Costs and Essential Drug Access—The Case of Naloxone

Abstract

Since the turn of this century, fatal drug overdoses involving opioids have continued to mount. Despite rhetorical assertions to the contrary, too little investment has been made in the science-based responses to this crisis and progress has been stymied by systems-level factors. 1 Persistent gaps in naloxone access illustrate how dysfunction in the pharmaceutical market hampers crisis response. Naloxone is remarkably safe and effective in the reversal of opioid overdose. This cheap, offpatent compound has been the mainstay of overdose prevention efforts by grassroots harm reductionists for more than 2 decades. 2 But as the evidence base supporting scale-up in naloxone distribution has grown, so have barriers to population-level access.Cost is one such barrier. In their timely study published in this issue of JAMA, Chua and colleagues 3 demonstrate that increases in cost sharing for naloxone prescriptions were associated with significant decreased odds of prescriptions being filled. They estimate that every $10 increase in cost sharing imposed by Medicare and commercial insurance would be associated with 2.3% and 3.1%, respectively, of naloxone prescriptions going unfilled. Such sobering evidence of medication abandonment is a unique strength of this analysis, because it may most closely approximate the sticker shock than other markers of patient price sensitivity.To reach their estimates of prescription abandonment, Chua et al 3 analyzed samples of 73 311 commercially insured and 106 076 Medicare patient claims. Their innovative analysis leveraged the fact that for some commercial and Medicare insurance plans, deductibles reset at the beginning of the calendar year. They repeated the analysis for claims of patients who were insured and of patients who pay for prescriptions with cash (who do not experience the same deductible reset) and found no changes in the odds of prescriptions being filled in the latter group. Their negative control approach makes the study's primary findings more robust and in line with prior evidence that cost sharing leads people to forgo taking critical medications. This has likely implications for morbidity and mortality. 4 It is also notable that in a secondary analysis, Chua et al 3 found that the effect of cost sharing is nearly identical on the rate of abandoned prescriptions regardless of whether cost sharing is defined as the amount patients would have to pay before or after applying secondary payments. This means that partial financial assistance may not be effective in the case of naloxone. Because free naloxone distribution through brickand-mortar and mail-based harm reduction programs remains limited, 5 pharmacy access is vital to a robust overdose crisis response.