In Opioid Settlements, Suboxone Plays a Leading Role

This story was updated to correct a misspelling of Dr. Yngvild Olsen’s name.

Read more Stateline coverage of the opioid crisis.

In this week’s $260 million settlement between drug companies and two Ohio counties hit hard by the opioid crisis, $25 million worth of the addiction medication known as Suboxone is a big part of the deal.

Suboxone would make up a much larger share of a proposed national settlement announced shortly afterward by a bipartisan group of state attorneys general: an estimated $26 billion over 10 years out of a $48 billion overall settlement.

But addiction experts question whether donated Suboxone — one of three evidenced-based medications used to treat opioid addiction — should be such a huge part of the settlements, because states could make a greater impact by spending the money on other measures.

“The primary barrier to getting more people into treatment is not the cost of the drug,” said Andrew Kolodny, senior scientist at the Institute for Behavioral Health at Brandeis University and co-director of the Opioid Policy Research Collaborative.

Suboxone costs roughly $500 a month for patients who pay out of pocket. Even so, Kolodny said, the real barrier to people with opioid addictions getting help is the lack of willing prescribers and the shortage of treatment programs.

Under the national settlement proposal, drug distributors Cardinal Health, McKesson and AmerisourceBergen; consumer products giant Johnson & Johnson; and the world’s largest generic drugmaker, Teva, would give states the $48 billion in cash and in-kind donations.

The settlement calls on Teva to provide as much Suboxone as needed over the next decade, an estimated value of $26 billion.

“Focusing on just one medication as a one-size-fits-all solution across the country,” said Yngvild Olsen, an addiction specialist in Baltimore who serves on the board of the American Society of Addiction Medicine, “misses the mark.”

“Different states may have different needs and obtaining the medication may not be top-most among them,” she said. “Without a robust trained workforce and funding for comprehensive services, a simplistic settlement may not get us very far.”

Matt Salo, director of the National Association of Medicaid Directors, agreed that instead of medicine, the equivalent value in cash would allow states more flexibility in addressing states’ unique addiction problems. 

“There’s no question that the value of a cash settlement outweighs the value of an in-kind contribution,” he said.

In the 1998 Tobacco Master Settlement Agreement valued at $246 billion over 25 years, there was an attempt to earmark up to 25% of the total amount for smoking cessation, Salo recalled.

“A worthy goal, but one that would have had very different impacts across states. Utah, for example, ran the numbers and concluded that, in order to spend that amount on smoking cessation programs, they would first have to start paying people to smoke.”

Abating an Epidemic

More than 48,000 people in the United States died from overdoses of prescription painkillers, heroin and fentanyl in 2017, according to the U.S. Centers for Disease Control and Prevention.

Research shows that people who receive addiction medications, including buprenorphine — the primary ingredient in Suboxone — methadone and naltrexone, which is sold as Vivitrol, are at least twice as likely to stay in treatment and recovery as those receiving addiction treatment without medication. The drugs, which block the effects of other opioids, also protect patients from accidental overdose.

But only about 10% of the more than 2 million Americans — about 200,000 people — with an opioid addiction are receiving treatment, and most treatment does not include these medications, according to data from the U.S. Substance Abuse and Mental Health Services Administration.

Addiction experts have long advocated for greater use of Suboxone and the two other opioid addiction medications. And Suboxone is often favored over methadone, because patients can take it at home rather than visiting a clinic every day or week.

Approved by the U.S. Food and Drug Administration in 2002, buprenorphine’s use has grown to represent more than half of the overall market for opioid addiction medications. In 2018, U.S. sales of branded Suboxone, a mixture of buprenorphine and naloxone, came to $1.9 billion, according to market research firm IQVIA.

Medicare, most private insurers and all but a handful of state Medicaid plans cover Suboxone, so many patients who use the drug don’t have to pay out of pocket.

But in much of the country, few doctors are qualified to write prescriptions for the controlled substance, and even fewer accept Medicaid payments. Cash payment is very common, said Brendan Saloner, a researcher at Johns Hopkins University who studies the availability of opioid treatment.

In the 14 states that have not expanded Medicaid to cover able-bodied adults with addiction, the medication provided under the settlement could help a substantial number of patients, he said.

And in states that have expanded the federal-state health program, the influx of settlement Suboxone might cut state Medicaid costs and allow the money to be spent on other addiction services, said Kenneth Stoller, who runs a treatment center in Baltimore that provides all three medications.

“But I would imagine states would rather have the money,” Stoller said, since Suboxone and the other two medications represent only a small portion of the total cost of treatment and recovery services.

And when all the other costs of abating the opioid crisis are accounted for, including child protective services, law enforcement, drug courts, employment training, housing and other medical expenses, the relative share of the costs represented by the medication recedes even more, he noted.

A National Proposal

The bipartisan attorneys general proposal was announced Monday afternoon by Democrats Josh Stein of North Carolina and Josh Shapiro of Pennsylvania, and Republicans Herbert Slatery of Tennessee and Ken Paxton of Texas.

They said they were optimistic that other states would join the agreement in the weeks ahead and that the more than 2,400 cities, counties and Native American tribes set to receive a share of the settlement proceeds also would agree.

“The opioid epidemic has ripped through our communities and left a trail of death and destruction in its wake,” Stein said. “This agreement is an important step in our progress to help restore people’s lives.”

In addition to the cash and medication, the companies in the settlement would agree to participate in a data-tracking program to ensure that opioid painkillers are not over-supplied and to change their marketing and distribution policies.

All three drug distributors issued a joint statement agreeing in principle to the proposal. Teva, the generic drugmaker, issued a similar statement. Details on the provision of free Suboxone to all who need it for the next 10 years remain to be worked out, according to representatives for the attorneys general and Teva.