Treatment of moderate to severe cancer pain will continue to be dominated by opioid analgesics for the foreseeable future. However, with the widespread epidemic of opioid abuse and misuse in the United States, prescribing restrictions on these agents are becoming more prevalent, affecting even cancer patients’ ability to access these critically important analgesics. Payers offer fairly broad coverage of new abuse-deterrent formulations (ADFs) of long-acting opioid analgesics on their largest commercial and Medicare Advantage plans, but because these new brands are considerably more expensive than traditional, generically available shorter-acting opioid analgesics, MCOs typically require greater patient cost-sharing for nonpreferred brands through the use of unfavorable formulary tiering (including specialty tiers).  They also use strategies such as prior authorization and quantity limits to limit physician overprescribing of these agents. Importantly, however, most surveyed physicians who treat cancer pain are not inclined to overprescribe opioid ADFs, at least at present, because they do not consider these agents necessary for the majority of their patients, only for those at high risk of misuse or abuse.

Table of contents

  • Cancer Pain - Access & Reimbursement - Detailed, Expanded Analysis (US)
    • Actionable Recommendations to Optimize Market Access
      • Successes and Stumbles
        • Successes Among Cancer Pain Therapies in the United States
        • Stumbles Among Cancer Pain Therapies in the United States
        • United States: Reimbursement Successes and Stumbles
        • Key Stakeholders in the Road to Market Access
          • United States: Stakeholder Dynamics in the Road to Reimbursement
        • Key Market Access Roadblocks
          • Reimbursement Dynamics
            • United States: Commercial Managed Care Organizations
              • Lessons Learned and Key Takeaways
              • Drivers of Reimbursement by MCOs for Cancer Pain Therapies
              • MCO Requirements for Abuse-Deterrent/Tamper-Resistant Properties for Long-Acting Opioid Analgesics
              • Drivers
              • Key Findings
              • Restrictions Used in Commercial Plans for Select Cancer Pain Therapies
              • Impact of TIRF REMS Access Program on Payer Coverage of Rapid-Acting Fentanyl Formulations
              • Key Restrictions on Branded Opioid Analgesics
              • Payer Use of Key Restrictions for Branded Opioid Analgesics
          • Pricing and Reimbursement, Policy, and Coverage: Impact on Prescribing
            • Patient Share and Physician Satisfaction
              • Key Findings
              • Patient Share for Moderate to Severe Cancer Pain
              • Physician Satisfaction with Currently Available Treatment Options
            • Prescriber Preference
              • Key Findings
              • Physician-Preferred Therapies for Moderate to Severe, Non-Neuropathic Cancer Pain
              • Physician-Preferred Therapies for Moderate to Severe Neuropathic Cancer Pain
              • Physician-Preferred Opioid Analgesics for Moderate to Severe Cancer Pain
              • Physician-Preferred Therapies for Breakthrough Cancer Pain
              • Physician-Preferred TIRFs for Breakthrough Cancer Pain
              • Current and Expected Use of Abuse-Deterrent Opioid Analgesics for Cancer Pain
            • Impact of Payer Policy on Prescribing
              • Key Findings
              • Impact of Reimbursement Restrictions on Access to Branded Cancer Pain Therapies for Commercially Insured Patients
              • Impact of Reimbursement Restrictions on Access to Branded Cancer Pain Therapies for Medicare-Insured Patients
              • Key Levers and Constraints on Select Cancer Pain Therapies
              • Oncologist-Reported Most Common Commercial Reimbursement Restrictions on Branded Cancer Pain Therapies
              • Pain Specialist-Reported Most Common Commercial Reimbursement Restrictions on Branded Cancer Pain Therapies
          • Market Access Landscape for Emerging Therapies
            • Likely Impact of Emerging Therapies
              • Likely Impact of Emerging Therapies for Cancer Pain
              • Physician Likeliness to Try New Abuse-Deterrent Opioid Analgesics
              • Physician Prescribing of Abuse-Deterrent Opioid Analgesics for Cancer Pain: Current and Future Trends
              • Payers' Anticipated Cost-Containment Measures for New Abuse-Deterrent Opioid Analgesics
              • Impact of Tier Placement on Physicians' Anticipated Use of Cebranopadol for Cancer Pain
              • Payers' Anticipated Cost-Containment Measures for Cebranopadol
            • Potential Placement of Emerging Therapy at Various Prices
              • Potential Reimbursement of Emerging Therapies for Cancer Pain
              • Formulary Placement of New Abuse-Deterrent Morphine at Various Price Points
              • Formulary Placement of New Abuse-Deterrent Oxycodone at Various Price Points
              • Formulary Placement of New Abuse-Deterrent Hydromorphone at Various Price Points
              • Formulary Placement of New Abuse-Deterrent Hydrocodone at Various Price Points
              • Formulary Placement of New Abuse-Deterrent Oxymorphone at Various Price Points
              • Formulary Placement of Cebranopadol at Various Price Points
            • Prescriber and MCO Opinion on Remaining Unmet Need
              • Key Findings
              • Physician Opinion on Key Areas of New Drug Development for Cancer Pain
              • Payer Opinion on Future Reimbursement Trends for Cancer Pain
              • Payer Opinion on Level of Need for New Analgesics for Specific Cancer Pain Subpopulations
              • Payer Recommendations for R&D Spending on New Drugs for Cancer Pain
          • Appendix
            • Physician Survey
              • Drug Classes Used to Treat Moderate to Severe Cancer Pain
              • Insurance Coverage of Patients with Moderate to Severe Cancer Pain
              • Cancer Patients with Mild, Moderate, or Severe Cancer-Related Pain
              • Moderate to Severe Cancer Pain Patients Taking Prescription Analgesics
              • Subtypes of Pain in Patients with Moderate to Severe Cancer Pain
              • Drug Treatment for Specific Subtypes of Moderate to Severe Cancer Pain: Oncologists
              • Drug Treatment for Specific Subtypes of Moderate to Severe Cancer Pain: Pain Specialists
              • Healthcare Providers Involved in Initial Treatment Decisions for Moderate to Severe Cancer Pain
              • Healthcare Providers Involved in Treatment Decisions for Difficult-to-Treat Moderate to Severe Cancer Pain
              • Oncologist-Reported Pain Specialist Involvement in Treatment Decisions for Moderate to Severe Cancer Pain
              • Pain Specialist-Reported Involvement in Treatment Decisions for Moderate to Severe Cancer Pain
              • Oncologist-Reported Top Reasons for Moderate to Severe Cancer Pain Patients' Discontinuation of Particular Analgesics (Part 1)
              • Oncologist-Reported Top Reasons for Moderate to Severe Cancer Pain Patients' Discontinuation of Particular Analgesics (Part 2)
              • Pain Specialist-Reported Top Reasons for Moderate to Severe Cancer Pain Patients' Discontinuation of Particular Analgesics (Part 1)
              • Pain Specialist-Reported Top Reasons for Moderate to Severe Cancer Pain Patients' Discontinuation of Particular Analgesics (Part 2)
              • Moderate to Severe Cancer Pain Patients Who Cannot Take Opioid Analgesics
              • Physician-Preferred Therapies for Moderate to Severe Cancer Pain Patients Who Cannot Take Opioid Analgesics
              • Distribution of Moderate to Severe Cancer Pain Patients Taking One or More Analgesics
              • Opioid Switching Within First Six Months of Therapy Among Moderate to Severe Cancer Pain Patients
              • Reasons for Opioid Switching Within First Six Months of Therapy
              • Oncologist-Reported Most Common Commercial Reimbursement Restrictions on Branded Cancer Pain Therapies
              • Pain Specialist-Reported Most Common Commercial Reimbursement Restrictions on Branded Cancer Pain Therapies
              • Oncologist-Reported Most Common Medicare Reimbursement Restrictions on Branded Cancer Pain Therapies
              • Pain Specialist-Reported Most Common Medicare Reimbursement Restrictions on Branded Cancer Pain Therapies
              • Impact of Abuse-Deterrent Properties on Physician Willingness to Prescribe Long-Acting Hydrocodone for Cancer Pain
              • Prescribing of Hysingla ER and Zohydro ER for Moderate to Severe Cancer Pain
              • Clinical Experience with Hysingla ER and Zohydro ER for Moderate to Severe Cancer Pain
              • Reasons for Not Prescribing Hysingla ER or Zohydro ER for Moderate to Severe Cancer Pain
              • Prescribing of Abuse-Deterrent Opioid Analgesics for Moderate to Severe Cancer Pain over Past Year
              • Importance of Widespread Availability of Abuse-Deterrent Opioid Analgesics by 2019
              • Expected Prescribing of Abuse-Deterrent Opioid Analgesics for Moderate to Severe Cancer Pain in 2019
              • Physician Opinion on Abuse-Deterrent Opioid Analgesics for Moderate to Severe Cancer Pain
              • Impact of TIRF REMS Access Program on Physician Access to Rapid-Acting Fentanyl Formulations for Moderate to Severe Cancer Pain
              • Moderate to Severe Cancer Pain Patients with Suboptimal Response to Currently Available Analgesics
              • Reasons for Not Prescribing Cebranopadol for Cancer Pain Within First Two Years on the Market
              • Likely Prescribing of Cebranopadol for Cancer Pain
              • Likely Line of Therapy of Cebranopadol for Cancer Pain
              • Cebranopadol Profile Presented to Survey Participants
            • MCO Survey
              • Payer Requirements for P&T Committee Review of a New Analgesic
              • Tier Placement of Branded Analgesics on Largest Commercial Health Plan
              • Copayment for Branded Analgesics on Largest Commercial Health Plan
              • Coinsurance for Branded Analgesics on Largest Commercial Health Plan
              • Payer Cost-Containment Strategies for Branded Analgesics Used to Treat Cancer Pain
              • Step-Therapy Protocols for Branded Analgesics Used to Treat Cancer Pain
              • Coverage Status of Branded Analgesics on Largest Medicare Advantage Plan
              • Tier Placement of Branded Analgesics on Largest Medicare Advantage Plan
              • Copayment for Branded Analgesics on Largest Medicare Advantage Plan
              • Coinsurance for Branded Analgesics on Largest Medicare Advantage Plan
              • Overall Drug Spend on Cancer Pain Relative to Other Therapeutic Areas
              • Preferred Pharmacoeconomic Models for Examining Cost-Effectiveness of a New Analgesic for Moderate to Severe Pain
              • Payer Requirements for Abuse-Deterrent/Tamper-Resistant Properties for Short-Acting Opioid Analgesics
              • Effect of Abuse-Deterrent Opioid Analgesics on Overall Drug Spend for Cancer Pain
              • Importance of Official FDA Labeling on Payer Reimbursement Decisions for Abuse-Deterrent/Tamper-Resistant Opioid Analgesics
              • Payer Labeling Requirements for Reimbursement of Abuse-Deterrent Opioid Analgesics
              • Payer Preferences for TIRFs
              • Impact of New Generic TIRFs on Coverage of Branded TIRFs
              • Impact of Generic Pregabalin on Coverage of Lyrica and Gabapentin

        Author(s): Bethany A. Kiernan, PhD

        Bethany A. Kiernan, Ph.D., is a senior director in the central nervous system/ophthalmology disorders unit of Decision Resources Group. While at Decision Resources Group, Dr. Kiernan has covered the market dynamics of numerous indications, including schizophrenia, depression, migraine, multiple sclerosis, epilepsy, and other disorders.

        Dr. Kiernan’s previous experience includes eight years of scientific research conducted at Tufts University School of Medicine, Case Western Reserve University, and the College of the Holy Cross. Dr. Kiernan earned her Ph.D. degree from Case Western Reserve University.


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