The Drug Management Learning Curve and Some Snake Oil

July 24th, 2006 by

It’s Monday morning, as good time as any for thinking about drugs. NCCI has issued an interim update of its comprehensive study (PDF) of drugs in the workers comp system. They find that drugs as a percentage of total costs continue to rise, but at a slightly slower rate. There appears to be a slow but steady uptick in the learning curve, as the system shifts to greater reliance on generic drugs, which are now prescribed 89 per cent of the time. Because it covers only through 2003, the study still reflects a heavy reliance on Vioxx (it does slip to #6 overall, down from its prior position as #2) and on oxycontin (holding its own at #4). With two anti-inflammatories leaving the market (Vioxx and Bextra), Celebrex should strengthen its #1 position in the forthcoming studies, despite some concerns about the side effects.
In trying to figure out why drugs are such a big part of the costs in Florida, NCCI discovered that the number one drug is Oxycontin – an expensive (and addictive) pain killer. Party time for the sales reps in Florida! How about a trip to…Disneyworld?
Our colleague Joe Paduda has done his own study of drugs in the comp system. His findings appear to align with NCCI’s, with the addition of some problems emerging with third party payers.
Snake Oil?
It’s not always easy to grasp the implications of NCCI’s study. The numbers are just so large. They are the sum total of millions of prescription decisions, made by thousands of doctors all across the country. Alex Berenson in the New York Times zeroes in on one doctor, a psychiatrist, who became so fond of Xyrem, a drug developed for the treatment of narcolepsy, that he morphed into a full time spokesman (“salesman”) for the manufacturer, Jazz Pharmaceuticals. Dr. Peter Gleason was recently busted for recommending the drug for a wide range of “off label” uses, including the treatment of depression. The active ingredient in Xyrem is gamma hydroxybutyrate, or GHB, an illegal street drug with a history of use in date rape. Dr. Gleason likes the drug because it knocks you out. Ditto for the date rapers.
In a news release about Dr. Gleason’s indictment, the FBI compared the doctor to a “carnival snake-oil salesmen.” (Can you spell “defamation”?) He abandoned his private practice to become a nationwide spokesman for the $600 per month drug, even coaching doctors to leave out the “disease diagnosis” line on the prescriptions.
But is it a crime? The article quotes noted civil liberties lawyer Harvey Silverglate: “What they are doing is criminalizing conduct that is not clearly criminal.” Indeed, doctors do have the right to recommend “off label” uses for drugs. Of course, they are supposed to base such recommendations on peer-reviewed research, as opposed to the anecdotal evidence that Gleason brings to the table. When Gleason says that the drug is “safer than table salt” and “safe for children,” he has probably crossed an ethical line. The question is whether he has committed a crime.
Meanwhile, Gleason’s annual earnings in excess of $100,000 from Jazz have abruptly dried up. The company has severed ties with him. In a most intriguing reversal, it appears that Gleason refused to provide testimony against Jazz, but Jazz is cooperating with the investigation and may well be preparing to testify against the good doctor.
From this vantage point, it appears that Gleason’s overwhelming faith in the drug may prove his downfall. No one need question the sincerity of his believe in Xyrem. It’s just what he was selling (a schedule III controlled substance) and the way he was selling it, as if it were a mocha colored syrup, in a clear bottle with a cork stopper. “Just rub a bit on and all your troubles go away…”