Managing the Costliest Drugs in Workers' Compensation

Workers' compensation costs continue to increase largely due to the growing expense of providing medical care to injured workers. A recent National Council on Compensation Insurance (NCCI) report indicates that medical costs increased an average of 5% to 5.5% per year from 2004 to 2009. PMSI's 2010 Annual Drug Trend Report for workers' compensation reveals that average pharmacy spending per injured worker increased by 6.5% in 2009 and that the top 10 drugs used in workers' compensation claims make up over 45% of the total pharmacy outlays (Table 1).

Oxycodone is a controlled substance, or Schedule II opioid (narcotic) analgesic. All opioid analgesics act in a similar fashion to relieve pain and are useful in the management of moderate-to-severe pain due to trauma, surgery, nerve damage, etc. Opioids are classified according to the duration of their effects. Short-acting agents, such as generically available oxycodone immediate release, are useful in the management of acute or breakthrough pain, and long-acting agents, such as OxyContin, provide baseline pain control. Breakthrough pain may occur despite the presence of a long-acting analgesic. When treating chronic, severe pain, a combination of long-acting and short-acting analgesics is typically recommended to ensure pain is adequately controlled and functional status is improved.

When treating pain, extended-release opioid formulations, such as OxyContin, should be prescribed only for those injured workers who have developed tolerance to the effects of short-acting opioids; otherwise, serious complications, including respiratory arrest and death, may occur. Early use (less than six weeks since date of injury) of long-acting opioids, such as OxyContin, can indicate a poorly designed treatment protocol or signal a pre-existing condition that should be investigated further. Even when used appropriately, the initiation of long-acting opioids signals that the case is progressing in severity and is in danger of becoming a chronic case. Monitoring these injured workers is essential to helping control drug costs.

Lidoderm is a topical patch that contains the local anesthetic lidocaine. It is used to manage neuropathic (nerve) pain, which is pain caused by nerve injury and which does not typically respond to traditional analgesics. Lidoderm is usually used to treat neuropathic pain in chronically injured workers and can be used alone or in combination with other medications. Use in the acute phase of injury could indicate possible pre-existing conditions or inappropriate use of the drug and should be investigated. Since Lidoderm now ranks second in drug spending for workers' compensation claims, efforts to detect and eliminate over-utilization are needed to help control overall costs.

Opioids are commonly combined with non-opioids, especially acetaminophen (Tylenol), to boost their analgesic effect. When taken together, acetaminophen permits lower doses of opioids to be used. These combination drugs are commonly prescribed to treat acute pain associated with traumatic, industrial injuries. The oxycodone formulations are more potent Schedule II medications compared to the hydrocodone formulations, which are classified as Schedule III drugs. Both combination drugs can be used together with long-acting opioids to treat breakthrough pain.

Used frequently in workers' compensation, these combination agents are typically inexpensive since most are available as generics. Claims professionals should encourage the use of generic formulations whenever possible to help control drug costs. Injured workers taking combination opioids containing acetaminophen should be monitored due to the danger of liver damage and possible death with excessive use of these medications. Pharmacy benefit managers normally have systems in place to provide oversight and warn the prescriber of the possibility of acetaminophen toxicity in claimants taking excessive dosages of these medications. Claims professionals should check with pharmacy benefit managers for instances of prescribers' failure to reduce acetaminophen dosages. Additional follow-up should be arranged for these cases.

Pregabalin and Gabapentin are anticonvulsants. Anticonvulsant medications are commonly used to manage seizure disorders; however, they are also commonly used to manage pain caused by nerve injury. Typically, neuropathic pain is diagnosed in the chronic phase of injury and does not respond to traditional analgesics, so medications such as anticonvulsants can be useful when treating chronically injured workers.

Claims professionals should investigate use of these medications if prescribed early in the life of the claim to determine inappropriate use or, possibly, a pre-existing condition.

The Duragesic transdermal patch is a long-acting Schedule II opioid analgesic. Its unique dosing mechanism allows for administration of the potent opioid fentanyl via the skin. Slow release of the opioid occurs over several hours allowing this medication to provide a steady level of chronic-pain relief. As a result, Duragesic is indicated for baseline control of moderate to severe pain.

Like other long-acting opioids, fentanyl patches should be prescribed only to opioid-tolerant individuals for the treatment of chronic pain. Early use of this medication in the acute phase of injury may signal the need to initiate additional monitoring of the claimant to prevent unsafe use of this medication and to evaluate for a pre-existing condition.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat inflammation associated with industrial injuries. Despite the abundance of generic formulations in this class, the use of Celebrex, a branded NSAID, continues to rise in workers' compensation claims. Celebrex's unique property of having a lower risk of gastrointestinal ulcers sets it apart from the other NSAIDs and drives its use. Unfortunately, the true need for this agent is limited mostly to injured workers with a history of gastrointestinal ulcers and/or bleeding disorders, which is a risk that is most often seen in older claimants and not the young and healthy.

Since the cost of brand medications is typically more than 20% higher than generic medications, efforts to increase the use of generic medications will reduce overall drug costs. Claims professionals should be aware of this and should work with their pharmacy benefit managers to identify opportunities for conversion to generic NSAIDS.

Oral formulations of fentanyl citrate, such as Actiq, Fentora and Onsolis, are Schedule II, rapid-acting, opioid analgesics. These formulations are indicated for the treatment of breakthrough pain in patients with cancer who take long-acting opioids for chronic pain. The use of these formulations in workers' compensation is primarily off-label, or outside of their FDA-approved indication, and has resulted in unintended, adverse effects for injured workers. Concern regarding the risk of addiction with these fentanyl citrate formulations persists due to their rapid delivery of opioid to the brain.

In general, fentanyl citrate formulations, such as Actiq, Fentora and Onsolis, should not be part of a workers' compensation formulary. As such, claims professionals should use caution when making payment authorization decisions for these medications. It is recommended that peer-to-peer consultation with the prescribing physician be used to discern the rationale for prescribing these medications and to suggest reasonable alternatives for the prescriber's consideration.

The use of antidepressants, such as Cymbalta, has increased significantly in workers' compensation over the past several years as medical knowledge regarding the treatment of pain and its relation to depression has increased. Cymbalta's dual indication for the treatment of neuropathic pain and depression has made this medication, according to PMSI's Drug Trend Report, the 10th highest in spending within workers' compensation.

Claims professionals should be aware of the dual use for Cymbalta. Depression and chronic pain often exist together. Both require treatment for optimal patient outcomes. Since treatment with this agent is typically initiated during the chronic phase of injury, use of Cymbalta during the early weeks of the treatment for the industrial injury may signify inappropriate use of the drug or perhaps a pre-existing condition. This should trigger an investigation to ensure the medication is being used appropriately.

Since total drug spending in workers' compensation claims is significantly influenced by only a handful of medications, claims professionals can positively affect claims costs by proactively addressing the proper prescription and use of these drugs.

Maria Sciame, PharmD, CDE, RRT, is Executive Director of Clinical Services at PMSI. The PMSI Annual Drug Trends 2010 report is available at www.pmsionline.com.