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Medications such as Abilify and Actiq are being used off-label to treat injured workers, prompting the workers comp sector to focus on curbing inappropriate prescribing that may be pricey and dangerous.
Research shows that about one in five of all prescriptions are written for off-label use, or uses outside those approved by the U.S. Food and Drug Administration.
Experts say the practice has popped up in workers comp with drugs such as Abilify, an anti-psychotic that's FDA-approved as an add-on treatment for adults with depression, but inappropriately used as a lone treatment of injured workers' depression or anxiety.
“We're starting to see more Abilify being added to problematic claims, and Abilify really doesn't have a place in work comp,” said Brian Carpenter, Atlanta-based senior vice president of pharmacy product development and clinical management for Healthcare Solutions. “It's a very expensive medication.”
About $6.5 billion was spent on Abilify in the United States in 2013, according to the IMS Institute for Healthcare Informatics.
“Certainly because of the cost and the fact that ... we believe there are other drugs that are therapeutically effective to do what it does, we would certainly try to have a conversation with a physician” to not use the drug to treat an injured worker, said Rita Wilson, Delray Beach, Florida-based CEO of Tower MSA Partners L.L.C., a Medicare secondary payer compliance company.
The impact of off-label drugs is difficult to quantify in workers comp since it's not always clear why a medication is prescribed, said Brigette Nelson, Cave Creek, Arizona-based senior vice president of workers compensation clinical management at St. Louis-based pharmacy benefit manager Express Scripts Inc.
However, sources said off-label use in comp is seen primarily in pain management.
Opioids make up a large percentage of off-label prescriptions, said Michael Gavin, Duluth, Georgia-based president of medical cost management company PRIUM.
“It has serious implications for injured worker health because the FDA is signaling to the physician community that these drugs should be used in really limited circumstances, and yet we see our work comp payer community spending $1.5 billion a year on them,” Mr. Gavin said.
It's important for PBMs and third-party administrators to be familiar with medications commonly prescribed off-label so they can appropriately flag and monitor claims, sources said.
State rules also can come into play. For example, a recent update proposed for the California Medical Treatment Utilization Schedule could limit off-label use by requiring physicians to prove with a study or alternate guideline that that treatment contrary to the state's schedule is appropriate.
Off-label prescribing becomes a problem when physicians prescribe potentially dangerous and expensive drugs, such as “Actiq instead of Vicodin or Norco,” said David Cooper, director of orthopedic surgery at The Knee Center in Wilkes-Barre, Pennsylvania.
Actiq, which is FDA-approved for breakthrough, chronic cancer pain, is a drug that sources agree has no place in workers comp.
“We've seen (Actiq) used in workers compensation for nonspecific low back pain,” Mr. Gavin said. “That's incredibly damaging. That's a very powerful narcotic.” He said use of Actiq has declined in recent years as “we've gotten smarter as a payer community.”
One of the most important things a TPA can do is partner with the right doctors to avoid off-labeling from the onset, said Debbie Michel, Chicago-based president of TPA Helmsman Management Services L.L.C.
And in states that allow it, conducting utilization reviews is considered a best practice to decide whether off-label use is appropriate, experts said.