Opioid Scripts Down, But CWCI Warns Against Replacing One Drug Problem with Another

Nancy Grover

Oakland, CA (WorkersCompensation.com) – Opioids previously comprised nearly one-third of the medications prescribed in California’s workers compensation system. Now they account for about 18 percent, according to researchers.

While that’s good news in the efforts to curb unnecessary prescribing of those drugs, stakeholders still need to be vigilant about the medications prescribed – both in terms of potential harm and the costs.

Study Findings

The California Workers’ Compensation Institute looked at data from 5.75 million prescriptions dispensed in the workers’ compensation system from January 2009 to June 2018. Their report says that anti-inflammatories, also called Non-steroidal Anti-Inflammatories, or NSAIDs, are prescribed more than opioids, while dermatologicals are now the highest cost drug group in terms of spending.

In terms of the drug categories prescribed in California the authors found:

  • NSAIDs were the most prescribed drugs in the first half of 2018, accounting for 31.7 percent.
  • Anticonvulsants comprised nearly 10 percent of the drugs prescribed and were third on the list, behind NSAIDs and opioids.
  • Musculoskeletal drugs (muscle relaxants) now account for just 7.3 percent of the drug share, while they had accounted for more than 10 percent of prescriptions in 2017. The researchers attribute the change to the new California drug formulary which does not exempt the drugs from utilization review.

Cost-wise, the rankings are different. In addition to the volume of prescriptions, other factors that influence amounts paid include allowable fees, average quantities and dosages dispensed, mode of delivery and the availability of generics. Opioids were third on the cost list, behind dermatologicals and anticonvulsants.


Dermatological drugs include higher priced creams, gels and patches used for pain management. The share of dermatologicals increased just slightly during the study period, from 5.0 percent in 2009 to 5.6 percent of all prescriptions in 2018. But their share of total drug spend rose from 10.1 percent to 17.6 percent. In 2017, they became the most costly drug group in the California workers’ compensation system, a trend that continued last year.

“The recent increases in the dermatologicals’ share of the prescription drug spend have coincided with a decrease in the prevalence of custom compounded topicals, which for several years had been an area of abuse and fraud in the system,” the report says. “This began to change in 2011…”

Legislation that tried to rein in the high cost of custom compounded drugs did not reduce the unit cost of compounds as much as had been hoped; however, it did help increase awareness, leading to a decrease in the total amount paid for them.

Some drug wholesalers who had sold those compound products “switched to marketing mass-produced, high-cost private label topicals, dispensed either through physician offices or mail order. As a result, over the past five years manufactured private-label topicals, which are identified by a single National Drug Code and usually contain one or more active ingredients commonly found in over-the-counter topical analgesics … have accounted for a growing share of the prescription dollars,” the researchers explained. “At the same time, other topical products that contain a prescription NSAID … have also contributed to the increases in dermatologicals’ share of the prescription payments.”

For example, the NSAID Diclofenac is available in brand and generic topicals, and some of the formulations and strengths are exempt from utilization review, “so they have become increasingly prevalent in workers’ compensation as physicians look for non-opioid alternatives to treat pain.”

The authors speculate that situation may change because of recent anti-fraud efforts targeting private label drugs. Also, recent research suggested some of these dermatologicals are no better at reducing chronic pain than topical treatments than have no medicine in them at all.

Continued Caution Urged

Efforts to curb unnecessary opioids should not result in simply replacing those drugs for others that may carry their own risks, the authors advise.

“Though opioid use is down, some drug groups that now account for a growing share of workers’ compensation prescriptions come with their own sets of issues, side effects, and potentially dangerous drug interactions,” the study says, “so care must be taken to avoid simply replacing one problem with another.”

Benzodiazepines, for example, are highly addictive and have been implicated in overdose deaths in recent studies. Originally prescribed as tranquilizers, these are found in multiple therapeutic drug groups, such as anticonvulsants and NSAIDs.

Recent research in the Journal of the American Medical Association revealed that general practitioners are increasingly prescribing these drugs for many conditions, including back and chronic pain, anxiety and insomnia.

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