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California banks on benefit of closed drug formulary

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While the use of opioids for injured workers in California has dropped, experts say rolling out a closed formulary that uses evidence-based medical guidelines next year has strong potential to further reduce what still is considered “excessive” usage of the addictive painkillers.

According to a May analysis by the California Workers' Compensation Institute, opioid prescriptions and dollars spent peaked at nearly 32% in 2009 and have fallen steadily since then. In 2014, the latest data available, opioids accounted for 27.2% of prescriptions and 24.4% of spending, according to Oakland-based CWCI.

The decline coincided with greater scrutiny of such prescriptions through utilization reviews and independent medical reviews; limits by pharmacy benefit managers, medical provider networks and payers; and greater use of generic drugs, CWCI said. However, “opioid use is still excessive” and in situations not supported by scientific literature, according to the analysis.

While California Gov. Jerry Brown last October signed into law a bill that requires establishing a workers comp formulary by July 1, 2017, with the intent of further reducing the overutilization of opioids, experts say attitudes also need to change.

“We have a prescribing culture in our country where we want to try to eliminate pain, and we usually go right to an opioid, but there can be better alternatives with which to start treatment depending on the nature of the injury,” said Brian Allen, Westerville, Ohio-based vice president of government affairs for the workers comp division of Optum.

Closed formularies — in effect in the states such as Washington and Texas — help ensure the medication prescribed is medically necessary and other alternative therapies are considered before relying on an opioid, Mr. Allen said.

A drug formulary creates a “pause moment” for everyone involved in treating injured workers' pain to consider less dangerous options, said Mark Pew, senior vice president at Duluth, Georgia-based medical management company Prium. “Too often, treatment becomes automatic without consideration for individual needs, and, once a bad choice is made, it often cascades into a series of more bad choices that complicate matters.”

A drug formulary “will change prescribing behavior,” Mr. Pew said.

Closed formularies require proof that nonformulary medications — called N drugs — are medically necessary before they can be prescribed to injured workers. A limited list of covered medications — called Y drugs — don't require authorization.

Dr. Robert Hall, Westerville, Ohio-based medical director for the workers comp division of medical cost management firm Optum, said the formulary will require physicians to take a more holistic view of each injured worker and whether the prescribed medications are effective.

The goal is to “see what else can be done to get patients back their function and quality of life. Whether it's pharmacy-related or a treatment program that involves physical medicine, there are lots of different areas that can be focused on as we go through the formulary process,” Dr. Hall said.

Alex Swedlow, the CWCI's Oakland-based president and author of the May report, said, for example, that a minor back sprain that can resolve itself in six weeks is not a good candidate for opioid treatment.

Citing a 2014 CWCI study that a formulary could save California $124 million to $420 million a year, Mr. Swedlow said that shows “just how much excessive cost we have in our system.”

Joe Paduda, principal of Madison, Connecticut-based Health Strategy Associates L.L.C., said there is “no question” a formulary would improve the opioid usage situation in California, adding more needs to be done.

“The state needs a binding utilization review, or they won't have regulations to enforce it,” Mr. Paduda said.

Some in California are trying to eliminate the state's utilization review and that could lead to care that is inappropriate according to medical guidelines being prescribed, he said.

“The California Applicants' Attorneys Association and other self-styled "workers' advocates' are calling for drastic changes to the current utilization review process that would return to the days of far too much lousy care, far too many opioid prescriptions, and far too many unnecessary surgeries,” he said.

Dr. Hall said California's formulary will need to be balanced and based on best practices.

This can help prescribers who may not realize that a drug they are prescribing is an “outlier' in best practices, he said.

A closed formulary “made a significant difference in Texas,” Mr. Allen said.