1. Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General Consumer and Prescriber Education Program which is funded by the multi-state settlement of consumer fraud claims regarding the marketing of the prescription drug Neurontin

2. Background In 2004, Warner-Lambert (now a division of Pfizer, Inc.) paid $430 million to settle claims that it was using continuing education grants to promote off-label uses of Neurontin.

3. Background The 50 state attorneys general who accepted the settlement of the Neurontin case have used $21 million to establish the Consumer and Prescriber Grant Program, www.ohsu.edu/cpgp/, designed to provide healthcare professionals and consumers information related to prescription drugs and their marketing. www.ohsu.edu/cpgp/

4. Objectives Develop critical skills to promote an evidence-based approach to the medical literature; Create awareness of the persuasive marketing practices of the pharmaceutical industry; Assess the impact that pharmaceutical costs can have on other healthcare priorities; Balance the ethical responsibility to the patient vs. the ethical needs of society in prescribing practices; and Develop skepticism about off-label indications for a drug without compelling evidence-based research that supports such use.

5. Methods Academic Detailing Focused on the utilization of behavioral health medications Didactic Lectures Focused on the evaluation of medical literature and pharmaceutical marketing Web-Based Tutorials Focused on the evaluation of medical literature and pharmaceutical marketing

6. Topic Selection Antipsychotics After specialty pharmaceuticals, antipsychotics are the most expensive drug class for the Oregon Health Plan Costing approximately $3.2 million each quarter Drug class where small changes can have a big impact on overall cost Provides a good example of some off-label use

7. Antipsychotic Utilization Profile

8. Antipsychotic Prescribing Rate—State Unique Patients

9. Antipsychotic Prescribing Rate—State Unique Patients 2% 28%

10. Antipsychotic Prescribing Rate— Lifeworks NW Unique Patients 2% 41%

11. Antipsychotic Prescribing Rate— Comparison Unique Patients LifeworksState

12. Antipsychotic Selection Cost is a factor in treatment selection when all else is considered equal. AbilifyRisperdal

13. Antipsychotic Selection Cost is a factor in treatment selection when all else is considered equal. Abilify Generic Risperidone

14. Antipsychotic Utilization Profile

15. Seroquel Dosing*—State Daily Seroquel Dose *Reflects use of dose for ≥90 days

16. Seroquel Dosing*—State Daily Seroquel Dose *Reflects use of dose for ≥90 days 14% 86%

17. Seroquel Dosing*—Lifeworks Daily Seroquel Dose *Reflects use of dose for ≥90 days 31% 69%

18. Seroquel 69% of patients on therapy for 90 or more days were on low dose (<300mg/day). Total n=24 31% of patients on therapy for 90 or more days were on therapeutic dose (300-800mg/day) Total n=6 No patients were on duplicate antipsychotic therapy with Seroquel for 90 or more days. Roughly 50% of patients started on Seroquel maintain treatment for 90 or more days.

19. Low Dose Seroquel The use of Seroquel as a sedative has not been studied and efficacy and safety are questionable. Adverse effects = anticholinergic side effects, hypotension, hyperprolactinemia, metabolic abnormalities, agitation and akathisia.

20. Low Dose Seroquel Cases of Seroquel misuse and abuse have been reported in the medical literature. Street name = “quell” and “Susie-Q”

21. Antipsychotic Utilization Profile

22. Quarterly Summary—Comparison Risperdal & perphenazine, % of all AP use, excluding clozapine and select 1 st generation AP

23. Quarterly Summary—Comparison Risperdal & perphenazine, % of all AP use, excluding clozapine and select 1 st generation AP Goal?

24. Quarterly Summary—Comparison Percent of Seroquel patients on therapeutic dose

25. Quarterly Summary—Comparison Percent of Seroquel patients on therapeutic dose Goal?

26. Antipsychotics—Cost DrugCost* haloperidol$23 perphenazine$45 clozapine$210 Risperdal$250 Risperdal M-Tab$310 Geodon$310 Invega$340 Abilify$440 Abilify Discmelt$450 Zyprexa$460 Seroquel (>300mg/d)$530 Zyprexa Zydis$550 * Avg retail cost for 30-days to OHP 1 st QTR 2007 Excludes rebate

27. Antipsychotics—Cost DrugCost* haloperidol$23 perphenazine$45 clozapine$210 Risperdal$250 Risperdal M-Tab$310 Geodon$310 Invega$340 Abilify$440 Abilify Discmelt$450 Zyprexa$460 Seroquel (>300mg/d)$530 Zyprexa Zydis$550 * Avg retail cost for 30-days to OHP 1 st QTR 2007 Excludes rebate DC

28. Antipsychotic Dose Optimization From October 2006 through September 2007 323 antipsychotic dose optimization change forms have been sent Expected savings per change = $220 323 X 60% = 194 194 X $220 = $42,680 $42,680 X 12 = $512,160

29. Identification of Specialty Practice: Primary Care and Psychiatry

30. Antipsychotic Prescribing Rate— Psychiatry Specialty Unique Patients

31. Antipsychotic Prescribing Rate— Psychiatry and Primary Care Unique Patients

32. Antipsychotic Prescribing Rate— Psychiatry and Primary Care % Patients

33. Seroquel Dosing*—Psychiatry Specialty Daily Seroquel Dose 81% 19% *Reflects use of dose for ≥90 days

34. Seroquel Dosing*—Psychiatry and Primary Care Daily Seroquel Dose 81% 19% *Reflects use of dose for ≥90 days 87% 13%

35. Quarterly Summary—Seroquel (% of patients within therapeutic dose range)

36. Quarterly Summary—RISP + PER (% of AP use)

37. Key Points Risperdal and perphenazine are cost- effective treatment alternatives Risperdal will be generic in 2008 Seroquel is not recommended for use as a sedative/hypnotic