Orlando, FL (WorkersCompenation.com) – Why is it that some of us need a higher dose of a medication to get the same effect as someone else? Why do side effects only impact certain people? Wouldn’t it be great if we knew ahead of time what drug at what dose would be optimal for each person?
Imagine the time and costs saved by getting an injured worker the precise medication needed, rather than going through the trial-and-error approach we use now. A simple, one-time blood test could dramatically reduce disability durations and expedite return-to-work times by knowing how each person metabolizes medications.
“I see a future where this could become the standard of care,” said Phil Walls, chief Clinical Officer for myMatrixx, an Express Scripts Company. “Imagine going to a physician today and for them to not take your temperature or blood pressure. What if we have a future where to not know your genetic makeup could be a potential liability.”
The technology for this world already exists. While in concept it may seem like a terrific idea, it’s not quite ready for prime time.
“The reason we’re talking about this today is because folks started asking questions,” Walls said. “They’ve heard from vendors about doing genetic testing. ‘What do they do?’ ‘Do they really help us?’ So we deiced to do this session.”
Walls moderated a panel of experts on DNA, Drugs and Doctors: How Genes Affect Your Response to Drugs, at the Workers Compensation Institute’s annual conference here.
Genetics play a key role in how a person metabolizes medications. Having this information could prevent adverse drug reactions – the fourth leading cause of death in the U.S. The costs associated with ADRs is around $136 billion annually.
“We are a drug taking society,’ Walls said. “We have an expectation there’s going to be a drug for everything.”
Identifying the most effective drug and dose for each person can prevent ADRs. The test for this is based on pharmacogenomics. Where pharmacogenetics deals with the role of genetic factors on drug effectiveness and ADRs, pharmacogenomics refers to the science that allows the prediction of drug response based on genetic factors. It can explain how a genetic variant can alter a person’s response to a medication or multiple drugs.
“I had my standard go-to medications. From time to time, one1 out of 10 patients would call me in horrible pain. I wondered why. I’d change the dose or the drug,” said Dan Hunt, DO, Corporate Medical Director for Accident Fund Holdings, Inc. “It really struck me that there are some people for whom some drugs don’t work too well.”
Hunt, who previously worked as a general surgeon, said he would assume the person was a malingerer. “I didn’t understand there might be a difference in how people metabolize the drugs; they don’t [metabolize them], or they do too quickly.”
A Pilot Study
Hunt and his team conducted a study beginning in 2017. For each patient prescribed an opioid, the company offered to pay for a one-time genetic test to help understand how each persons genetic makeup affects his reactions to the drugs. But the path to the project was bumpy.
“The first step was to talk to the Office of General Counsel, the Legal Department,” Hunt said. “He said, ‘so, you’re going to test people’s genetics? As an insurance carrier, we are going to test their genetics? What if someone loses their job [because of it it]”?
To overcome the issue of patients’ privacy, the company had to assure them that only their providers – not the insurer – would see the results. The carrier would know the test was done only if and when a bill showed up.
There was also the hurdle of getting physicians to buy into the idea of the tests and ordering them for their patients. “We can’t dictate anything to the providers, they decide care,” Hunt said.
The company decided to send a letter to each patient in California who was prescribed an opioid. They likened the genetic test to a culture a doctor would prescribe for an infection to determine the best antibiotic. The letter suggested injured workers ask their providers to do the test, at the carrier’s expense.
“It turned out that since we were not going to get the results, only the provider, there was very little feedback that [injured workers] were opposed,” Hunt said “It was more from the providers – they were slower to adopt.”
A total of 1,500 letters were sent and 800 injured workers tested. “Fentanyl utilization was significantly reduced,” Hunt reported. “And about 40 percent of injured workers tested had a change in opioids.”
While the results seemed impressive, Hunt pointed out that the tests coincided with California’s implementation of its drug formulary, which likely also had an impact.
“It’s got some challenges, but it’s something that is worthwhile,” Hunt said. “A challenge will be the salability and monitoring people afterward. The adoption has really been quite slow and required a lot of work.”
In addition to concerns about patient privacy and slow adoption among providers, additional challenges stand in the way of widespread testing. There are questions, for example, about who should have access to a patient’s genetic profile and how to prevent genetic discrimination in the workplace.
Among other hurdles noted by the speakers are:
- The reimbursement pathway of testing has not been established
- Ethical issues with genetic testing and data sharing
- The integration of pharmacogenomics, personalized medicine, and the payer and the regulatory environment
- Clinician are generally not educated about the issue
- The response to a medication may be a result of the interactions of multiple genes
Right now, pharmacogenomics is being used on a limited scale, especially for psychiatric medications and addiction treatment. “Eventually people will accept the use of genetic testing for their own wellbeing,” said Will Franken, corporate Risk Manager for Seaboard Corporation. “I think genetic testing will grow in time, especially when employees get more comfortable with it.”