While there’s good progress on opioids, we have to stay attentive to what progress really means. It is saving careers and lives of injured workers. We have learned that opioid prescribing for injured workers involves a subtle balance between treatment gain, alternatives to opioids, and risks to the patient. A recent report from the Workers’ Compensation Research Institute (WCRI), a highly respected think tank, appears to overlook this by focusing only on cost of the drugs. If WCRI is overlooking, a lot of other people probably are as well.
WCRI issued an analysis in February of the potential outcomes Louisiana were to use, for its injured state employees, a drug formulary introduced in Texas about seven years ago. The report was limited. WCRI wrote that it did not “study the impact of a drug formulary on patient outcomes and overall medical costs or estimate the potential cost savings for all workers’ compensation claims in the state.”
Drug formularies are lists of approved drugs. In workers’ comp, they serve three purposes. The lesser two of the three are, first, to reduce the use of brand vs. less expensive but equally effective generic drugs, and, second, to rule out drugs for unrelated medical conditions. But the most urgent role, given today’s crisis, is to control the use of opioids.
WCRI reported that about 40% of those injured Louisiana state employees who received a prescription for a work injury had received at least one drug the Texas formulary would have disallowed. About one fifth of all prescriptions would have been disallowed. It estimated that the state government could save up to about 30% on its drug expenses. The cost reduction appears mainly due to elimination of long-acting opioids.
There is no analysis of how the formulary would have impacted patient safety, might have altered care, or affected claims outcomes.
Reputable organizations say that formularies are a means to protect the welfare of patients. The International Association of Industrial Accident Boards and Commissions (IAIABC) said that “Several states have used a workers’ compensation formulary as one tool to successfully reduce the use of potentially harmful prescription drugs and decrease prescription drug costs.”
The American College of Occupational and Environmental Medicine said state regulators need to measure opioid utilization and cost “as well as selected outcome quality metrics such as total claim cost, disability duration, patient satisfaction and compliance, and the rate of adverse effects resulting from treatment delays.”
Let’s grant that Louisiana state officials may have told WCRI they were only interested in drug costs. Why would WCRI agree to perform this study?
Part of my discomfort arises from its use of the Texas formulary as a model. When introduced, Texas gained attention and deserved approbation as it was one of the first serious initiatives to address opioid misuse. In retrospect, the state’s approach was not ideal.
That formulary tended to reduce the prescribing of opioids to a simple binary prescribing decision: Yes or no. That’s it. Again, practice and research has shown that opioid use involves a subtle balancing of options for treatment in light of life threatening risks. For a small share of injured workers, opioid use makes sense. It is by no means clear if prescribers get this balance correctly. The Texas formulary does not provide a good template for other states.
Some time ago I asked Texas regulators involved with its formulary what they learned about the consequences of disapproving the use of opioids. They said in effect that they had nothing to report because they had not tracked tapering off practices, other treatment and claims outcomes. They noted that there had been very few appeals from prescribing doctors to disallowances. They construed the relative absence of appeals as implicit agreement by doctors.
But absence of appeals could have raised a red flag. Disallowances may have given prescribers an excuse for ridding themselves of difficult patients even if opioids were in fact appropriate. What happened to these patients? They presumably remained on workers’ compensation. Did they switch doctors? Did they take to using illicit drugs? Was there an increase in drug overdoses and deaths? The insurer’s role goes well beyond cutting off opioids.
In California, the Workers’ Compensation Insurance Rating Bureau just released a study of opioid treatment and tapering with insights that reveal a thoughtful approach. It focused on chronic and high opioid usage. It asked: What happened with workers who were weaned off opioids? It found that, “No clear patterns of non-drug treatments (e.g., physical medicine) for weaning off of opioids were evident, although the weaning process typically involved a gradual decrease in opioid prescribing combined with a mix of alternative non-drug treatments and non-narcotic drugs.”
Opioid usage in workers’ comp has been declining since about 2012. Yet there remain too many injured workers on opioids, and weaning is a dangerous process. I have estimated before that between 2000 and 2010, at least 2,000 people died from use of opioids while on workers’ comp disability. Formularies are here to save lives more than to save money.
ABOUT THE AUTHOR
Peter Rousmaniere is widely known throughout the workers’ compensation industry, both for his writing and consulting experience. Based in the picture perfect New England town of Woodstock, VT, he is a regular on the conference circuit, and is deeply in tune with trends and developments within the industry. His passion is writing and presenting on issues largely related to immigration, and he maintains a blog on the subject at www.workingimmigrants.com.