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Anticonvulsants, a class of drugs originally intended and only federally approved to treat epilepsy, are increasingly commonplace in treating injured workers for pain, producing mixed reactions from workers compensation experts.
Despite their positioning as an alternative to opioids, stakeholders say anticonvulsant drugs are not without their own risks of abuse.
“There’s an awful lot of prescribing of Lyrica,” said Craig Prince, a West Chester, Pennsylvania-based clinical pharmacist for Coventry Workers’ Comp Services, whose pharmacy benefits management program now lists euphoria-producing anticonvulsants — Lyrica being one of them — as the number one drug spend in workers comp. “(Anticonvulsants) have tripled in use since about 2010.”
In California, anticonvulsants accounted for 9.7% of the workers compensation prescriptions in 2018 and an overall 136.6% rise in use since 2009 that researchers with the California Workers’ Compensation Institute, which culled the data, deemed was “likely associated with the continued decline in opioids,” according to a report released in February.
Such drugs are now number three in California for treating pain, after opioids and anti-inflammatory drugs, according to the Oakland-based institute.
The Ohio Bureau of Workers’ Compensation, which provides comp insurance for all state employers, reported data to Business Insurance showing that anticonvulsants are now second to opioids when treating pain, ahead of the third most-prevalent remedies in the system, which are anti-inflammatory drugs.
The emergence has much to do with the health industry’s overall step away from opioid prescribing, experts say.
“I do think that doctors are trying to do the right thing,” said Phil Walls, Tampa, Florida-based chief clinical officer for myMatrixx, an Express Scripts company. “It’s good to see the opioids go down, but it’s like a balloon — as one area gets smaller, another area will get larger. The concern is (anticonvulsants) can be misused … I would categorize that as a rising concern.”
“Doctors are prescribing fewer opioids because they are afraid to do so,” said Dr. Steven Feinberg, a pain expert and founder of the Palo Alto, California-based Feinberg Medical Group who also sits on the California Division of Workers’ Compensation Pharmacy and Therapeutics Committee. “But (anticonvulsants) are not benign drugs, and they can cause side effects. The pendulum is always swinging one way or another.”
Dr. Feinberg, the senior author of the American Chronic Pain Association Resource Guide to Chronic Pain, noted in a section covering anticonvulsants that “there have been scattered reports of misuse … for their intoxicating effects.”
Most anticonvulsant drugs found in the comp system include the generic gabapentin and the more expensive brand name Lyrica, according to several experts. Gabapentin — the most commonly prescribed — was approved by the U.S. Food and Drug Administration in 1993 to treat epilepsy and other nerve conditions.
“They found out (the anticonvulsant) did not work as well as other drugs (for epilepsy), but a side effect was that it worked for nerve pain,” said Dr. Terrence Welsh, Columbus, Ohio-based chief medical officer for the Ohio Bureau of Workers’ Compensation.
The drug then went “off label” for treating pain, meaning it did not have FDA approval for pain management, and health care providers increasingly began prescribing the drug for pain, he said. “Off label doesn’t have a negative connotation in this context,” Dr. Welsh said.
Anticonvulsants such as gabapentin and Lyrica help stabilize interactions between nerves and the brain, he said.
“When someone has a damaged nerve, they also have unstable properties,” meaning pain from nerve damage stemming from an injury such as a pinched nerve in the neck or spine can be alleviated by calming the “electricity” between nerves and the brain, he said.
But a side effect to such drugs could be “relaxation, a euphoric effect … an altered sensation,” not unlike drugs that are often abused, said Mr. Walls.
Sounding the alarm in February was Cordant Health Solutions, a Denver-based company that provides drug monitoring for chronic pain patients, when it revealed data that showed how increasingly drug tests for gabapentin use are finding both the drug and unprescribed opioids in the urine of injured workers.
The company’s concerns are centered on the “polydrug pattern” found in gabapentin use: the drugs, which work to relax nerves, can produce a high alone and even more so with opioid use, leading researchers to see gabapentin as the next drug of abuse, according to Cordant. The company provided data to Business Insurance that found that of 430 workers comp patients prescribed gabapentin, 14.4% also had opioids in their system.
“We are seeing this increase in the prescribing of gabapentin, (and) when we talk to providers, they think we are nuts — what’s the big deal?” said Michele Settel, Tampa-based senior vice president and general manager for workers compensation at Cordant. “There are dangerous side effects at higher dosages.”
“As far as being the drug that would cause physical dependency, there is no question that would be the case, as with any drug like that,” said Richard Stripp, New York-based chief scientific and technical officer at Cordant. “Anything that affects dopamine can be addictive.”
Anticonvulsants are not considered as dangerous as opioids, but “the tide is turning, and people don’t think it’s as safe and benign as they were once considered,” Mr. Prince said.
The prescribing of medications deemed to be pain treatment alternatives to opioids has significantly risen in California.