Friday, July 10, 2009

The High Price of Sanity: What Antipsychotics Cost

When I was in medical school, there were these medications that were used to treat hallucinations and delusions (what we psychiatrists call "psychosis") and sometimes extreme agitation. They were the neuroleptics, and they worked: medicines like thorazine, and haldol, and mellaril, and navane. Oh, and like prolixin, too. They worked, but they came with a horrible stigma and lousy side effects. Some people tolerated them with no problems, some people even preferred how they felt when they were on them, but a lot of people found them to be pretty awful. Some made patients very tired -- this is why they are also referred to as major tranquilizers. Others were less sedating, but they made people very stiff: a side effect called Parkinsonism because they chemically gave people a temporary state similar to Parkinsons' Disease. You can sometimes look at someone and know they are on medication, and this is never good. And sometimes they caused a permanent, irreversible movement disorder called Tardive Dyskinesia. Okay, so people really don't like taking these medications, and sometimes they can be fine-tuned with other medications to halt the side effects, but they come with a price.

By the time I was a resident, the new generation of antipsychotics had come along. Risperdal, Zyprexa, Geodon, Abilify, Seroquel, Invega, the list marches on. These medications also worked and people didn't mind taking them (...okay, some people didn't mind taking them). They are also used for mood stabilization, to calm agitated states, for mania, as augmentation for depression, and sometimes for sleep. They aren't addictive, they aren't as stigmatized, and the immediate side effects aren't so troublesome. It's much easier to get patients to consider taking them and my experience is that in the short run, they help a lot of people feel better and function better. The down side has been that in some people they cause weight gain, diabetes, and hypercholesterolemia/hyperlipidemia. We don't seem to know who will have these problems (clearly, not every one does) and sometimes people are so sick without them that we're stuck fixing one disease while contributing to, or causing, another, and that needs treatment, too. And did I mention that these medications cost a fortune. If that's not enough, we have to order regular blood tests to monitor for the problems they cause, and patients may need more and expensive medications to treat the conditions the medicines cause.

So how much does it cost to stay sane? The state of Maryland, apparently, spends $80 million a year for atypical antipsychotics (these newer medications) for patients with Medicaid, and I suppose for uninsured patients in the hospital. This doesn't count the patients who self-pay, or have private insurance, or who get samples from their doctor, or who have Medicare. So the cost of keeping my state sane is pretty high. So far, only one of these medications, risperidone, is available in a generic.

Okay, so I price-shopped. I called some pharmacies, and here's the price for 30 pills. Remember, some people take higher doses-- I priced middle-range doses-- and some patients take several pills a day:

DRUG Walgreens   CVS   Sam’s Club Independent
Risperidone (Risperdal brand), 3mg $339 $385 $292 $295
Risperidone (generic), 3mg $170 $203 $150 $  46
Quetiapine (Seroquel brand), 25mg $  85 $103 $  82 $  97
Quetiapine (Seroquel brand), 200mg $265 $324 $262 $262
Haloperidol (Haldol brand), 5mg $  10 $  11 $    4 $  28
Aripiprazole (Abilify brand), 10 mg $449 $542 $440 $450

Hmmm, so there's a $3/pill differential for Abilify, depending on where you get it?
Oh, and I wondered about the generic risperidone--- $203 at CVS and $46.50 at a local independent pharmacy? I asked the pharmacist to check it twice, and then I called a second mom & pop pharmacy, and their price was just under $40. If you pay cash, it's worth shopping around. Are these the prices your insurance company pays? I doubt it-- they negotiate deals and have formularies. I asked how much the state pays for the medications for a patient with Medicaid, and none of the pharmacists I asked could tell said it was top secret. Okay.

One note on Haldol, the older generation medication-- I'm not sure if the $28 price was for generic or name brand, the others were all for the generic.