# Presentation: 235024

## Methadone Utilization in the U.S., 2002 - 2006

- Laura Governale, Pharm.D., MBA
- Team Leader, Drug Utilization Data Specialist
- Division of Surveillance, Research and Communication Support
- Office of Surveillance and Epidemiology
- July 20, 2007

##  Outline

- Summary of data presented on May 2003, Methadone Associated Deaths
- sales and prescription utilization data years 1998 - 2002
- Current data, Years 2002 - 2006
- Sales data
- IMS Health, IMS National Sales PerspectivesTM Retail and Non-Retail
- Prescription and patient-level data:  _*new data resources*_
- Verispan, Vector One®:  National (VONA)
- Verispan, Vector One®:  Total Patient Tracker (TPT)
- Physician survey data:  _*new data resources*_
- Verispan, Physician Drug and Diagnosis Audit (PDDA)
- Conclusions

## Summary of data presented from May 2003 meeting, Years 1998 - 2002

- Annual numbers of retail purchases and retail prescriptions of methadone have increased over the past 5 years1
- Annual numbers of prescriptions for oxycodone, morphine, hydrocodone and methadone are increasing as well2
- methadone use, by far, the least of these four compounds surveyed
- Data do not permit conclusions about use of methadone in Opioid Treatment Programs (OTPs).

- 2 IMS Health, National Prescription Audit *Plus*, Years 1998 – 2002, Extracted April 2003.

- 1 IMS Health, Retail and Provider Perspectives, Years 1998 – 2002, Extracted April 2003.

## Sales dataYears 2002 - 2006

- IMS Health, IMS National Sales PerspectivesTM Retail and Non-Retail

## IMS Health, IMS National Sales PerspectivesTM

- Measures sales data from manufacturers to retail and non-retail channels of distribution
_**Extended Units**_ are the number of tablets, capsules, milliliters, ounces, etc. of a product shipped in each unit
- _Retail Channels_ - chain, independent, mass merchandisers, food stores with pharmacies, and mail-order pharmacies
- _Non-Retail Channels_ - federal facilities, non-federal hospitals, clinics, long-term care facilities, home health care (began 1998), HMOs, miscellaneous channels (began 1999; prisons, universities, other)
- unknown number of OTPs in the sample

**Notes:**
The IMS Health Retail and Provider Perspectives databases measure the sale of a given product from the manufacturer to various settings.

These databases measure sales volume information and unit sales from the manufacturer to various channels of distribution.  The units measure in these databases are EXTENDED UNITS, which are individual tablets, capsules, milliliters and so on.  

Retail perspective measures chain, independent, mass merchandisers, food stores with pharmacies, and mail-order pharmacies.

Provider perspective measures federal facilities, non-federal hospitals, clinics, long-term care facilities, home health care (began 1998), HMOs, miscellaneous channels (began 1999; prisons, universities, other).  There are an unknown number of OTP’s in the sample. 

## Sales data:  Total extended units of methadone sold to retail and non-retail channels of distribution, Years 2002 – 2006, IMS Health, IMS National Sales PerspectivesTM

- Overall sales of methadone have increased by 89% between year 2002 and 2006
- Sales in retail channels have doubled since 2002, whereas only 59% increase in the non-retail sector

- IMS Health, IMS National Sales PerspectivesTM, Years 2002 - 2006, Extracted July 2007.

## Sales data:  Total extended units of methadone 40 mg sold by channels of distribution, Years 2002 – 2006, IMS Health, IMS National Sales PerspectivesTM

- Largest sales increase for the 40 mg strength, especially in the retail sector
- slight decrease in sales for non-federal hospitals, and clinics.

- IMS Health, Retail and Provider Perspectives, Years 2002 - 2006, Extracted July 2007.

**Notes:**
The 40 mg strength of methadone has quadrupled since year 2002 to 2006.  

## Prescription and Patient-level DataYears 2002 – 2006(new data resources)

- Verispan, Vector One®:  National (VONA)
- Verispan, Vector One®:  Total Patient Tracker (TPT)

## Verispan, LLC  Vector One®:  National (VONA)

- Verispan’s Vector One®:  National (VONA) is a national-level projected prescription and patient-centric tracking service.
- Receives over 1.5 billion prescription claims per year, representing over 100 million unique patients.
- The number of dispensed prescriptions is obtained from a sample of approximately 59,000 pharmacies throughout the U.S., accounting for nearly all retail pharmacies and represent nearly half of retail prescriptions dispensed nationwide.
- Retail pharmacies include:
- national retail chains,
- mass merchandisers,
- pharmacy benefits managers and their data systems,
- provider groups.
- Data on prescribing specialty and patient age/gender are available as well as state level data.

## Prescription data:  Proportion of total dispensed prescriptions for selected opioid drug products, Years 1997 and 2006, Verispan, VONA

- Verispan, VONA, Years 1997 - 2006, Extracted July 2007.

**Notes:**
This slide shows the proportion of total dispensed prescriptions for these selected opioids.  You can see that back in year 1997 methadone prescriptions accounted for less than 1% of the share, but in year 2006, it accounts for 2% of share.  These pie charts also shows the growing proportaion of use for hydorcodone/APAP products, oxycodone/APAP products, oxycodone product, fentanyl products, and morphine products.  The products with declining proportions are:  propoxyphene and codeine/APAP.  

## Prescription data:  Total prescriptions dispensed in U.S. outpatient retail pharmacies for methadone by strength, Years 1997 – 2006, Verispan, VONA

- Verispan, VONA, Years 1997 - 2006, Extracted July 2007.

**Notes:**
This graph shows prescription volume for all strengths of methadone.  
Dispensed prescriptions for methadone has increased two and a half times since year 2002 – 2006.
The 10 mg strength is the most commonly dispensed strength in the retail pharmacies.

## Patient-level data:  Total number of unique patients receiving a prescription for methadone in U.S. outpatient retail pharmacies, Years 2002 -2006, Verispan, Total Patient Tracker (TPT)

- Verispan, Total Patient Tracker,  Years 2002 - 2006, Extracted July 2007.

**Notes:**
In year 2006, approximately 721 thousand patients received a prescription for methadone.  This was an increase of approximately 10% since the previous year 2005, and over a two-fold increase in the number of patients since year 2002.

## Annual percent change in prescription volume by patient age groups

- Verispan, VONA, Years 2002 - 2006, Extracted July 2007.

|   | % increase from |  |  |  |  |
| --- | --- | --- | --- | --- | --- |
|   | '02 to '03 | '03 to '04 | '04 to '05 | '05 to '06 | '02 to '06 |
| Methadone | 34% | 28% | 23% | 14% | 141% |
|   0-16 | 17% | 19% | -3% | -1% | 35% |
|   17-25 | 53% | 31% | 23% | 11% | 172% |
|   26-39 | 30% | 21% | 19% | 20% | 126% |
|   40-49 | 29% | 23% | 17% | 11% | 108% |
|   50-64 | 41% | 33% | 30% | 20% | 193% |
|   65+ | 33% | 30% | 26% | 8% | 137% |
|   UNSPEC. | 17% | 154% | 12% | -47% | 75% |

**Notes:**
Again, this table is based on the previous graph.  It shows the annual growth rate for methadone dispensed prescriptions by patient age.  The highest rate of growth occurred from year 2002 to 2003.  Still, the age 50-64 year age group has experienced the highest rate of growth in methadone usage for all time periods.  

Most rapid growth for age 50-64 category followed by the age 17-25 group.

## Prescription data:  Methadone prescriptions by new, continuing, and switch/add-on parameters, Years 2002 – 2006, Verispan, VONA

- During year 2006, majority of methadone prescriptions are for continuing patients (84%) versus new patients (2.5%) or switch/add-on patients (13%).

- Verispan, VONA, Years 2002 - 2006, Extracted July 2007.

**Notes:**
We can break down the new prescriptions characteristics by looking at where these prescriptions are coming from:  New patients, continuing patients, or switch/add-on patients.  

By new patient new Rxs, these are new prescriptions dispensed to patients who have not had a prescription filled for any product in the “pain” market within the past 6 months.  Therefore, you can consider these patients opioid naïve and also never having a dispensed prescription for any other prescription pain product.

Continuing patient Rxs are those new prescriptions that are dispensed to patients who have had a prescription for an opioid or any other prescription pain product in the past 6 months.  As you can see, prescriptions from continuing methadone patients primarily make up the methadone new prescription market.

Switch/add-on patient Rxs represent those prescriptions that are dispensed to patients who have had a prescription dispensed in the pain market in the previous 6 months.  They could either be adding methadone to their current therapy or switching from another drug in the pain market to methadone.  

## Projected number of Switch/Add-On new prescriptions (NRx) for methadone dispensed in U.S. retail pharmacies, Year 2006

- Most common product dispensed prior to methadone prescription is hydrocodone/APAP.

|  | Retail NRx | Share |
| --- | --- | --- |
|  | Swt/Ad Pt | % |
| methadone Switch/Add-On From | 509,225 | 100.0% |
|   Hydrocodone/APAP | 147,725 | 29.0% |
|   methadone | 133,713 | 26.3% |
|   Oxycodone w/APAP | 36,010 | 7.1% |
|   Oxycodone | 35,176 | 6.9% |
|   Tramadol | 16,815 | 3.3% |
|   Endocet | 15,351 | 3.0% |
|   Propoxyphene-N/APAP | 15,075 | 3.0% |
|   Morphine Sul Non Inj | 13,743 | 2.7% |
|   Fentanyl Transdermal | 10,304 | 2.0% |
|   Acetaminophen w/Cod | 8,874 | 1.7% |
|   Hydromorphone HCl | 7,432 | 1.5% |
|   M-Oxy | 5,433 | 1.1% |
|   OxyContin | 4,852 | 1.0% |
|   |  |  |

- Verispan, VONA, Year 2006, Extracted July 2007.

**Notes:**
This table shows what the previous prescription was before methadone.  It shows where the market gain for methadone came from the following products.  For example, approximately 29% of new prescriptions for methadone came from the Hydrocodone/APAP market in year 2006.  Nearly 26% of new methadone prescriptions came from a different brand of methadone.  And over 7% of new methadone prescriptions came from a previous prescription for oxycodone/APAP.  

## Prescription data:  Total dispensed prescription for methadone by top 10 prescribing specialties in U.S. outpatient retail pharmacies, Years 1997 – 2006, Verispan, VONA

- Verispan, VONA, Years 1997 - 2006, Extracted July 2007.

- Beginning year 2005, prescriptions written by GP’s surpassed anesthesiologists.

**Notes:**
Physician specialty data shows that beginning in 2005, general practitioners (which includes family medicine, osteopathic and general practice) have surpassed anesthesiologists in the prescribing of methadone that is dispensed from retail pharmacies (again, excluding mail order).  

For year 2006, 
General practitioners: 1,023,939 (approx. 26.2%)
Anesthesiologists: 879,982 (approx. 22.5%)
Internal Medicine:  576,287 (approx. 14.7%)

## Physician survey dataYears 2002 and 2006(newer data resources)

- Verispan, Physician Drug and Diagnosis Audit (PDDA)

## Office-based physician survey data
monthly survey that monitors disease states and the physician intended prescribing habits on a national-level
designed to provide descriptive information on the patterns and treatment of diseases encountered in office-based physician practices in the U.S.  
audit is composed of approximately 3,100 office-based physicians representing 29 specialties across the US

Limitations
Denominator is “visits” - not patients
Cross-sectional data
Sample sizes can be small when use is low, producing unreliable estimates

**monthly **_**survey**_** that monitors disease states and the physician intended prescribing habits on a national-level**
**designed to provide descriptive information on the patterns and treatment of diseases encountered in office-based physician practices in the U.S.  **
**audit is composed of approximately 3,100 office-based physicians representing 29 specialties across the US**
**Limitations**
**Denominator is “visits” - **_**not patients**_
**Cross-sectional data**
**Sample sizes can be small when use is low, producing unreliable estimates**

- Verispan, Physician Drug and Diagnosis AuditTM (PDDATM)

## Top 10 diagnoses associated with methadone use during visits to office-based physicians, Years 2002 and 2006, Verispan, Physician Drug and Diagnosis Audit (PDDA)

- Verispan, PDDA, Years 2002 - 2006, Extracted July 2007.

- Increasing number and proportion of use for non-drug abuse conditions.

**Notes:**
	2002		
TOTAL MARKET	489	100.0%	
BACK DISORDER NEC & NOS	120	24.6%	
DRUG DEPENDENCE	62	12.7%	
GENERAL SYMPTOMS	60	12.2%	
INTERVERTEBRAL DISC DIS	47	9.6%	
NONDEPENDENT DRUG ABUSE	26	5.3%	
OTHER SOFT TISSUE DIS	19	4.0%	
ALCOHOL DEPENDENCE SYNDR	14	2.8%	
OTHER CERVICAL SPINE DIS	12	2.5%	
FOLLOW-UP EXAMINATION	9	1.8%	
OSTEOMYELITIS	9	1.9%	
All Others	110	22.5%	

	2006		
TOTAL MARKET	952	100.0%	
BACK DISORDER NEC & NOS	168	17.7%	
PAIN NEC	110	11.5%	
SECONDRY MAL NEO GI/RESP	37	3.9%	
SEC MALIG NEO OTH SITES	37	3.9%	
DRUG DEPENDENCE	37	3.9%	
NONDEPENDENT DRUG ABUSE	31	3.3%	
INTERVERTEBRAL DISC DIS	29	3.1%	
OSTEOARTHROSIS ET AL	29	3.1%	
MAL NEO TRACHEA/LUNG	28	3.0%	
GENERAL SYMPTOMS	27	2.8%	
All Others	418	43.9%	

## Conclusions

- Large growth seen in sales data, especially to retail channels.
- More than twice the number of patients in year 2006 that filled a prescription for methadone compared to 2002.
- Most commonly dispensed strength in retail pharmacies is 10 mg in the last 10 years.
- Largest growth seen in sales and the number of dispensed prescriptions for methadone 40mg.
- Most rapid growth in dispensed prescriptions for age 50-64 category followed by the age 17-25 group.
- During year 2006, majority of methadone prescriptions are for continuing patients (84%) versus new patients (2.5%) or switch/add-on patients (13%).
- Most common product dispensed prior to methadone prescription is hydrocodone/APAP.
- More prescriptions prescribed by general practitioners than anesthesiologists in 2005 and 2006.
- Proportion of use for opioid abuse treatment declining in year 2006 relative to year 2002.

## Backup slides

## Prescription data:  Total number of prescriptions dispensed for selected opioid drug products, Years 1997 – 2006, Verispan, VONA

- Verispan, VONA, Years 1997 - 2006, Extracted July 2007.

**Notes:**
This slide shows trends of total prescriptions of oxycodone, fentanyl, morphine, and methadone dispensed in retail settings, EXCLUDING MAIL ORDER.  Not shown on this graph is hydrocodone, which leads this group with over 104 million prescriptions dispensed in 2005.

## Prescription data:  Total dispensed prescriptions for methadone in U.S. outpatient retail pharmacies by patient age, Years 2002 – 2006, Verispan, VONA

- Verispan, VONA, Years 2002 - 2006, Extracted July 2007.