Debate Heats Up Over Whether Opioids Belong in Formulary

Friday, June 2, 2017 | 2

If one of the goals of workers’ comp drug formularies is to reduce opioid use, why do some formularies list certain opioids as a preferred first-line therapy?

That’s an issue that was raised by Sheral Kellar, director of the Louisiana Office of Workers' Compensation Administration, in recent comments to WorkCompCentral.

Kellar said she is opposed to House Bill 592 in Louisiana, which would establish a drug formulary based on the drug list published as Appendix A to Work Loss Data Institute’s Official Disability Guidelines. She said prescribing decisions are best left to physicians. The House passed the bill, which is now in Senate committee.

Kellar also noted that in the ODG formulary, hydrocodone, which is a top-prescribed opioid in Louisiana, is listed as a “Y” drug, meaning it is a preferred, first-line drug, under ODG’s definition.

“Hydrocodone, therefore, can be prescribed and dispensed with no restrictions,” she said. And unlimited access to the drug would not help curb opioid abuse among injured workers, Kellar added.

Joseph Paduda, principal of Health Strategy Associates, picked up on Kellar’s comments in his Managed Care Matters blog on Tuesday. Kellar is right about formularies, Paduda wrote in the post, which drew a slew of comments from readers.

“Formularies that always allow opioids make no sense,” he said.

But Phil LeFevre, senior vice president for ODG, said a drug’s “Y” designation in the formulary doesn’t mean there are no restrictions on its prescribing. The drug list should be used in concert with treatment guidelines, to which the formulary is linked, he said.

For treatment of acute pain, opioids are “not recommended except for short use for severe cases, not to exceed two weeks," ODG states. In addition, opioids are not recommended as a first-line treatment for chronic non-malignant pain, and not recommended for patients at high risk for misuse, diversion or substance abuse.

Louisiana’s HB 592 was amended in the House to clarify that the formulary would include Appendix A of ODG, along with applicable portions of the ODG guidelines specific to the drugs in Appendix A.

While ODG lists as a “Y” drug hydrocodone-acetaminophen, which includes brand-name Vicodin, other forms of hydrocodone are listed as “N,” or not preferred. Those include hydrocodone-ibuprofen and extended-release hydrocodone.

Similarly, oxycodone-acetaminophen is “Y,” while extended-release oxycodone is “N.” No forms of fentanyl are “Y” drugs. The idea is to steer prescribers away from stronger, long-acting opioids as first-line treatment, LeFevre said.

But even drugs that are listed as not preferred may be prescribed to injured workers with preauthorization, according to formulary rules.

“Preferred or ‘Y’ doesn’t mean preferred or yes forever, and ‘N’ doesn’t mean never,” LeFevre said.

In the comment section of his blog, Paduda said he’s concerned that under the “Y” and “N” formulary proposed in Louisiana, most payers are likely to give blanket approval to all “Y” drugs and deny all “N” drugs. 

The ODG formulary being proposed in Louisiana is already in use by workers’ comp systems in Texas, Tennessee, Arizona and Oklahoma. Ohio and Washington created their own workers’ comp formularies, and both allow certain opioids including hydrocodone-acetaminophen as first-line treatments.

In Ohio, the Bureau of Workers’ Compensation’s approach to the formulary “is to treat the injured worker who needs medication, and that means not withholding opioids from someone in acute pain,” a BWC spokeswoman said in an email.

In addition, the state plans to limit opioid prescriptions for acute pain to a seven-day supply for all adult patients, not just injured workers.

California’s Division of Workers’ Compensation is blazing its own trail with a proposed drug formulary that would not list any opioids as preferred drugs, except for limited supplies in “first-fill” situations within a week of the date of injury. The proposal is now in the rule-making process.

Mark Pew, senior vice president of Prium, said formularies and treatment guidelines work hand-in-hand. Ideally, doctors would review treatment guidelines before prescribing, and follow the guidelines, but that isn’t always the case.

Having a list that labels drugs “yes” or “no” will at least cause doctors to “hit the pause button” before prescribing a non-preferred drug, he said.

A drug formulary by itself isn’t enough to solve the opioid problem, Pew said. Other measures such as prescription drug monitoring programs and alternative strategies for treating pain are needed.