Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was...
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![Page 1: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/1.jpg)
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
![Page 2: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/2.jpg)
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.
![Page 3: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/3.jpg)
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.
![Page 4: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/4.jpg)
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.
![Page 5: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/5.jpg)
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
![Page 6: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/6.jpg)
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
![Page 7: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/7.jpg)
Antipsychotic Utilization Profile
![Page 8: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/8.jpg)
Antipsychotic Prescribing Rate—State
0
500
1000
1500
2000
2500
3000
3500
4000
HAL PER ABIL GEO RISP SERO ZYP
Uni
que
Pat
ient
s
![Page 9: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/9.jpg)
Antipsychotic Prescribing Rate—State
0
500
1000
1500
2000
2500
3000
3500
4000
HAL PER ABIL GEO RISP SERO ZYP
Uni
que
Pat
ient
s
2%
28%
![Page 10: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/10.jpg)
Antipsychotic Prescribing Rate—Lifeworks NW
0
10
20
30
40
50
60
70
HAL PER ABIL GEO RISP SERO ZYP
Uni
que
Pat
ient
s
2%
41%
![Page 11: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/11.jpg)
Antipsychotic Prescribing Rate—Comparison
0%
5%
10%
15%
20%
25%
30%
35%
40%
HAL PER ABIL GEO RISP SERO ZYP
Uni
que
Pat
ient
s
Lifeworks State
![Page 12: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/12.jpg)
Antipsychotic Selection
Cost is a factor in treatment selection when all else is considered equal.
Abilify Risperdal
![Page 13: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/13.jpg)
Antipsychotic Selection
Cost is a factor in treatment selection when all else is considered equal.
Abilify
Generic Risperidone
![Page 14: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/14.jpg)
Antipsychotic Utilization Profile
![Page 15: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/15.jpg)
Seroquel Dosing*—State
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low Dose
(<300mg)
Therapeutic Dose
(300-800mg)
High Dose
(>800mg)
Dai
ly S
eroq
uel D
ose
*Reflects use of dose for ≥90 days
![Page 16: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/16.jpg)
Seroquel Dosing*—State
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low Dose
(<300mg)
Therapeutic Dose
(300-800mg)
High Dose
(>800mg)
Dai
ly S
eroq
uel D
ose
*Reflects use of dose for ≥90 days
14%
86%
![Page 17: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/17.jpg)
Seroquel Dosing*—Lifeworks
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low Dose
(<300mg)
Therapeutic Dose
(300-800mg)
High Dose
(>800mg)
Dai
ly S
eroq
uel D
ose
*Reflects use of dose for ≥90 days
31%
69%
![Page 18: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/18.jpg)
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.
![Page 19: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/19.jpg)
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.
![Page 20: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/20.jpg)
Low Dose Seroquel
Cases of Seroquel misuse and abuse have been reported in the medical literature. Street name = “quell” and “Susie-Q”
![Page 21: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/21.jpg)
Antipsychotic Utilization Profile
![Page 22: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/22.jpg)
Quarterly Summary—Comparison
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
2007 Q3
2007 Q2
2007 Q1
2006 Q4
Lifeworks State
Risperdal & perphenazine, % of all AP use,
excluding clozapine and select 1st generation AP
![Page 23: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/23.jpg)
Quarterly Summary—Comparison
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
2007 Q3
2007 Q2
2007 Q1
2006 Q4
Lifeworks State
Risperdal & perphenazine, % of all AP use,
excluding clozapine and select 1st generation AP
Goal?
![Page 24: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/24.jpg)
Quarterly Summary—Comparison
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
2007 Q3
2007 Q2
2007 Q1
2006 Q4
Lifeworks State
Percent of Seroquel patientson therapeutic dose
![Page 25: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/25.jpg)
Quarterly Summary—Comparison
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
2007 Q3
2007 Q2
2007 Q1
2006 Q4
Lifeworks State
Percent of Seroquel patientson therapeutic dose
Goal?
![Page 26: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/26.jpg)
Antipsychotics—Cost
Drug Cost*
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 OHP1st QTR 2007Excludes rebate
![Page 27: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/27.jpg)
Antipsychotics—Cost
Drug Cost*
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 OHP1st QTR 2007Excludes rebate
DC
DC
DC
DC
![Page 28: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/28.jpg)
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
![Page 29: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/29.jpg)
Identification of Specialty Practice: Primary Care and Psychiatry
![Page 30: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/30.jpg)
Antipsychotic Prescribing Rate—Psychiatry Specialty
0
200
400
600
800
1000
1200
1400
1600
1800
HAL PER ABIL GEO RISP SERO ZYP
Uni
que
Pat
ient
s
![Page 31: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/31.jpg)
Antipsychotic Prescribing Rate—Psychiatry and Primary Care
0200400600800
10001200140016001800
HAL PER ABIL GEO RISP SERO ZYP
Psychiatry Primary Care
Uni
que
Pat
ient
s
![Page 32: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/32.jpg)
Antipsychotic Prescribing Rate—Psychiatry and Primary Care
0%
5%
10%
15%
20%
25%
30%
35%
40%
HAL PER ABIL GEO RISP SERO ZYP
Psychiatry Primary Care
% P
atie
nts
![Page 33: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/33.jpg)
Seroquel Dosing*—Psychiatry Specialty
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low Dose
(<300mg)
Therapeutic Dose
(300-800mg)
High Dose
(>800mg)
Dai
ly S
eroq
uel D
ose
81%
19%
*Reflects use of dose for ≥90 days
![Page 34: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/34.jpg)
Seroquel Dosing*—Psychiatry and Primary Care
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low Dose
(<300mg)
Therapeutic Dose
(300-800mg)
High Dose
(>800mg)
Psychiatry Primary Care
Dai
ly S
eroq
uel D
ose
81%
19%
*Reflects use of dose for ≥90 days
87%
13%
![Page 35: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/35.jpg)
Quarterly Summary—Seroquel (% of patients within therapeutic dose range)
-10% 0% 10% 20% 30% 40% 50% 60%
2007 Q3
2007 Q2
2007 Q1
2006 Q4
Psychiatry Primary Care
![Page 36: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/36.jpg)
Quarterly Summary—RISP + PER
(% of AP use)
-10% 0% 10% 20% 30% 40% 50% 60%
2007 Q3
2007 Q2
2007 Q1
2006 Q4
Psychiatry Primary Care
![Page 37: Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was made possible by a grant from the State Attorney General.](https://reader036.fdocuments.us/reader036/viewer/2022081516/56649edb5503460f94beb358/html5/thumbnails/37.jpg)
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