1. Medstat MercuryMD Micromedex PDR Solucient Substance abuse medications: Trends and prescribing patterns by physician specialty November 5, 2007 American Public Health Association Annual Meeting

2. Medstat MercuryMD Micromedex PDR Solucient 2 Authors Tami Mark, PhD 1 Rita Vandivort-Warren, MSW 2 1 Thomson Healthcare 2 Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration

3. Medstat MercuryMD Micromedex PDR Solucient 3 Funding Substance Abuse and Mental Health Services Administration Views expressed do not necessarily reflect those of SAMHSA or DHHS

4. Medstat MercuryMD Micromedex PDR Solucient 4 Presentation Objective Recently, several new medications have been approved to treat substance abuse conditions. We will present data on retail prescribing trends of medications whose primary indication is for substance abuse treatment (i.e., alcoholism, opioid abuse).

5. Medstat MercuryMD Micromedex PDR Solucient 5 Questions Addressed How have new medications to treat alcoholism and opioid addiction diffused? Have new alcoholism medications replaced older medications or added to overall use? Which types of specialists are adopting new mediations the fastest? How does the rate of use of substance abuse medications compare to medications to treatment other psychiatric illnesses such as depression?

6. Medstat MercuryMD Micromedex PDR Solucient 6 Background on Alcoholism Medications Currently four products marketed in the US for the treatment of alcoholism –Naltrexone (Revia) –Naltrexone IM (Vivitrol) –Disulfiram (Antabuse) –Acamprosate (Campral)

7. Medstat MercuryMD Micromedex PDR Solucient 7 Alcoholism Medications Approval Time Line

8. Medstat MercuryMD Micromedex PDR Solucient 8 Study Design We obtained estimates of prescriptions and sales in retail pharmacies and mail order, overall and by physician specialty IMS’ National Prescription Audit (NPA) Plus TM database for –Weighted sample: 36,368 retail pharmacies –Volume of new and refilled prescriptions for drugs primarily used to treat substance abuse Physician specialty information assigned by IMS (based on DEA #) Note that medications dispensed in clinics or inpatient settings are not included

9. Medstat MercuryMD Micromedex PDR Solucient 9 Alcoholism Prescription Trends. 1998-2007 (000s) Source: IMS Health

10. Medstat MercuryMD Micromedex PDR Solucient 10 Alcoholism Prescription Trends, 1993-2007 (000s) 1993 Disulfiram = 175,000 2003 Naltrexone = 185,000 Disulfiram = 208,000 Total = 393,000 2006 Naltrexone = 196,000 Disulfiram = 182,000 Campral = 293,000 Total = 671,000 Source: IMS Health

11. Medstat MercuryMD Micromedex PDR Solucient 11 Market Share of Alcoholism Prescriptions, YTD August 2007 Source: IMS Health

12. Medstat MercuryMD Micromedex PDR Solucient 12 Market Share of Alcoholism Medication Sales ($), YTD August 2007 Total = $52 million (about $78 million projected) Source: IMS Health

13. Medstat MercuryMD Micromedex PDR Solucient 13 Sales in Perspective Blockbuster drugs have over $1 billion in sales No alcoholism drug is a blockbuster yet 2006 Sales figures –Campral: $31.5 million –Naltrexone: $20.4 million –Vivitrol: $1.6 million –Disulfiram: $8.8 million

14. Medstat MercuryMD Micromedex PDR Solucient 14

15. Medstat MercuryMD Micromedex PDR Solucient 15 Prescriptions by Specialty

16. Medstat MercuryMD Micromedex PDR Solucient 16 Summary of Trends Naltrexone doubled the market of alcoholism prescriptions, although prescription rates were still very low Campral diffusion has been much faster than naltrexone Within three years Campral prescriptions exceeded those of naltrexone and it became the most widely prescribed alcoholism medication Naltrexone and Campral do not appear to replace existing medications but rather to add to available choices for alcoholism medications No alcoholism drug is close to being a blockbuster ($1 billion in sales) despite large potential market What will current sales figures portend for future pharmaceutical company efforts to develop and market alcoholism medications?

17. Medstat MercuryMD Micromedex PDR Solucient 17 Summary of Trends Psychiatrists and GPs are main prescribers of alcoholism medications, as expected Variation in prescribing by psychiatrists: Naltrexone > Campral > Disulfiram Reflection of marketing and familiarity with medications?

18. Medstat MercuryMD Micromedex PDR Solucient 18 Background Suboxone and Subutex Subutex (buprenorphine hydrochloride) Suboxone (buprenorphine hydrochloride and naloxone hydrochloride) Approved for the treatment of opiate dependence (in 2002) Prevent symptoms of withdrawal from heroin and other opiates Subutex is given during the first few days of treatment, while Suboxone is used during the maintenance phase of treatment

19. Medstat MercuryMD Micromedex PDR Solucient 19 Background Suboxone and Subutex Previously opiate dependence treatments like methadone could be dispensed only in a limited number of clinics that specialize in addiction treatment. Subutex and Suboxone are the first narcotic drugs available under the Drug Abuse Treatment Act (DATA) of 2000 for the treatment of opiate dependence that can be prescribed in a doctor’s office. Only qualified doctors with the necessary DEA (Drug Enforcement Agency) identification number are able to start in- office treatment and provide prescriptions for ongoing medication.

20. Medstat MercuryMD Micromedex PDR Solucient 20 Prescription Trends for Suboxone and Subutex (000s) Source: IMS Health

21. Medstat MercuryMD Micromedex PDR Solucient 21 Trends in Sales of Suboxone and Subutex ($ Millions) Source: IMS Health

22. Medstat MercuryMD Micromedex PDR Solucient 22 Prescriptions for Suboxone and Subutex by Physician Specialty Source: IMS Health

23. Medstat MercuryMD Micromedex PDR Solucient 23 Summary Opiate Medication Trends Prescriptions and sales are showing rapid growth 2007 sales of Suboxone projected to be about $190 million Mix of GPs and Psychiatrists are prescribing