The numbers are in: U.S. spending on diabetes drugs increased from $10 billion to $22 billion per year between 2002 and 2012, according to a recent study. And most of that cost was due to skyrocketing prices for one diabetes medication: insulin. Take, for example, Lantus, one of the most popular insulins on the market. The price of a 10-milliliter vial has shot up from under $40 in 2001 to around $275 today.
And these costs are hitting more people every year. About 30 million people in the U.S. have diabetes – up from 10 million 20 years ago – with another 89 million experiencing prediabetes. One study estimates that up to one-third of Americans could have diabetes by 2050. With so many people affected by rising insulin costs, it makes sense to wonder why prices are so high.
Human versus analog insulins
Today there are two major categories of insulin. Synthetic “human” insulin was introduced in the early 1980s and appears under brand names like Humulin R and Novolin 70/30. Genetically modified “analog” insulin was developed in the 1990s to provide several benefits over human insulin. Analog insulins take effect more quickly, their effects are more consistent and predictable, and they reduce the frequency of low and high blood sugar. Popular analog insulins are Lantus, Humalog, and Novolog. The prices for both types of insulin have risen over the years, but analog insulin is often much more expensive (compare $25 for Novolin 70/30 versus $323 for Humalog 50/50).
Due to the added convenience and benefits of analog insulin, 96% of insulin prescriptions in the U.S. are now for analogs. However, a growing body of research suggests that synthetic human insulin is just as effective for managing diabetes.
Manufacturing insulin is expensive
Producing insulin is more expensive than producing many other drugs. Insulin is a large complex molecule, and to create it manufacturers use recombinant DNA technology to engineer insulin-producing bacteria. In pharmaceutical terms, insulin’s size and complexity deem it a biologic. Because insulin is a biologic, any “generic” versions (termed biosimilars for biologic drugs) are subject to much more stringent–and expensive–approval processes by the FDA.
Because of the expense of producing insulin, even when biosimilar versions are produced, they only reduce costs for the drug by about 20%, compared to an average of 80% reduction for standard generics. Basaglar, the first insulin biosimilar, was introduced in December 2016 and costs around $235.
Elevating prices: the “big three” insulin makers
Just three pharmaceutical companies–Sanofi, Eli Lilly, and Novo Nordisk–manufacture insulin, and they vigorously defend their formulations against cheaper biosimilar versions. Sanofi recently brought lawsuits against both Merck and Mylan to avoid production of biosimilar versions of Lantus, its blockbuster insulin.
What’s more, a recent class action lawsuit against the three manufacturers claims that each of the companies set artificially high prices for their drugs in order to gain preferred status within the insurance companies’ lists of covered drugs. This system of discounting has a few problems. First, the discounts may not be passed on to consumers and instead can raise premiums, copays, or deductibles. Secondly, even those who are insured may be required to pay a portion of that inflated price out of pocket, not to mention uninsured patients who are on the hook to pay even more.
Incomplete insurance coverage raises costs
There are several ways that incomplete insurance coverage can negatively impact patients who use insulin.
The first is when the insurers and payers adjust their list of covered drugs (the formulary) to favor cheaper drugs for their member populations, with the result of cutting out coverage for some drugs that are popular. This made big news in late 2017, when CVS Caremark dropped coverage of Lantus in favor of the biosimilar Basaglar. Consumers who used Lantus were faced with the choice of switching to another brand or paying full price for their drug of choice.
Another factor that has led to higher costs for consumers is the increased use of high-deductible insurance or coinsurance plans. With a high-deductible plan, patients are forced to pay the full amount for insulin until they reach their deductible limit, which can be thousands of dollars each year.
Finally, people who use insulin and have Medicare Part D prescription coverage often find themselves in the “donut hole,” where they’ve surpassed their initial Part D coverage limit but have not yet reached their out-of-pocket maximum of $5,000. During that time, they must purchase insulin themselves, although at a 65% discount.
How to reduce the expense of insulin
The expense of insulin has led some people to cut down their insulin intake, which can be extremely dangerous. Rather than risking your health, try these strategies to reduce costs.
- If you have insurance, make sure your brand of insulin is on the formulary. For example, while CVS Caremark dropped Lantus, they still cover Basaglar, Levemir, and Tresiba.
- Ask your doctor about switching insulins. Human insulin is a fraction of the cost of analog insulin, and biosimilar Basaglar provides a modest cost savings.
- Keep watch for the introduction of Lusduna, a new biosimilar developed by Merck. Approved by the FDA, Lusduna is currently held up due to a lawsuit brought by Sanofi.
- Use coupons available from GoodRx and insulin manufacturers. Information about coupons are available on the GoodRx page for each drug.
- The American Diabetes Association is advocating for lower insulin prices. Go to https://makeinsulinaffordable.org to join the effort and find more resources for lowering costs.
In 2015, Americans spent $1,200 per capita on prescription medications, the highest rate in the world. In the U.S. a 30-day prescription to Xarelto (used to treat blood clots) costs $292, on average – where that same prescription costs just $126 in the UK, $102 in Switzerland, and just $48 in South Africa, according to a 2016 survey by the International Federation of Health Plans. A 28-day supply of Humira, used for Crohn’s disease and rheumatoid arthritis, costs a whopping $2,669 in the US – but just $822 in Switzerland and $1,362 in the UK.
Just why are prescription drug prices so high in the U.S compared to other countries? There are four main reasons.
- No single-payer negotiation. The U.S. doesn’t negotiate prices with pharmaceutical manufacturers like other countries do. In countries where there is single-payer healthcare—in other words where the government pays for most health care costs—those governments have huge negotiating power with pharmaceutical companies to lower prices. In the U.S., a patchwork of private insurers and smaller government programs negotiate prices with drugmakers individually, reducing their bargaining power.
- Little governmental regulation. In many other countries, governments regulate how much a medication can cost. For example, Canada’s Patented Medicine Prices Review Board (PMPRB) requires that a new medication cannot cost more than the median price of the drug in other countries. Countries in the European Union use similar pricing constraints. The U.S. does not impose similar rules, and therefore pharmaceutical companies set the prices for medications at their will, usually the peak of what they think the market will withstand. This leads to high prices, especially for innovative or unique drugs.
- Prices are rising faster than inflation. Pharmaceutical companies not only set the prices for new drugs when they hit the market, they increase the prices of existing drugs too. According to AARP, in 2015, prices for a sample of 268 widely used brand name drugs increased by 15.5%, compared to an inflation rate of less than 1%. Especially for older brand-name drugs and even generics, dramatic increases can occur. Several instances of astronomical price increases have made the news recently, such as EpiPen and Daraprim.
- Lack of research comparing drugs. A recent study in the Journal of the American Medical Association pinpointed the lack of comparative research across drugs as yet another cause for higher drug spending among Americans. While most doctors are sensitive to the fact that their patients want to avoid high drug prices, their primary goal is to treat patients effectively. It is often easy to find medical research about the efficacy of particular drugs, but there is less research comparing brand-name drugs against each other. Without that research, prescribers may be hesitant to prescribe a cheaper drug that they are less familiar with.
If drug prices are making a dent in your wallet, there are ways to save:
- Ask your doctor about cheaper options: Especially once generic versions of drugs are available, there may be less expensive choices out there.
- Use a GoodRx coupon: GoodRx helps you compare drug prices at various pharmacies and provides coupons for the lowest prices for many drugs. Independent researchers found that GoodRx is the best discount service for finding the lowest price.
- Make sure your insurance covers your medication, or go for a different one: Your insurance may not cover a particular drug, but usually it will cover another option for your condition.
- Manufacturer assistance programs or coupons can lower prices: If you’re purchasing a brand name drug, pharmaceutical companies often offer coupons or patient assistance programs. GoodRx highlights manufacturer coupons in the savings tips sections of our drug pages.
- Purchase a 90-day supply: Purchasing a larger supply of your medication can cut costs, as long as you clear it with your insurer. In order to fill a 90-day supply, you need a new prescription from your healthcare provider.
- Cut higher dose pills in half: Sometimes filling a higher dose prescription and cutting pills in half can save money. You’ll need to contact your doctor to get a new prescription and make sure that’s a safe option.
- Use a mail-order pharmacy: Private insurance and Medicare may offer discounts if you fill your prescriptions through their mail-order pharmacies, especially for generic drugs.
- Use an online pharmacy, with caution: Online pharmacies can provide good deals, but be wary of the “too good to be true” offers in the wilds of the internet. Follow these tips to make sure you’re dealing with a reputable online pharmacy.
Special note: Considering crossing the border for your medications? Just know that it is illegal to import pharmaceuticals even for personal use.
Prescription opioids like oxycodone, hydrocodone, codeine, and morphine have long been considered some of the most helpful drugs for managing acute pain, where the body is immediately reacting to trauma or injury. Each year, over 200 million opioid prescriptions are given out in the United States.
Unfortunately, the rates of opioid abuse and overdose deaths have skyrocketed in recent years, leading healthcare providers and patients alike to be cautious about the use of opioids. And now it turns out that there is another reason to avoid opioids: they may not be the most effective treatment for acute pain after all.
Do opioids work better than other drugs?
A recent study in the Journal of the American Medical Association throws into question how well opioid drugs actually treat acute pain.
In the study, researchers assigned 416 emergency room patients with moderate-to-severe pain to one of four treatment groups. Three of the treatment groups received a combination of a common opioid painkiller (either oxycodone, hydrocodone, or codeine) plus 300 mg of acetaminophen, a common non-opioid pain medication often sold over the counter as Tylenol. The fourth group received 400 mg of ibuprofen, a non-opioid painkiller, plus 1,000 mg of acetaminophen.
The result? All four groups experienced the same levels of pain relief. While opioid drugs did help to reduce pain, they were no more effective than a combination of non-opioid painkillers.
What are other options for pain treatment?
While opioids are usually given for acute pain, some of the following options also work well for chronic pain, or pain that lasts longer than six months.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Ibuprofen, naproxen, and aspirin are known as nonsteroidal anti-inflammatory drugs (NSAIDs). They control pain, lower fevers, and reduce inflammation. NSAIDs are often considered to be the first line of defense for acute pain, especially pain that doesn’t respond to non-drug treatments.
NSAIDs are available over-the-counter with brand names including Advil, Motrin, Aleve, Bayer, and Excedrin. NSAIDs are also available in prescription strength, with common brand names like Celebrex, Naprelan, Anaprox, Voltaren, and Feldene.
One word of caution: long-term use of NSAIDs can lead to stomach distress or bleeding in your gastrointestinal tract, and the FDA warns that non-aspirin NSAIDs may increase the risk of heart disease and stroke.
Acetaminophen is used on its own as a painkiller and is also an active ingredient in many combination medicines for pain and colds. It is a popular over-the-counter option, sold under brand names like Tylenol. Acetaminophen is especially helpful in addressing acute pain for conditions like headache, arthritis, and cancer pain.
Acetaminophen does not cause the gastrointestinal or cardiovascular side effects of NSAIDs, but taking amounts in excess of the recommended dosage may lead to liver damage or even liver failure. Because acetaminophen is present in so many medications, check whether other medications you’re taking contain acetaminophen as well.
A category of antidepressants called tricyclic antidepressants have the most evidence for treating pain, especially nerve pain. Imipramine (Tofranil), nortriptyline (Pamelor), desipramine (Norpramin), and amitryptiline (Elavil) are tricyclic antidepressants. While these drugs can be helpful, they aren’t effective for everyone.
Some evidence shows that two other categories of antidepressants–selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), or serotonin and norepinephrine reuptake inhibitors (SNRIs) such as duloxetine (Cymbalta)–are also helpful for chronic pain, but more research is needed.
Anti-epileptics can be taken to address chronic nerve pain and chronic pain from conditions like diabetes, shingles, chemotherapy, herniated disks, and fibromyalgia. Research on how well anti-epileptic medications work for pain is unclear. Some people may receive significant benefits while others may not receive any pain relief at all.
Newer anti-epileptic drugs such as gabapentin (Neurontin), and pregabalin (Lyrica) have more evidence of being effective painkillers than older drugs, and they carry fewer side effects. But, some studies have shown that older antiepileptic drugs such as carbamazepine (Tegretol) and phenytoin (Dilantin) can also help for certain pain conditions. However, these older medications cause more side effects.
Corticosteriods, commonly referred to as just steroids, decrease inflammation and reduce the activity of the immune system. They can reduce swelling and pain for conditions like cancer, back injuries, arthritis, joint pain, and nerve pain. Steroids can be helpful for short-term treatment of acute pain and are also used for the management of some chronic pain conditions., Common steroids used for pain relief are dexamethasone (DexPak), prednisone (Deltasone), and prednisolone (Prelone).
Steroids can be taken orally, applied as a cream, injected, or inhaled. Steroids do come with side effects such as weight gain, high blood pressure, and weakened immune system. Taking low doses of steroids for short periods can minimize those side effects. Injecting steroids directly into an area of pain also reduces side effects and promotes targeted treatment of the affected area.
Non-drug treatments like exercise, physical therapy, yoga, acupuncture, cognitive behavioral therapy, biofeedback, chiropractic, and relaxation training can provide pain relief, especially for chronic pain., In fact, organizations as diverse as the American College of Physicians, the U.S. Department of Veterans Affairs, and the Centers for Disease Control and Prevention recommend non-drug treatments as the first course of action for chronic pain. Although side effects for non-drug treatments tend to be minimal, be sure to consult with a healthcare provider before beginning any new treatment activities.