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California closed drug formulary proposal puts spotlight on opioids

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Doctors who wish to repeatedly prescribe opioids to injured workers in California starting July 1 will have to subject the claim to a review process, according to an overview of the proposed workers compensation prescription drug formulary set to go into effect next summer. 

“Prescribers will not be able to do what they’ve always done,” said Dr. Robert Goldberg, San Francisco-based chief medical officer for pharmacy benefit management firm Healthesystems L.L.C., who led a webinar Wednesday hosted by the Western Occupational and Environmental Medical Association in San Francisco. “We need to reduce our reliance on opioids … we need to get away from sedative hypnotics.” 

In 2015, California lawmakers passed Assembly Bill 1124, which establishes an evidence-based closed drug formulary by July 1, 2017. Closed formularies limit approved medications for workers comp claims, and prior to the new law, California legislators had carefully examined closed formularies in Texas and Washington state. 

Meanwhile, experts have said that closed formularies can curb opioid use by controlling how much is prescribed and when. 

Dr. Goldberg’s presentation provided an in-depth look at the proposed system in California, which lists 257 drugs as preferred or nonpreferred based on evidence of whether the drugs work, and how, using the American College of Occupational and Environmental Medicine’s guidelines. Those that are nonpreferred will always need a prospective review, which Dr. Goldberg said could take up to five days. 

Dr. Goldberg, who helped develop the formulary, added that all opioids are on the nonpreferred list. However, three of them — Percocet, Vicodin and morphine — can be prescribed for four days within seven days of an injury, but no more without a review.

Three other nonpreferred drugs — one painkiller with opioid-like addiction side effects and two sedative muscle relaxers — can also be prescribed under those limitations. Any other muscle relaxers and opioids will require a review, he said. 

For pain relief, 97% of nonsteroidal anti-inflammatory drugs are on the preferred list, he said. 

Twenty-five percent of the drugs prescribed in California’s workers comp system are opioids, Dr. Goldberg said, and the upcoming formulary is a step in “prescribing away from opioids.”

“Perhaps we have a problem in California,” he said, adding that reliance on pain medications in workers comp has prevented better outcomes. “My hope is that there we will renew a focus on return to work.”