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Sharp drop in opioid prescriptions raises questions over other drugs


Opioid prescribing in workers compensation nosedived to an all-time low last year, a new report finds, but experts say there are concerns with other drugs being used for pain management. 

AmTrust Financial Services Inc. reported in October that only 15.2% of its workers compensation claims for 2021 involved an opioid prescription, down from 60% in 2017 and 25% in 2018. The data represents a reduction of 75% in prescriptions containing an opioid over four years, the insurer said. 

The numbers are in line with other reports. 

Enlyte Group LLC subsidiary Mitchell International Inc. reported in July that in 2021 30.3% of injured workers had opioid prescriptions.

Workers comp opioid spending has declined more than 62% since 2016, according to data collected in 2021 by Maggie Valley, North Carolina-based consulting company CompPharma LLC. 

Concerns are emerging, however, that other drugs are moving in to replace opioids as a pain management go-to in comp. Foremost are nonsteroidal anti-inflammatory drugs; neurological drugs, such as gabapentin, which target nerve pain; topical creams; muscle relaxers; and anti-anxiety drugs in a class known as benzodiazepines, according to experts. 

The latter two are of particular concern, as they are considered sedatives similar to opioids, though not as potentially deadly, experts say.

“While opioids have decreased significantly, it’s kind of become a more diffused problem, and it’s now branched out into other controlled substances,” said Silvia Sacalis, a Tampa, Florida-based licensed pharmacist and vice president of clinical services for Healthesystems LLC. “These are other controlled substances that unfortunately have similar side effect profiles to opioids with the sedation and the impact on cognition, which is what keeps injured workers from returning to work.”

Just as there are guidelines for opioids, guidelines exist for drugs such as benzodiazepines and muscle relaxers, which limit such drugs to short-term use, said Nikki Wilson, Omaha, Nebraska-based senior director of clinical services for Mitchell Pharmacy Solutions, an Enlyte company. 

“There are a lot of caveats for use, as both of them can be associated with dizziness and increased levels of nervous system depression,” she said. “And official disability guidelines support use of muscle relaxants only for specific conditions, and not beyond 21 days of use. It’s acute only. So, this is one of the things we monitor even more for limited use.” 

Benzodiazepines are “one drug class that is important to talk about,” said Dr. Marcos Iglesias, Hartford, Connecticut-based vice president and chief medical director of Travelers Cos. Inc. “That’s because benzodiazepines have been used a lot in the industry with pain management.” The industry, just as it has with opioids, has been trying to reduce benzodiazepine prescriptions, he said, adding that the figures are dropping. Muscle relaxers, however, are “flat” in terms of prescriptions, he said. 

“Every drug has some benefits and many of these drugs have risks, and some of them can be potentially quite severe,” Mr. Iglesias said. 

It’s one reason managed care in comp is moving away from drugs — when possible, said Melissa Burke, Southington, Connecticut-
based vice president and head of managed care and clinical for AmTrust Financial Services Inc.

“There are many other ways to treat pain than with opioids, and that’s where the industry has gone,” she said. “We’re very vigilant about ensuring (workers) have what they need. 

“If it’s post op, if they have an immediate need for a pain medication, they’re getting it; we are certainly not getting in the way of that. But we’re ensuring that step two and phase two of their injury recovery process is finding something that’s addressing their needs for pain management and addressing what’s causing the pain.” 

Sometimes, the answer is drugs other than opioids, she said. This involves “identifying whether it is truly an anti-inflammatory need, or do we need something for neuropathy? Do we need a non-pharmacologic treatment like acupuncture therapy? Do they just need cognitive behavior therapy to address what’s internally driving them to focus on their pain?” she said.

Doctors are also getting better at looking at alternatives and proceeding with caution, said Dr. Adam Seidner, Hartford, Connecticut-based chief medical officer for Hartford Financial Services Group Inc.

“The doctors are making sure that they’re doing a proper assessment and that they have the proper management and that they feel comfortable taking care of these patients, both in the acute and chronic pain situations,” he said. “The proper management of acute pain is … important because if it’s not done correctly, it can lead to long-term, chronic pain.” 

And while opioids have gone down “drastically” in comp, it doesn’t mean the industry’s work is done, said Joe Paduda, Skaneateles, New York-based president of CompPharma LLC. 

“While the actual prescription reporting for workers compensation claimants, for drugs paid for by workers comp, has gone down, it does not mean that all those patients who were taking opioids that were paid for by workers comp are not still taking opioids.” 

There are reasons to suspect injured workers are tapping into group health policies, or paying cash for opioids, and still going to work, he said. 

Ms. Sacalis, who has spoken out against issues with “polypharmacy” among injured workers who may be on other medications unrelated to their work injury, warns “it’s now important to be more vigilant than ever” in managing prescriptions.