Buprenorphine is an important medicine.
Our clinical teams prescribe a lot of buprenorphine. It saves lives, reduces harm and helps people recover. But as our Director of Pharmacy, Roz Gittins, wrote recently:
Over the past few months the spiralling costs of heroin withdrawal drug buprenorphine is threatening the treatment plans of thousands of clients.
Just six months ago the cost of buprenorphine was about £15 for a month’s supply. Now it’s closer to £130. In one of our services the prescribing bill for buprenorphine shot up from nearly £3,000 to over £21,000 in just two months.
This matters because budgets in substance misuse services have been set on the basis of lower buprenorphine costs. These services are largely funded by contracts from local authorities, with year on year reductions often written in. If drug costs increase, then providers have no option but to make cuts elsewhere.
Parliament and the media are asking questions — but we’re making little progress
Over the last number of months we’ve spoken with Public Health England (PHE), the major pharmaceutical suppliers, and Parliamentarians to see if there’s any prospect of relief. MPs and peers from across political parties (and none) have asked questions in the Commons and the Lords, and the media has raised the profile of this issue.
But the disappointing reality seems to be that Government won’t intervene:
The Department is aware that since this short-term supply issue, the market price has increased. This increased purchase price is reflected in the reimbursement price paid to pharmacies, to ensure that supplies remain available to patients. The market for buprenorphine has generally been competitive and we expect the supply situation to improve over the coming weeks which is likely to result in an increasingly competitive market.
- Lord O’Shaughnessy. Parliamentary Under-Secretary for Health and Social Care
These price reductions haven’t materialised. And from what we know now, the higher prices are unlikely to come down in the near future.
Vital heroin withdrawal drug’s price increased by 700% in two months
Why tackling the rising cost buprenorphine is crucial for thousands of people in treatment
This is an issue that affects everyone in our sector
Over the past few months I’ve been working closely with the Medical Directors of other charities and NHS providers. This issue affects us all and we’ve been sharing our thinking, intelligence and approaches. The most important thing for us all is to make sure that people can access the best medicine at the right time.
It’s a good example of us working collaboratively together. I hope and expect that we’ll be able to build on this to share good practice in other areas too.
Each organisation is taking a different approach. No-one wants to switch to methadone only. One option is to move to the branded drug Espranor, which would give greater certainty over price for the next 12 months. We have decided to stick with generic buprenorphine while taking action to reduce costs where it’s clinically appropriate to do so.
What we’re doing — in practical terms
Our first step in every case has been to talk with our commissioners. Many have been supportive and agreed to help us meet the costs where they can. But this isn’t possible in every area, and is becoming harder for many commissioners to sustain.
Where commissioners haven’t been able to help with drug costs, we’re making a number of changes to our clinical services that preserve patient choice and effective treatment, while allowing us to help as many people as possible.
Our new approach is to:
Reduce supervised consumption across all prescribing, including other medication as well.
This is where the person has to take their daily dose in a pharmacy (and every time that happens, there is a cost incurred). While safeguarding remains a high priority for us, we also appreciate that sometimes people remain on supervised consumption for longer than is always necessary to help them progress with their recovery. We will only change someone’s dispensing arrangements where it’s safe to do so.
This will reduce costs as we will not have to pay for supervision. It’s also a better experience for many clients.
We are reviewing all prescriptions that are currently supervised to see if this is still necessary. We are prioritising those on longstanding supervised consumption or on supervised consumption for only some days.
We’re being careful here. Some clients will need to remain on supervised consumption, especially where there are safeguarding issues including safe storage and potential risks to children.
Reduce the number of tablets used to make up the required dose of buprenorphine.
That means using multiples of bigger tablets, rather than lots of small ones. For example, prescribing 16mg (2x 8mg) rather than 14mg (1x 8mg and 3x 2mg) unless it is a brief step in a reduction.
We’re being careful here too. In-between doses will be needed for reductions, although these steps should be brief. And we’re remembering that buprenorphine can be increased in 8mg steps for those needing higher doses.
Reduce the length of time of buprenorphine prescribing.
We’re respecting client preference where indicated but use buprenorphine mainly for detox/reducing prescriptions, rather than for stabilisation or maintenance. If people are not ready for a reduction we’re considering whether they may be better off on methadone.
Change to methadone if not stable or using on top of optimised buprenorphine.
One of the main clinical advantage of buprenorphine is that it reduces people’s ability to use on top. So if this isn’t working, then switching to methadone may be more appropriate.
Again, we’re being being careful here. Methadone may not be suitable due to allergy, over-sedation, interaction with other medication and other clinical factors. A switch involves titration from buprenorphine to methadone: waiting 24–72 hours or for visible sign of mild withdrawal then careful titration due to risk of residual blocking effect.
Continue to prescribe generically.
We are not routinely offering Subutex or Espranor because these are still more expensive than generic drugs (even with discounts) and we are prepared to accept the risk of ongoing price fluctuations.
How we’re making this shift
In practice this means our clinicians are running reports on all clients receiving buprenorphine. They are then discussing each client with the lead recovery worker and developing individual plans. As always, our clinical and medical leads, senior pharmacists, lead clinical pharmacists and associate medical directors are on hand for advice.
We believe this a sensible and proportionate response.
We also think it’s right to share the detail of what we’re doing openly, because this is an important issue that affects us all.
We’ll keep this approach under review and are keen to hear from others about their response.