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Putting the hurt on pain medications

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Tighter control of long-acting opioids is expected to change prescribing behaviors, but workers compensation claim payers should watch for an uptick in the use of other powerful narcotics.

The Work Loss Data Institute's Official Disability Guidelines, the foundation of closed drug formularies and treatment guidelines in Texas and Oklahoma, is reclassifying four long-acting opioids as nonformulary drugs, or “N” drugs, for first-line use.

As of Feb. 1, Duragesic, MS Contin, Embeda and Levo-Dromoran will be treated the same as OxyContin and other long-acting opioids that are already considered “N” drugs, which can't be prescribed to injured workers without preauthorization, Phil Denniston, president and CEO of the Encinitas, California-based Work Loss Data Institute, said in an email.

“Increasingly, the total body of evidence indicates that no long-acting opioid should be first-line for treatment of acute or chronic nonmalignant pain,” he said.

On the other hand, “Y” drugs such as ibuprofen and Percocet can be dispensed without preauthorization, but they may be subject to retrospective reviews.

Sources said physicians who currently prescribe the soon-to-be “N” drugs for injured workers will either have to prove medical necessity or find alternatives.

The Work Loss Data Institute announced the reclassification three months before the effective date because “we were sensitive to users in Texas and elsewhere,” Mr. Denniston said. “We want to ensure that new patients are not being put on these drugs,” as well as have enough time to wean existing patients off the drugs.

Sources compared the advance notice to Texas' closed drug formulary rollout, which affected new claims in September 2011 and legacy claims in September 2013.

A “legacy claim cleanup process” gives people time to revisit their drug regimen, said Mark Pew, senior vice president at PRIUM, a Duluth, Georgia-based medical management company.

“Do they really even need an opioid still?” Mr. Pew said. “Or maybe is it now time to rethink the possibility of a more active lifestyle, more conservative therapy or cognitive behavioral therapy — other things that are nonpharmacological in nature?”

Some injured workers might suffer withdrawal symptoms if they were to be “cut off cold turkey,” he said.

The notice also lessens chances of there being an influx of utilization reviews, as prescribing behavior is likely to change ahead of Feb. 1, Mr. Pew said.

Workers comp payers can help the change by starting a dialogue with physicians, sources said.

Some of Helios' payer customers have already reached out for help identifying patients taking these medications, said Tron Emptage, Columbus, Ohio-based chief clinical officer at the pharmacy benefit manager.

The hope is that this reclassification causes physicians to question whether opioids are medically necessary for injured workers, Mr. Pew said, but there will be cases where “Y”-status opioids are prescribed instead.

That said, opioids can be medically necessary for injured employees who, for example, are “going through post-op(erative) physical therapy, which can really be painful,” Mr. Pew said. “But there needs to be an exit strategy by the doctor. This is not a lifelong drug regimen.”

Prior to the reclassification, “physicians always had multiple alternatives to choose from in a given (drug) category,” Phil Walls, chief clinical and compliance officer at Tampa, Florida-based PBM Matrix Healthcare Services Inc., which does business as myMatrixx, said in an email.

Ultram ER will be the only remaining “Y” drug option “in the long-acting opioid category,” he said. Ultram ER, the brand name for extended release tramadol, is a Schedule IV controlled substance, meaning there's less abuse and addiction potential than Schedule II opioids such as Duragesic and MS Contin, Mr. Walls said.

Mr. Emptage said Helios will be watching short-acting “Y”-status opioids, such as Vicodin, “very carefully” to make sure there are no unintended consequences

“One of our biggest concerns” is that physicians will just “start managing their (long-term pain) patients only utilizing short-acting” drugs, Mr. Emptage said.

These reclassifications are garnering significant attention since “people look to (Official Disability Guidelines) as the groundbreaker on the formulary effort,” said Brian Allen, Westerville, Ohio-based vice president of government affairs at Helios.

The guide is used in Texas and Oklahoma, will soon be used in Tennessee and California has talked about using the guide as the basis for its impending formulary, sources said.

Mr. Allen said the guide “will have an influence on what happens in other states.”