Is Cost the Primary Barrier to Use of Liposomal Bupivacaine for Postoperative Analgesia after Third Molar Extractions?

Abstract

The use of opioid analgesics for postoperative pain has played a large role in the current opioid epidemic. Third molar extraction is commonly the first surgical procedure that young patients experience and their first exposure to opioid analgesics. Current literature suggests that the use of liposomal bupivacaine (Exparel) may help limit the need for opioid analgesics in the postoperative period.1 The medication is delivered at the time of surgery and can keep the patient comfortable for up to 3 days following the procedure, at which point a majority of the post-surgical pain has decreased, and NSAIDs offer sufficient pain control. However, many insurance companies do not currently cover the expense of this medication, and a single-dose vial can cost approximately $1702. The cost of the liposomal bupivacaine could be a barrier to its application. This study aims to investigate if cost is the primary barrier to liposomal bupivacaine use and to determine where this fiscal threshold lies.A 13-question survey was given to patients 18 years or older at their consultation for third molar removal. Data, including demographics such as gender, level of education, household income, and willingness to pay out-of-pocket for a non-narcotic alternative for postoperative analgesia, were collected.The data collected were analyzed using Pearson's Chi-square analyses to see if any differences existed among the predictor variables using a significance value of P = .05. The data were further analyzed by selecting for the group that was not willing to pay for the medication and the group who had no financial impediment in obtaining the medication. Using Pearson's Chi-square analyses with a significance value of P = .05, the data were compared to see if differences existed between the same predictor variables selecting for the 2 groups.A total of 187 patients were surveyed. In total, 19.1% of the participants are willing to pay out-of-pocket for a non-opioid alternative for postoperative analgesia at its current market price; 40.5% of the participants are willing to pay between $25-$50; 23% of the participants are willing to pay below $25. Lastly, 17.4% of the participants are not interested in paying any amount for the non-opioid alternative.When comparing those not willing to pay any amount for an alternative to those willing to pay any amount for an alternative, there was no difference among gender, previous opioid use, and knowledge about opioids' addictive potential. However, there was a difference in race, education level, and income level. In addition, race and education level also correlated with income level; 82.6% of the participants are able or willing to pay for an alternative medication. The amount by which they are willing or able to pay correlates with their financial status; 19.1% of patients can currently afford the available liposomal bupivacaine at its current market price. The entirety of this group falls into a category of annual household income of greater than $100,000.This study suggests that the current cost of liposomal bupivacaine is the primary barrier to its use as an alternative to opioid analgesics for postoperative pain in third molar extractions. If the out-of-pocket cost for the medication can be reduced to below $25, then approximately 82% of the participants will be able to afford the medication, further limiting the use of and dispensing of opioid analgesics.