Drug formularies remain a crucial tool in combating the opioid epidemic in the workers compensation industry despite obstacles states face in their efforts to implement them, according to experts.

Formularies can be the opportunity for a “pause moment” that allows prescribers to take a step back and determine if an individual requires opioids, said Mark Pew, senior vice president at Prium, a division of Genex Services L.L.C., a Duluth, Georgia-based medical cost management firm.

“Unfortunately, what happened starting in the mid-1990s is that there became a Pavlovian response that if someone is in pain we have to prescribe them opioids because we want to get ahead of the pain … and it became the status quo,” Mr. Pew said.

“What drug formularies have done is created regulatory and administrative obstacles to writing a script without any kind of consequence or thought. It’s also heightened the sensitivity and expanded the conversation in society, in workers compensation, with injured workers, with doctors and with nurses, that we need to think about pain and how we manage pain differently,” he said.

A drug formulary’s role in workers compensation reform is to set the standard for medical care and treatment in relation to medications.

“If you think about it this way, whoever our group health care provider is has a formulary in place that preliminarily says what medications you have access to without requiring additional review or authorization,” said Don Lipsy, Memphis, Tennesseebased managed care specialty products manager with Sedgwick Claims Management Services Inc.

“This is a version that each state has put together and codified, and typically isn’t static. It evolves over time either based upon guidelines or pharmacy and therapy committees or whatever mechanism each state chooses that dictates ‘here are the medications that are acceptable for treatment of injured worker conditions.’ If you need something that is not within that drug list or formulary, it requires preauthorization, depending on which state, or requires another form of heightened review,” Mr. Lipsy said.

State efforts to adopt drug formularies for the workers compensation industry have met various obstacles.

In 2017, Louisiana and Pennsylvania attempted to pass formularies that ultimately did not move forward.

In Louisiana, the formulary was not adopted in early June, and the state Senate did not put the issue on its calendar for consideration before the end of the legislative session.

In Pennsylvania, the House of Representatives’ Labor and Industry Committee voted on June 13 with revisions passing by 14-12, and it was referred to the Rules Committee on June 21, 2017.

“I think there has been a significant amount of misinformation about drug formularies,” said Joe Paduda, Skaneateles, New York-based president of CompPharma L.L.C.

“There has been a lack of understanding that formularies enhance patient safety and promote return-to-work and healing,” Mr. Paduda said. “Instead, some people in the industry purport that formularies are a way to prevent patients from getting the treatment they need. I think there has also been fear on the parts of some people in the community who are injured-worker advocates that this would somehow be harmful to patients.”

Along with these concerns, prescribers and dispensers have said careful thought must be given to the process of implementing a formulary and how this effort might affect patients, Mr. Paduda said.

Patients who are currently taking medications that would require prior authorization post-drug formulary need adequate time for the process to be implemented, he said.

Other states have not given up on the possibility of implementing drug formularies despite the obstacles.

The New York State Workers Compensation Board started seeking public comments on a proposed drug formulary in December with a Feb. 26 deadline. The legislation to implement this formulary was signed into law in April 2017 and will become effective July 1 of this year.

After a previous delay, the California Division of Workers Compensation announced in December that it would move forward with plans to adopt an evidence-based drug formulary for medical providers treating injured workers, which started Jan. 1.

Massachusetts and Indiana are also considering drug formularies.

In Indiana, S.B. 369, authored by state Sen. Randall Head, R-Logansport, was introduced in January and would require a drug formulary for employees who file notice of injury or occupational disease. S.B. 369 had its first reading in the Indiana Senate on Jan. 4, and was referred to the Committee on Pensions and Labor.

In Massachusetts, H.B. 4033, sponsored by Gov. Charlie Baker, would require the Department of Industrial Accidents to establish a formulary. The bill is before the House Committee on Mental Health, Substance Use and Recovery.

Texas adopted a drug formulary in 2011 and has been cited by many in the workers comp industry as a success story and a possible model for other states.

“Texas has had a formulary for a while, and it’s one that’s had some ability to educate the providers ... they saw significant reduction in the number of inappropriate medications, they saw reductions in their opioid medications ... it clearly does have a positive impact,” said Dr. Dan Hunt, Lansing, Michigan-based medical director at AF Group.

Opponents of drug formularies question whether they benefit injured workers, but Dr. Hunt noted they can have positive effects and these results can be used to measure future impact.

“It’s hard to prove, but I would argue that you could use the impact on opioids as sort of a surrogate, but that’s just one part of a formulary,” he said.