The Food and Drug Administration approved a powerful new opioid Friday for use in health care settings, rejecting criticism from some of its own advisors that it would inevitably be diverted to illicit use and cause more overdose deaths.
At the same time, FDA Commissioner Scott Gottlieb issued an unusual statement saying he would seek more authority for the agency to consider whether there are too many similar drugs on the market. That might allow the agency to turn down future applications for new opioid approvals if the drugs are not filling an unmet need.
"We need to address the question that I believe underlies the criticism raised in advance of this approval," Gottlieb wrote. "To what extent should we evaluate each opioid solely on its own merits, and to what extent should we also consider...the epidemic of opioid misuse and abuse that's gripping our nation?"
As the worst drug crisis in U.S. history has accelerated, agency critics and some public officials have clamored for that holistic approach to narcotic painkillers, instead of the FDA's practice of ruling on each opioid application on its own.
Gottlieb has pledged that the FDA would do more to balance efforts to curb the epidemic--which killed a record 49,000 users in 2017, according to preliminary data-- with the needs of people in need of strong pain relief. But Friday's statement is the first detailed indication of how the FDA might use its drug-review process to tackle the overall problem.
Gottlieb said he would bring a plan to the FDA's Opioid Policy Steering Committee and perhaps Congress. The guidelines would allow the agency to consider a narcotic's benefit to public health, its risk of being diverted for inappropriate use or abuse and its unique benefits to groups of people in pain before deciding to approve an opioid.
"In this way, [drug companies] would know up front where the opportunities are for developing new drugs that meet the FDA's standards for safety and effectiveness," he wrote.
The drug approved Friday is a tiny, 30-microgram pill form of sufentanil, a powerful, 34-year-old opioid commonly used after surgery and in emergency rooms. Each pill, placed under the tongue for quick absorption, would have the same impact as five milligrams of intravenous morphine. Each pill would come in a plastic applicator that looks like a syringe.
The drug is intended for use within health care settings and perhaps on the battlefield. It would not be available to retail consumers.
The manufacturer, a California company called AcelRx, will market the drug under the name Dsuvia at a wholesale price of $50 to $60 per dose. A spokeswoman said the company is not providing information on expected sales.
AcelRx aready has approval for 15- and 30-microgram versions of the drug in Europe.
An FDA advisory committee recommended approval of the new drug in a 10-3 vote on October 12. But Raeford Brown, a professor of anesthesiology and pediatrics at the University of Kentucky who chairs the committee, then took the rare step of publicly condemning that decision and urged the FDA to reject the drug. Brown missed the meeting because he was speaking at a medical conference that day.
Brown, Sen. Edward J. Markey (D-Mass.) and the advocacy group Public Citizen have predicted that Dsuvia will be diverted to illicit use and cause more opioid overdose deaths. In a news release issued before Friday's decision, Public Citizen contended that "if approved, Dsuvia will be abused and start killing people as soon as it hits the market."
The drug will not be sold in pharmacies. The FDA believes that controls on drugs inside medical facilities are tight and the greatest risk of diversion is among medical personnel themselves.
A 2016 survey conducted by the federal Substance Abuse and Mental Health Services Administration shows that narcotics are rarely stolen from a doctor's office, clinic, hospital or pharmacy. Fewer than 1 percent of people said they acquired opioids that way.
But hundreds of millions of doses of prescription painkillers have been diverted from the pharmaceutical supply chain to illegal users over the past 15 years. In many cases, illicit users obtain them from friends, relatives or rogue doctors and pharmacists, according to the survey.
One factor that weighed heavily in the Dsuvia decision is military interest in the drug, Gottlieb said in his statement. The military wants to explore whether the pill can be used as a battlefield painkiller that is less cumbersome than liquid analgesics. The Pentagon has spent millions of dollars helping to fund AcelRx's research, public documents show.
"The FDA has made it a high priority to make sure our soldiers have access to treatments that meet the unique needs of the battlefield, including when intravenous administration is not possible for the treatment of acute pain," Gottlieb wrote.
Pamela Palmer, an anesthesiologist, said she founded the company to reduce the number of deaths caused by opioid dosing errors in hospitals and ambulatory care centers. She said caregivers can make these mistakes as they calculate the amount of clear liquid painkillers such as morphine to administer intravenously.