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Shift to opioid alternatives raises concerns


The use of opioids for pain management in workers compensation continues to decline, replaced by non-steroidal anti-inflammatory drugs, muscle relaxants and dermatological agents. And while the industry lauds the decline in opioid prescribing, the uptick in usage of the more-expensive alternatives is causing concern. 

According to recently released preliminary data from the Workers Compensation Research Institute, the payment share of opioids in 28 study states fell to 8% in the first quarter of 2020 from 21% in the first quarter of 2015. Meanwhile, the share of payments for dermatological drugs increased to 21% from 11% during the same time period, and the payment share of non-steroidal anti-inflammatory drugs rose to 19% from 17%.

In California, NSAIDs accounted for nearly 24% of total drug expenditures in 2020, compared with 14% in 2018, when the state’s drug formulary took effect, according to research from the California Workers Compensation Institute. 

Two high-priced drugs — fenoprofen and ketoprofen — which are exempt from prospective utilization review, accounted for more than a quarter of NSAID drug expenditures in the state in 2020, despite representing just 1% of NSAID prescriptions. 

“They’re older drugs … drugs that have been on the market since I was in medical school 30 years ago,” said Dr. Craig Ross, Bala Cynwyd, Pennsylvania-based regional medical director for Liberty Mutual Holding Co. Inc. “Why physicians are choosing them right now is a little baffling to me. I don’t know that there’s any great advantage to either of those over other NSAIDs.” 

The reason for the high price is equally baffling, Dr. Ross said. In California, the average amount paid for a prescription of fenoprofen calcium totaled $1,479 in 2020 — a 636% increase over the average charge in 2016, and the average amount paid for ketoprofen in 2020 was $1,097, up 11-fold from $99 in 2016, according to the CWCI. 

“In our book of business, we narrowed down that 70% of (fenoprofen) prescribing is coming from three physicians,” said Phil Walls, Tampa, Florida-based chief clinical officer for myMatrixx, an Express Scripts company. “Three generic companies we’ve identified are charging an average wholesale price per pill higher than the original brand drug Nalfon. All it takes is a few bad actors to totally disrupt the system and drive outrageous cost.” 

While Ryan Hamm, Dublin, Ohio-based clinical pharmacist for CorVel Corp., said the increased use of NSAIDs is not surprising given the push for physicians to find alternatives to opioids for pain management, he also questions the reasons behind the increased prescribing of fenoprofen and ketoprofen in California. 

“I don’t know why they’re picking (those) drugs over other ones,” Mr. Hamm said. “Speaking pharmacologically, there’s not that much difference between NSAIDs, just minor differences in how fast they work.”

Another major cost driver in workers compensation drug expenditures is private-label topicals, such as creams, gels and ointments, which are independently manufactured and not recommended based on evidence-based guidelines. These carry “a much higher price tag” than comparable products approved by the Official Disability Guidelines Workers’ Compensation Drug Formulary, also known as ODG, said Vennela Thumula, policy analyst for Cambridge, Massachusetts-based WCRI. 

Private-label topicals “present some inherent challenges,” said Silvia Sacalis, vice president of clinical services at Tampa, Florida-based Healthesystems LLC. “They’re not (U.S. Food and Drug Administration) approved, therefore there are no clinical studies that demonstrate safety and efficacy.” 

In addition, physician dispensing of private-label topicals bypasses typical pharmacy checks as they relate to drug and disease interactions, she said. 

“Because most of them are physician-dispensed, it means they’re not going through the proper channels. They’re skipping over a lot of checks and balances because the injured worker is not getting the medication from a pharmacy,” said Reema Hammoud, Southfield, Michigan-based assistant vice president of clinical pharmacy for Sedgwick Claims Management Services Inc. 

Ms. Hammoud noted that most private-label topicals are medications that are higher strengths of existing medications — many of which are low-cost, over-the-counter drugs. 

“If you think about it, if something was really that beneficial, the FDA would approve it, and it would be manufactured by pharmaceutical companies,” Ms. Hammoud said. 

One issue is that many physicians don’t know the cost of the drugs they’re dispensing, Mr. Hamm said. 

“Unless you tell them, most are probably not going to know what the drug costs are,” he said. “That’s why I think it’s so important to have that communication aspect and outreach; sometimes they really don’t know.” 

Formularies and utilization reviews are also effective ways to reduce the prescribing of expensive drugs or those that are not evidence-based, though there are limitations, Ms. Sacalis said. 

Another issue is that formularies don’t always account for fluctuating costs, and that’s “where things can go upside down,” she said. 

Even though some states such as California have robust formularies, “there’s always going to be loopholes,” Ms. Sacalis said.








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