Monday, July 23, 2012

Politics and Prescribing: The Case of Atomoxetine

Prior authorizations for medications have been a huge waste of physician time and they are a now classic strategy used by PBMs and managed care companies to force physicians to prescribe the cheapest possible medication. The politics for the past 20 years is that all of the medications in a particular class (like all selective serotonin reuptake inhibitors) are equivalent and therefore the cheapest member of that class could be substituted for any other drug. The managed care rhetoric ignores the fact that the members of that class do not necessarily have the same FDA approved indications. It also ignores basic science that clearly shows some members of the class may have unique receptor characteristics that are not shared by all the members in that class. Most of all it ignores the relationship between the physician and the patient especially when both have special knowledge about the patient's drug response and are basing their decision-making on that and not the way to optimize profits for the managed care industry.

The latest best example is atomoxetine ( brand name Strattera.).  Atomoxetine is indicated by the FDA for the treatment of attention deficit hyperactivity disorder. It is unique in that it is not a stimulant and that it is not potentially addicting. Many people with attention deficit hyperactivity disorder prefer not to take stimulants because they feel like they are medicated and it dulls their personality. In that case, they may benefit from taking atomoxetine. The problem at this time is there are no generic forms of atomoxetine in spite of the fact that there are many good reasons for taking it rather than a stimulant. As a result physicians are getting faxes from pharmacies requesting a "substitute" medication for the atomoxetine. Stimulants are clearly not a substitute. Some people respond to bupropion or venlafaxine but they are not FDA indicated medications for attention deficit hyperactivity disorder. Guanfacine in the extended release form is indicated for ADHD in children, but it is also not a generic and is probably at least as expensive.  There is no equivalent medication that can be substituted especially after the patient has been out of the office for a week or two and a discussion of a different strategy is not possible.

I am sure that in many cases the substitutions are made and what was previously a unique decision becomes a decision that is financially favoring the managed care industry. I would like to encourage anyone in that situation to complain about this to the insurance commissioner of your state.  It is one of the best current examples I can think of to demonstrate the inappropriate intrusion of managed care into the practice of medicine and psychiatry.

George Dawson, MD, DFAPA

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