Pictured above is an old fashioned epipen. It’s used to dispense a cheap drug when needed. The device is pictured because this week brought a new article on a new rectangular, “talking’ epi dispensing evice known as the Auvi-Q. In my opinion, epi devices are illuminating examples of why health care costs are soaring needlessly. A NYT article on the talking, rectangular device also seems to me to illustrate the growing problem of insipid reporting. Why, one would think, do most people really need to pay $ 240 for a pair of talking shots that will be obsolete if not used in 18 months? And why does our market seem to not include much less expensive devices?
Facts. In tv shows involving emergency rooms, doctors frequently ask for injection of “.2 of epi.” That’s epinephrine, more commonly known as adrenaline. It raises heart rate and blood pressure. It’s most frequently used for the treatment of acute allergic reactions to avoid or treat the onset of anaphylactic shock. Epi works by relaxing the muscles in the airways and tightening the blood vessels.
Why do I care about this topic? I learned the lessons of epi when my middle-aged body suddenly reacted strongly and adversely (anaphylactic shock) to bee stings that were not a problem when I was a kid. How bad? I passed out on a commuter train when I tried to stand up and exit the train a few minutes after I was stung. Thanks to decades of swimming, I’m equipped with a strong heart and so did not die, but an estimated 40-100 people do die every year from stings. Thus, anaphylcatic shock is a big deal – a survey on frequency is here.
Since then, I carry an epipen in summer months in Chicago when bees and wasps are out. Is the pen larger than I’d like? Yes, half as long would be much more convenient. The current pen does not fit into a hip pocket. The new device apparently solves that problem and that’s a positive, but……
Is it hard to use an epipen: do we need a talking pen? No, it’s not hard to use an epipen. In fact, I’ve used an epipen after being stung. Twist off the end cap, put the nose of the pen on your mid-thigh and then push in the plunger to give yourself a shot. It takes only a few seconds. And Intelliject, creator of the new device, offers this simple graphic of how to use the new rectangular device. So, why do we need a talking device, and how many languages will it speak? Maybe the makers could include SIRI in the device and get the weather too, at even higher price?
The real problem, in my opinion? The pricing of epidevices. The new device is said to be priced at $240 for a pair of the devices, as reported by the NYT article. That’s nuts – adrenaline is hardly novel, and apparently is produced in bulk for little cost – alibaba shows here several suppliers of forms of apparently low cost adrenaline with no lack of supply. Most of the cost apparently lies in promotion, packaging, distribution and profit.
As of 2005, a summary of a medical article reported that: “In Dr. Simons’ survey, widespread availability of epinephrine autoinjectors for emergency self-treatment of anaphylaxis in the United States, Europe, Canada and Australia contrasted with limited availability in Asia, South America and Africa. Survey results revealed the cost for epinephrine autoinjectors were reported to range from U.S. $30 to U.S. $110, and could vary 2-fold within the same country. The purchase cost in some countries is equivalent to a month’s salary for many patients. ” A fall 2012 medical article apparently is focused on the price increases for epi devices, but the article is behind a pay wall. Also see this abstract from Dr. Simons on epi devices.
According to Allergy Notes:
“The wholesale price of 1 epinephrine autoinjector increased annually from $35.59 in 1986 to $87.92 in 2011 (147%). Among patients prescribed autoinjectors, only 40% of teens/adults and 60% of children less than 12 years of age had them refilled over a 6-year period. The retail price of the new “EpiPen 2-pak” that the patients often quote is more than $250 for each “pak”. In August 2012, the FDA approved Auvi-Q – the first-and-only epinephrine autoinjector with audio and visual cues that guide patients and caregivers step-by-step through the injection process. No information about the price of Auvi-Q is available at this time but it is not expected to cost significantly less than EpiPen.”
The price also is a big deal because epipens expire every so often – the time length is about 12 – 18 months, as described in this 2010 survey article on epinephrine use. The price increases and design “improvement” bring to mind incredibly Dina Rasor’s 1985 book on expensive Pentagon hammers and toilet seats, among others. That problem also continues today.
In the UK, ChemistDirect sells adrenaline injections for less than $10 for a 1 ml syringe. In Canada, less than $20. And if you want epi for a horse in the US, it’s also cheap – less than $ 20 per bottle. And, perhaps there’s something I do not “get,” but it appears CMS will only reimburse .062 cents as the cost for epi when given by a doctor under code JO171.
And, of course one wonders about other options. What about over the counter epi devices – why are these prescription devices ? And, if I can buy an automatic weapon without a prescription, what’s so dangerous about an epi dispensing device? What would the cost be if we turn loose generic makers of epi devices?
Back to the insipid article. The article does not ask any of the questions above. Instead, it’s a lovely puff piece about how is this all working out for the inventors of the new rectangular device, a pair of twins who suffer from food allegeries and so faced risks of anaphylcatic shock. I admire their desire to create a device in a more convenient size, but beyond that, it’s hard to see much to applaud. According to the NYT article, though, the device is now out on the market and they’ve pocketed a lucrative licensing deal for wrapping some plastic and a needle around a life saving drug:
“This week, the brothers’invention —a slimmer device shaped like a smartphone —hit pharmacy shelves nationwide, the culmination of a single-minded quest that began15 years ago and ended in a $230 million licensing deal with the French pharmaceutical giant Sanofi.”
Concluding thoughts? I love science and innovation, and I’m all for providing incentives and payoffs to scientists who devise new “drugs” or genomic therapies. But it seems to me a shame to see products like this on the market, and destined to raise health insurance premiums when insurers pay for these products that involve low science but big, artificial barriers to entry into the market. Razor blades come to mind. So, I can’t just can see why the NYT would applaud this device when too many cannot afford to pay a $ 240 per month premium for even basic health insurance, much less the price of this device that will be obsolete in 18 months or so when the epi no longer is fresh.
It’s also too bad so many writers appear to do little more than accept spin created for media, as opposed to asking real questions and seeking out facts, and questioning the spin. Here, one might note that Sanofi this past week issued YouTube promotions and an Auvi-q press release on January 28, 2013, which follows more media releases last August . Meanwhile, the web site of the creators of the new device also includes promotional information. And the same author also wrote last fall on epinephrine and epipens, but focused on Mylan’s product offering.
Maybe more facts would change my opinion. Maybe costs to produce adrenaline are skyrocketing due to a Chinese cartel similar to the rare earths cartel, but it’s sure hard to imagine a cartel on this substance. And I cannot find any evidence of large price increases for making adrenaline. It’s also possible the the devices produce only a 10-15% profit if enough costs are allocated by creative bean counters to create Pentagon-like accounting. And offshore licensing fee also could help to create costs and move profits into tax havens. In sum, I’m dubious that this product really adds anything useful except a new shape for a shot dispenser, which is hardly rocket science. All we need is compact device that works reliably at a modest price. But the market seems to lack such a device, and instead we see prices rising dramatically for current epi devices, putting them out of reach for many and raising overall costs for no apparent good reason.