Rousmaniere: Important Drug Trends

Summer has come in and the annual flock of reports on medications in workers' comp have arrived. Pharmacy benefit managers publish them to review the prior year, point out trends, and profile their techniques for managing drugs.  

The most notable news from 2013 is that powerful painkillers are heading downwards in use. Between about 2000 and 2008, opioid prescribing and pain clinic use skyrocketed. Then, growth rates tapered off and now are negative. Does this mean that drug addiction, overdose and death risks are declining? Can this new phase lead to better claims vocational outcomes? What if long-term ("chronic") opioid use dived by 25% or more?

Opioid prescribing throughout health care began to decline in 2011 or 2012. The most influential factors were likely national alarm overprescription drug-related deaths, growing awareness that opioids might lead to higher pain sensitivity, and realization that opioids have become a gateway to the use of illicit drugs by youths. In 2010, 60% of drug overdose deaths involved pharmaceutical drugs, mostly opioids. The message got to doctors. Opioids led, by my rough estimate, to several hundred deaths of injured workers per year, if not more.  

In the past 10 years, drug costs' share of total ultimate medical costs rose to 19%, according to NCCI's actuaries. The relative roles of utilization and prices fluctuated from year to year. In the more recent years, drug costs got closer to overall medical cost increases, about 3% a year. Utilization shifted down while prices per pill continued upwards, with frequent instances of double-digit increases in brand drugs.

Each PBM report covers a large spectrum of topics in its own nuanced way of data presentation and interpretation.

Progressive Medical/PMSI (they merged in late 2013) reported a per pill cost increase of 7.8%, which was offset by a decline in utilization to yield an overall decrease in the average prescription cost per claim of 1.7%. First Script (Coventry) reported that the average wholesale price of drugs rose by 12.5%, the biggest increase in the past four years, but narcotics such as Oxycontin and Vicodin declined in use and dollar costs. Healthcare Solutions said that as prescribing became less opioid-centric, anti-inflammatory, anticonvulsant and antidepressant drug use increased. "It's healthier for the patient," Jim Andrews, the firm's executive vice president of pharmacy, told me. 

Prescribing behavior is heavily influenced by drug company promotion more than the medical community likes to acknowledge. The Reed Group found that "80-94% of opioid trials have industry conflicts." In the late 2000s, doctor office dispensing expanded in many states that allowed it. A recent research article found that medical costs in cases where opioids were dispensed by physicians rather then pharmacies were 78% higher, indemnity costs were 57% higher, and lost-time days were 85% higher.

Innovations in brand drugs might bring better patient outcomes but almost certainly sharply higher costs. Express Scripts reported that compounded medications rose in per-user-per year by 126% in 2012. It described these drugs as "tailored drugs prepared by mixing, combining or altering ingredients" and significantly more expensive than conventional medications. The company reported that specialty medications, used for inflammatory conditions and elsewhere, were only 1% of total drug costs but were nine times more expensive than the average traditional medication. 

Getting back to the big topic of opioids, their lowered use may save lives. Using data provided by Gary Franklin, who pioneered research on injured workers and opioids, I calculate that the fatality rate of injured workers on sustained opioid treatment is greater than the country's most dangerous jobs such as logging and fishing.

State agency interventions in recent years have had an impact on prescribing. Florida enacted in 2010 and 2011 laws to regulate pain clinics and create a prescription drug-monitoring program. A research study found significant subsequent reductions in diversion rates. Texas' formulary for drugs greatly cut use of targeted drugs among claims. Washington, the foremost state in detecting problems long ago, engineered a reduction in prescribing, in dosage and in deaths. 

How do changes in prescribing trends impact work recovery chances? Let's start with the patient. In reply to my inquiry, Progressive/PMSI told me that the average age of newly injured workers taking medications is about 43 years. That fairly matches the estimated average age of all workers on the date of injury. But it found that for those who have received at least six months of opioid treatment, the average age is about 51 years. Aging affects how we respond to drugs. One can surmise that the aging typical worker on extended opioid treatment is likely to have more issues with comorbidities and consider not returning to the workforce.  

Dependence on opioid early leads to continuing use at high dosage, despite no research evidence that opioids work in the long term. Healthcare Solutions notes that "the longer the use, functional restoration, detox, chronic pain management, cognitive behavioral therapy programs are needed." Anecdotes from the field suggest that many people on extended opioid treatment do not have real access to these services.  

Prescribing doctor preferences and claims payer reluctance to approve interventions play a part. Prescribing is sharply skewed toward a relative few persistent doctors. The California Workers Compensation Institute says that 10% of prescribers account for over 80% of prescriptions. Dr. Franklin cautions that there remains a "cohort of workers who have developed dependence from the past 10 years. How are we going to move them forward?"  

In the most interesting exhibit among all the reports, Progressive Medical /PMSI showed that a comprehensive intervention strategy for one unnamed client (page 21) sharply lowered the number of injured workers on medications after two years. The drugs impacted were not cited, nor was information included about claims outcomes. This and the other PBMs would do well to try to replicate these results. 

What if there were a 25% or even 50% reduction in rate of injured workers on chronic opioid therapy one year post-injury? We'd want to see data on recovery and claims closure rates.  

The PBM reports illuminate important and otherwise hard to understand aspects of treating work injuries. The content and tone of these reports have evolved from technical notes for pharmacists to thoughtful explorations for claims executives. They provide an essential reference point not only for all three million injuries a year, but also for exploring how a small but very expensive share of them might be positively affected by intervention.    

Express Scripts. 2013 Workers' Compensation Drug Trend Report

First Script, Drug Trend Analysis. 2013

Healthcare Solutions (2013 report to be published late June).

Progressive Medical/PMSI. 2014 Workers' Compensation Drug Trend Report