Paying The Price
The rising cost of buprenorphine
has caused serious concern in the
treatment field. DDN looks at the
issues behind it.
he 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,
‘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.’ DDN
November 2018 | drinkanddrugsnews | 9