you know, I still have a lot of XYZ left over from the last script."

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We in the United States sho... (Below threshold)

July 9, 2010 12:06 AM | Posted by Amara: | Reply

We in the United States should be trying to take care of our lives without a 14.6 Billion dollar antipsychotic habit. Psychiatry and Pharmaceuticals have teamed up to created a country of drug addicts. It's up to us to say 'no'.

For more information take a look at he website of Citizens Commission on Human Rights - cchr.org

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I've developed this effect ... (Below threshold)

July 10, 2010 7:37 PM | Posted by Elisa: | Reply

I've developed this effect of having a very bad memory/processing speed several months after getting off of an SSRI/SNRI. The first drug that did this to me was Serzone, the second was Effexor. Yet they make me feel so good while I take them! Is there any evidence they cause long-term memory damage? Seems like a lot of people feel the same way.

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Woohoo...Scientology comes ... (Below threshold)

July 11, 2010 11:54 AM | Posted, in reply to Amara's comment, by Anonymous: | Reply

Woohoo...Scientology comes to visit....don't take drugs, let Scientology control your mind instead. Must say I love the irony of someone pushing covert Scientology here when Hubbard was pretty much a textbook narcissist. Delicious, delicious irony...

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Most patients now call thei... (Below threshold)

July 20, 2010 8:07 PM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

Most patients now call their pharmacy for refills and doctors will sign them electronically. Very few refills are done paper and pencil at the time of the appointment.

Vistaril is still commonly prescribed because it is non addicting and is dirt cheap. It is on the WalMart $4 list, and other stores have followed suit.

I believe that part of why depakote is no longer prescribed as much is the presence of serious risks to fetal development--neural tube defects early and mental retardation later in pregnancy. No psychiatrist wants to risk that. Once you start thinking about alternatives for half your patients, it is easy to forget about Depakote for the men as well. Also, most longer term patients have tried it in the past. Once the novelty has worn off, a lot of patients won't continue on something or be willing to retry something from the past. Long-term, depakote still has strong evidence behind it to recommend it.

Atypical antipsychotics have the advantage of having "ego glue," helping people with underdeveloped coping skills or maladaptive skills to better deal with stressors. They can also help with sleep, adding to the appeal.

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What do medicine, medicatio... (Below threshold)

January 7, 2011 5:57 PM | Posted, in reply to Anonymous's comment, by Is it that simple: | Reply

What do medicine, medications, real estate, higher education have in common in the US?

The cost is typically subsidized by government and/or insurance companies.

The cost has risen quite a bit more than one would expect otherwise.

The best way to control cost is to make the consumer pay: You're paying for this medication. Do you want to one that costs 5$ or 250$.

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I've been on generic Lexapr... (Below threshold)

May 27, 2013 6:23 PM | Posted by Foobs: | Reply

I've been on generic Lexapro for a few months now, and it is TOTALLY F'ing AWESOME... It's almost like it gave me a split personality; depressed, impatient Foobs who has a stretch of 3 or 4 days overy month or so in which he is a nervous wreck is still there, but I can completely ignore him.

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