by Dennis M. Sponer, CEO, ScripNet
It may not be politically correct to focus our attention on the cost of opioid utilization when there is a clear and present danger to many workers’ compensation claimants who are prescribed and use opioids for long-term musculoskeletal pain. But in the end, the legal and administrative controls that can be utilized to guard against opioid abuse, misuse, dependence and addiction, are the same ones that will control the rising cost of opioids in workers’ compensation. So, with great care not to deny patients opioid pain medication, if, and when it is appropriate to help them with short-term pain, let’s look more closely at the uses and abuses of opioids in the workers’ compensation system and steps that we can take to manage this problem more effectively.
NCCI, WCRI, and CWCI have reported extensively on the rising utilization and cost of opioids in workers’ compensation, so there is no need to repeat that here. But it is important to understand who and what is stimulating the expanded use of opioids. In the late 1990’s many states passed laws or relaxed regulations on the type, quantity and/or frequency of opioids that physicians could prescribe. Although the FDA has only approved opioids (fentanyl specifically) for cancer-related pain, the FDA does not restrict physicians from writing off-label opioid prescriptions for non-cancer pain. Only the manufacturers are restricted from off-label marketing of opioids. With exceptions, a decade of relaxed state and federal oversight has opened the door for manufacturers, physicians and patients to overuse and potentially abuse opioids in workers’ compensation. A recent study by CWCI found that around 3% of physicians in California were responsible for more than 65% of Schedule II workers’ compensation payments, and over half were used to treat minor back injuries. In recent years, drug manufacturers and intermediaries have greatly expanded programs that enable physicians to dispense opioids from their offices, at higher prices than the local pharmacy and a contribution to their bottom line.
These issues have received national media attention and select state legislatures, regulators and the Federal Government have taken steps to control the growth of opioids. The State of Washington, under the leadership of Dr. Gary Franklin at the Department of Labor and Industries, first published opioid dosing guidelines in 2006, and despite drug manufacturer lawsuits and political pressure, Washington State passed legislation in 2010 that tightened standards on physicians who prescribe opioids for non-cancer pain. Those standards included treatment plans, a discussion of opioid risks with the patient, a written agreement with the patient that outlines how the drugs should be taken, and a review of the treatment plan and the patient’s progress at least every six months. ScripNet had an extended discussion with Dr. Franklin about his efforts, which will appear in next month’s eNewsletter.
And we previously reported, the State of Texas’ Closed Formulary based on Official Disability Guidelines (ODG) www.disabilitydurations.com/treatment.htm, restricts “N” class drugs without a review for medical necessity. And the California State Compensation Insurance Fund (SCIF) requires doctors in its network to agree not to prescribe opioids lasting longer than 60 days without prior approval. And the White House recently launched a program (Epidemic: Responding to America’s Prescription Drug Abuse Crisis) supporting state-based prescription drug education, monitoring and enforcement.
These are important steps and we need to encourage all states to enact such legislation and regulatory oversight, but carriers and PBMs also have a critical role to play in the effective management of opioids in workers’ compensation. This role should include proactive education, monitoring and adjudication of opioid prescriptions. ScripNet develops customized formularies with each of its clients, supported by clinical analysis and management, to determine which and how opioid prescriptions are to be filled. Opioids are then controlled at the point of sale for each client’s claimants, through the ScripNet Pharmacy Network. Physicians, pharmacists and adjusters must all be aware of the warning signs of opioid abuse, including doctor shopping, filling prescriptions from multiple pharmacies and multiple occasions of lost or stolen prescriptions, among others. ScripNet’s drug utilization reviews (DUR) will catch much of this behavior on a concurrent or retrospective basis, but all parties involved in the process must be aware and alert to possible abuse and act accordingly. Opioid abuse is a national problem that must be managed at the local level. We are interested in your thoughts about these and other measures that you think are appropriate to manage the cost and risk to patients in the use of opioids in workers’ compensation.