Topical creams are becoming part of the mix of pain treatment options as doctors look for alternatives to addictive opioids.

However, the costs of such creams, particularly when doctors dispense compound versions, is an area of concern for employers and workers compensation stakeholders seeking effective, affordable pain treatments for injured workers, experts say.

“We clearly know — outside of workers compensation, as well as in workers compensation — we need to support reducing opioids,” said Dr. Nina McIlree, vice president of medical management at Zurich North America in Schaumburg, Illinois. “That is a treatment that has become truly, clearly detrimental not just to that injured worker’s recovery and safety but also to society. And so the efforts such as topicals is something that we’re far more interested in discussing, supporting and understanding how to use them safely.”

Topical treatments are typically used for joint pain in body parts such as the knee, elbow or shoulder, said Dr. Teresa Bartlett, Troy, Michigan-based vice president of medical quality for Sedgwick Claims Management Services Inc.

Topical creams are particularly useful for patients who are unable to take pills due to medical issues such as allergies to dyes used on pills or an inability to swallow pills, said Ben Roberts, vice president of compliance at Wayne, Pennsylvania-based managed care services company Genex Services L.L.C. They have also been used as a way to minimize pain before beginning a physical therapy session and are usually introduced after acetaminophens such as Tylenol or nonsteroidal medications like ibuprofen, respectively, said Dr. McIlree.

As employers work with workers compensation insurers and health care providers, they need to keep the costs of these creams, their overall effectiveness and proper usage in mind, experts say.

Over-the-counter creams like Bengay and Icy Hot cost less than $10, but their prescription compound counterparts can range from $1,000 to $5,000 depending on how much insurers are willing to foot the bill, said Dr. Bartlett.

While the range of topical creams can vary greatly in price, their effectiveness remains up for debate, experts say. Patients who used topical creams to treat pain reduced their opioid use and other concurrent medications over time, according to a 2018 study published in the medical journal Postgraduate Medicine.

But a 2010 analysis published in the Journal of Pain Research found that studies examining the efficacy of topical pain relief creams had small sample sizes and control groups and that there had not been a systematic review of every drug class, making it difficult to assess how well such creams work. The 2010 analysis also pointed out that examinations of adherence, meaning how well the patient takes the medication as directed, among people with chronic diseases present conflicting results.

There are prescription-strength creams similar to over-the-counter creams that are effective, but Dr. Bartlett said that some expensive topical creams contain other drugs like antidepressants or muscle relaxers that cannot be absorbed through the skin, which “therefore is wasteful and not a good choice.”

“Usually, if you put those through a utilization review, they’re not approved, because there’s no evidence to substantiate that they work because they can’t be absorbed,” Dr. Bartlett said. “A lot of times, those things aren’t coming from a pharmacy or a (pharmacy benefits manager). They’re being billed out of a doctor’s office or a compounding pharmacy not running through your PBM.”

In addition to assessing whether a topical is good for employees, Shital Mars, CEO of Progressive Care, a North Miami, Florida-based personalized health care service company and pharmacy, recommended making sure employees are applying the correct amount of prescribed medication to optimize effectiveness.

Dr. Bartlett advises employers to verify whether the patient is actually taking the medicine and that the medication is appropriate to treat that patient’s specific injuries.

“They’re not (always) tailored to individual need — they’re just an expensive compound claim,” Dr. Bartlett said. “And sometimes doctors may be getting some money back for prescribing them.”

Some states have implemented formularies to restrict compound medications, said Mr. Roberts. With topical creams, employers will need to be aware of changing regulations regarding compound medications and work closely with their pharmacy benefit managers and utilization review vendors to learn whether they’re using compound medications and ensure that these medications are medically necessary, he said, adding that compound drugs are not approved by the U.S. Food and Drug Administration.

As regulations on compound medications change, payers and employers need to watch the caps on the percentage of the average wholesale price of compound drugs to make sure the costs are reasonable, Mr. Roberts said. Such caps are meant to reduce the financial incentive for prescribing pricier medications.

Employers must make sure that they maintain a close relationship with their insurers, claim professionals, and injured workers to improve their health as soon as possible, Dr. McIlree said.

“Patient safety, efficacy of treatment and cost-effectiveness: those three things should be balanced with effectiveness and patient safety being at the forefront,” she said. “You always want to look to the most cost-effective treatment as the patient goes through the recovery process.”