Spring/Summer 2020

Growing Pains: The Shift from Opioids to Other Pain Therapies

fast focus

Workers' comp physicians are prescribing fewer opioids to treat pain among injured workers, but as prescribing trends shift to different forms of therapy, what concerns accompany these therapies?

For over a decade, the workers’ comp industry has battled endlessly against the inappropriate utilization of opioid pain medications. The opioid epidemic has caused 400,000 overdose deaths since 1999,1 along with untold financial ramifications.

But over the last few years, the tide has been turning. Overall opioid prescribing has been declining since 2012, with a 19% reduction in the annual prescribing rate from 2006-2017.2

This trend is so prevalent that workers’ comp professionals in managed care are now shifting their attention to other matters. According to a 2020 workers’ comp industry insights survey conducted by Healthesystems, while chronic pain remains the top most concerning health risk within claimant populations, opioids are no longer viewed by industry professionals as a top program challenge, health risk, or claim risk.3

While there’s still work to be done to end the opioid epidemic, especially in regard to synthetic opioids like fentanyl, it is clear that, within the industry, different pain therapies are being embraced. Our survey data aligns with a study by the Workers’ Compensation Research Institute (WCRI) of 27 state workers’ comp systems that found prescription opioid utilization is decreasing while the utilization of other pain management therapies are on the rise.4

As the industry embraces different pain therapies, what should workers’ comp professionals know about these therapies?

ALARMING FATIGUE TRENDS

While employers are greatly concerned with fatigue, only 20% of workers understand the risks of fatigue,18 potentially putting them at risk for workplace injuries and long-term health effects. This is made worse considering:18

23%

reduction in opioid prescriptions from 2012-20172

Healthesystems analysis found that the percentage of claims with opioids in the first 90 days decreased by

>30%

from 2016-20193

24%

drop in daily MME per prescription from 2006-20175

17 STATES

saw MME per injured worker drop 30% or more4

Opioid prescribing dropped anywhere from

8-25%

across 27 states from 2011-20164

NSAIDS

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used to treat a variety of different pains and aches for many short and long-term conditions. Commonly used NSAIDs include:

Aspirin
Ibuprofen (Motrin®, Advil®)
Naproxen (Aleve®)
Celecoxib (Celebrex®)
NSAID UTILIZATION

NSAIDs made up over 1 in 3 pain medications for injured workers from 2016-20184

NSAIDs surpassed opioids as the most commonly prescribed drug group among California injured workers in 20186

NSAID CONCERNS

While NSAIDs are typically much safer than opioid pain medications, they do come with their own set of risks, including cardiovascular risks and gastrointestinal concerns.

NSAID RISKS

Cardiovascular concerns
Gastrointestinal concerns
Drug-drug interactions

NSAIDs can cause high blood pressure and increase the risk of heart attack or stroke, which can be problematic for injured workers with comorbid cardiovascular diseases, or who are taking other medications that increase blood pressure, including antidepressants or erectile dysfunction medications.

In fact, back in 2015 the FDA strengthened their warning that NSAIDs can cause heart attacks and strokes, advising patients to seek immediate medical attention if they experience symptoms of chest pain, shortness of breath, weakness in one side of the body, or slurred speech. Risk of heart attack or stroke can occur as early as the first weeks of using an NSAID, and the risk may increase with longer use of an NSAID.7

RISK OF HEART ATTACK OR STROKE CAN OCCUR AS EARLY AS THE FIRST WEEKS OF USING AN NSAID.7

Furthermore, NSAIDs can irritate the stomach and intestinal lining, leading to stomach pain, stomach ulcers, intestinal bleeding, and other gastrointestinal concerns. Patients already at risk or currently suffering from certain gastrointestinal concerns may need to avoid NSAIDs.

ACETAMINOPHEN

Acetaminophen is used to treat minor aches and pains (in addition to fever) and is much safer than opioids, while also avoiding the gastrointestinal and cardiovascular concerns associated with NSAIDs.

60 MILLION AMERICANS CONSUME ACETAMINOPHEN ON A WEEKLY BASIS8

ACETAMINOPHEN CONCERNS

Acetaminophen can potentially damage the liver, and long-term use can cause liver toxicity. These risks increase significantly with alcohol consumption or the use of blood thinners like warfarin. Furthermore, acetaminophen overdoses can be fatal, as they may cause liver failure.

ACETAMINOPHEN RISKS

Liver damage
Liver toxicity
Overdose
Therapeutic duplication across multiple products

Patients already at risk of liver disease should be cautioned against utilizing acetaminophen, as should older patients who may be more sensitive to potential liver damage.

Additionally, acetaminophen is available over-the-counter (OTC), and so a patient’s use of acetaminophen may not be documented on a claim. Furthermore, acetaminophen is contained in many combination medications, including cold medications that a patient may be taking in addition to their workers’ comp medications. Patients and claims professionals may be unaware of high-levels of acetaminophen utilization across a diverse drug regimen, which can lead to overdose.

Every year, acetaminophen use results in:8

GABAPENTINOIDS

Gabapentinoids are anticonvulsant (anti-seizure) drugs used to treat neuropathic (nerve) pain. Common gabapentinoids found in workers’ comp include :

Pregabalin (Lyrica®)
Gabapentin (Neurontin®)

Some gabapentinoids are classified as Schedule V drugs, either federally or by select states.

GABAPENTINOID UTILIZATION

Gabapentinoid prescribing increased 64% from 2012-20169

In 2018, gabapentinoids became the 3rd most prescribed class of drugs among injured workers in California6

CONCERNS

Gabapentinoids contain mood-altering properties, and excessive use significantly increases the risk for suicidal thoughts and overdose. Furthermore, gabapentinoids can be abused, and they can potentially lead to serious breathing difficulties.

GABAPENTINOID RISKS

Mood alterations
Suicidal thoughts
Potential for abuse
Overdose
Breathing difficulties, which are more severe for older populations

One study of 190,000 people found gabapentinoid users experienced:10

26% higher risks

for suicidal behavior or suicide

22% higher risks

for head or body injury

24% higher risks

for overdose

13% higher risks

for car accidents

Law-enforcement data has found that gabapentinoid diversion is on the rise,11 as these drugs can be used in high doses to achieve a high, similar to intoxication.

GABAPENTINOID ABUSE AND MISUSE

74K gabapentin exposures were reported to the U.S. Poison Centers from 2013-201712

Systematic reviews of medical databases from 2012-2015 documented 9K cases of gabapentinoid abuse from 2012- 201513

Growing misuse and abuse of gabapentinoids has caused Ohio and Massachusetts to require the dispensing of gabapentinoids to be reported to prescription drug monitoring programs (PDMPs). Ohio alone saw 426 million solid oral doses dispensed to patients in 2017.14

Furthermore, the FDA issued a warning that serious breathing difficulties may occur in patients using gabapentinoids who have respiratory risk factors, including respiratory disease like chronic obstructive pulmonary disease (COPD). These risks are further amplified among older populations.15

MUSCLE RELAXANTS

Muscle relaxants are used to alleviate muscle spasms and pain in workers’ comp. Several muscle relaxants are classified as Schedule IV drugs. Common muscle relaxants in workers’ comp include:

Carisoprodol (Soma®)

Cyclobenzaprine (Amrix®, Fexmid®)

Methocarbamol (Robaxin®)

Baclofen (Lioresal®, Gablofen®)

CONCERNS

Muscle relaxants should only be used short term, as adverse effects include mood change, impaired thinking, paralysis, central nervous system (CNS) depression, respiratory depression, and heart failure. Patients already at risk for these factors may not be ideal candidates for muscle relaxants, and overuse of muscle relaxants can lead to dependence, withdrawal and abuse.

MUSCLE RELAXANT RISKS

Mood change and impaired thinking

Paralysis

CNS depression

Respiratory depression

Heart failure

Potential for addiction and abuse

The U.S. Poison Centers found that one muscle relaxant alone, baclofen, saw toxic exposures increase by 36% from 2014-2017, with admission to a healthcare facility required in over half of those cases.12 Meanwhile, emergency department visits doubled between 2004 and 2009 for carisoprodol, another common muscle relaxant.16

PHYSICAL MEDICINE

Physical medicine focuses on restoring functional ability to patients facing physical impairments, which may result from workplace injury, primarily through active physical exercises or manual therapeutic techniques.

Physical medicine services in workers’ comp may include physical therapy, occupational therapy, and work hardening and work conditioning. The Centers for Disease Control and Prevention (CDC) recommend the utilization of physical therapy for treating chronic pain,17 and medical research has established that physical medicine can:

Reduce long-term opioid use by 10%18

Decrease prescription costs 28%19

Reduce disability scores and mean time off work by 50%20

PHYSICAL MEDICINE UTILIZATION IN WORKERS’ COMP

Physical medicine makes up 13% of medical costs in workers’ comp claims21

In California, the share of total payments for physical medicine increased 75% from 2013-201822

An analysis of 170,000 soft tissue injuries saw at least one physical medicine service utilized in over 50% of claims22

CONCERNS

While physical medicine can do well for treating the root cause of pain, this is only the case when physical medicine is effectively managed.

Non-adherence to physical medicine evidence-based guidelines can double treatment utilization, while increasing prescription costs by up to 40%.19 Meanwhile, evidence-based physical medicine can reduce the number of physical medicine visits by 59%.18 This indicates that using appropriate modalities is critical to controlling overall utilization.

Furthermore, claims with 15 or more physical therapy visits were six times more likely to result in high medical costs and four times more likely to result in six months of lost time.23 While the need for so much physical therapy could be tied to the severity of injury, hence a need for more frequent care, it is also possible that so many visits could signal ineffective utilization.

Effective physical medicine requires transparency into the services delivered, along with their costs, and the clinical metrics taken from each visit, which can be used over time to measure the effectiveness and value of service.

MEDICAL MARIJUANA

Over the last decade, medical marijuana has seen an increase in support from the general public, academic researchers, and clinicians across the country. Though there is much confusion and controversy surrounding the use of marijuana for pain, as it is a Schedule I controlled substance, there is clinical evidence that marijuana can benefit patients experiencing chronic pain and neuropathic pain.24

In fact, one systematic review and meta-analysis of 79 trials found that marijuana use, when compared to placebo, yielded:24

An average

37%

reduction in pain

5x greater improvement

in neuropathic pain

45% increase in

reported quality of life

3x the likelihood to

reduce pain intensity

20x improvement in

pain disability

Growing support for marijuana has led to many prescribers recommending the drug for the treatment of pain. In fact, legislators in New York, Illinois, and Colorado allow patients to swap out opioid prescriptions for medical marijuana.

MEDICAL MARIJUANA UTILIZATION ACROSS THE NATION

CONCERNS

First and foremost, marijuana should not be a first-line treatment for chronic or acute pain, and should only be reserved for use when other, more traditional therapies fail. There is also still a significant lack in clinical research as to the long-term impacts of marijuana therapy, which creates confusion surrounding:

Appropriate dosing

Toxicity

The standardization of drugs products with consistent ingredient levels

Efficacy of different formulations and routes of administration

The impact of long-term use

Potential for drug-drug or drug-disease interactions

And of course, marijuana comes with its own set of inherent risks.

MARIJUANA RISKS

Drowsiness, dizziness, confusion, sedation, and disorientation
Impairment which can lead to workplace accidents and motor vehicle accidents
Worsening of respiratory illness if smoked
Potential for physical dependence or addiction
Mental health concerns such as anxiety, short-term memory loss, psychosis, and hallucinations

ALTERNATIVE THERAPIES

In the last several years, there has been a growing interest in alternative medicine, including modalities for the treatment of pain. While there is a wide variety of alternative therapies available, clinical research has found that the following modalities could help reduce chronic pain:29-33

Massage therapy

Yoga

Acupuncture

Mindfulness-based meditation/stress reduction

Virtual Reality

GROWING INTEREST IN ALTERNATIVE THERAPIES

50 reputable institutions around the U.S recently established alternative medicine programs, including Harvard, Stanford, Duke University, and the Mayo Clinic34

32-40% of millennials are more open to alternative therapies like acupuncture over prescription drugs35

ACOEM, ODG, the FDA, and the American College of Physicians support certain alternative therapies for the treatment of pain29, 36-37

CONCERNS

With so many different alternative therapies available, it may be difficult to keep track of the growing research surrounding each therapy. However, it is important to differentiate alternative therapies that may offer clinical benefit from those that do not.

Whether or not it is visible on a claim, injured workers could be utilizing alternative therapies in addition to, or in replacement of, their managed care treatment. When an injured worker takes additional medications for a comorbidity not related to injury, that medication may not be visible on a claim, potentially leading to drug-drug interactions. In the case of supplements, herbal remedies and other ingested materials, this is no different.

Furthermore, it is important to understand the qualifications the various providers of these services possess. Inappropriate practices could jeopardize patient health and discerning the validity of certain practitioners could be difficult.

GROWING PAINS, GROWING OPPORTUNITIES

As prescribers continue to shift away from opioids and towards other therapies for pain, claims will continue to grow more complex. We may know what happens when faced with high opioid utilization, and we may already have program strategies to counteract these effects, but these prescribing shifts foreshadow new developments in store for claims management.

While moving away from opioids is likely to reduce overall risk, new risks may lie in store, requiring a growing awareness of new and evolving factors. Partnering with a strong PBM partner can provide clinical guidance on a multitude of therapies and help insurers to facilitate and address further industry developments in the treatment of pain.

Overall Considerations

Just as the use of opioid medications requires various considerations, so does the use of other pain therapies.

When utilizing non-opioid pain therapies, it is important to consider factors such as age, gender, ethnicity, comorbidities, and other personal health matters, as these attributes can greatly impact the safety and effectiveness of therapy.

WILL ACUPUNCTURE GAIN STEAM AS A TREATMENT FOR PAIN?

One alternative therapy that has seen growing popularity lately is acupuncture, the practice of inserting needles into the body to relieve pain.

Previously dismissed by western medicine, not only have systematic reviews of medical literature demonstrated that acupuncture could be useful in reducing chronic pain,29 but certain clinical trials found that acupuncture could be more effective in improving symptoms of low-back pain than NSAIDs,38 and that claims involving acupuncture more consistently saw lower-dose opioid use.17

While more research is necessary to definitively establish acupuncture’s effectiveness in the treatment of pain, New York, California, and Washington State cover acupuncture in workers’ comp to varying degrees, as does the Center for Medicare and Medicaid Services.

References

  1. Scholl L, Seth P, Kariisa M, et al. Drug and opioid-involved overdose deaths – United States, 2013-2017. MMWR Morb Mortal Wkly Rep 2019;67:1419–1427. DOI: http://dx.doi.org/10.15585/mmwr.mm675152e1
  2. Prescribing practices: changes in opioid prescribing practices. Centers for Disease Control and Prevention. Last updated Aug 12, 2019. https://www.cdc.gov/drugoverdose/data/prescribing/prescribing-practices.html
  3. Healthesystems analysis.
  4. Wang D, Thumula V, Liu TC. Interstate variations in dispensing of opioids, 5th edition. WCRI. July 31, 2019. https://www.wcrinet.org/reports/interstate-variations-in-dispensing-of-opioids-5th-edition
  5. 2018 Annual surveillance report of drug-related risks and outcomes – United States. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Aug 31, 2018. https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf
  6. Young B, Hayes S. California workers’ compensation prescription drug utilization & payment distributions, 2009-2018: Part 1. CWCI. Feb 2019. https://www.cwci.org/document.php?file=4190.pdf
  7. FDA Drug Safety Communication: FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes. FDA. July 9, 2015. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-strengthens-warning-non-aspirin-nonsteroidal-anti-inflammatory
  8. Agrawal S, Khazeni B. Acetaminophen toxicity. StatPearls – NCBI Bookshelf. Dec 16. 2019. https://www.ncbi.nlm.nih.gov/books/NBK441917/
  9. Medicines use and spending in the U.S.: a review of 2016 and outlook to 2021. QuintilesIMS Institute. May 2017. https://structurecms-staging-psyclone.netdna-ssl.com/client_assets/dwonk/media/attachments/590c/6aa0/6970/2d2d/4182/0000/590c6aa069702d2d41820000.pdf
  10. Molero Y, Larsson H, D’Onofrio BM, et al. Associations between gabapentinoids and suicidal behaviour, unintentional overdoses, injuries, road traffic incidents, and violent crime: population based cohort study in Sweden. BMJ 2019; 365. June 12, 2019. doi: https://doi.org/10.1136/bmj.l2147
  11. Buttram ME, Kurtz SP, Dart RC, et al. Law enforcement‐derived data on gabapentin diversion and misuse, 2002‐2015: diversion rates and qualitative research findings. Pharmacoepidemiology & Drug Safety. May 10, 2017. https://doi.org/10.1002/pds.4230
  12. Reynolds K, Kaufman R, Korenoski A, et al. Trends in gabapentin and baclofen exposures reported to U.S. poison centers. Clinical Toxicology. Dec 1, 2019. https://doi.org/10.1080/15563650.2019.1687902
  13. Evoy KE, Morrison MD, Saklad SR. Abuse and misuse of pregabalin and gabapentin. Drugs. March 2017;77(4):403-426. doi: 10.1007/s40265-017-0700-x
  14. Carloss T. Common drug used as alternative to opioids could become controlled substance: emerging pattern of abuse of gabapentin. ABC News 5 Cleveland. https://www.news5cleveland.com/news/local-news/common-drug-used-as-an-alternative-to-opioids-could-become-controlled-substance
  15. FDA warns about serious breathing problems with seizure and nerve pain medicines gabapentin (Neurontin, Gralise, Horizant) and pregabalin (Lyrica, Lyrica CR). FDA. Dec 19, 2019. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-serious-breathing-problems-seizure-and-nerve-pain-medicines-gabapentin-neurontin
  16. Hospital emergency department visits involving the misuse of the muscle relaxant drug carisoprodol have doubled over five years, study shows. SAMHSA. Nov 3, 2011. https://www.samhsa.gov/newsroom/pressannouncements/201111031215
  17. CDC guideline for prescribing opioids for chronic pain: promoting patient care and safety. Centers for Disease Control and Prevention. 2018. https://www.cdc.gov/drugoverdose/pdf/guidelines_at-a-glance-a.pdf
  18. Sun E, Moshfegh J, Rishel CA, et al. Association of early physical therapy with long-term opioid use among opioidnaïve patients with musculoskeletal pain. JAMA. Dec 14, 2018. doi:10.1001/ jamanetworkopen.2018.5909
  19. Childs JD, Fritz JM, Wu SS, et al. Implications of early and guideline adherent physical therapy for low back pain on utilization and costs. BMC Health Serv Res 15, 150 (2015). https://doi.org/10.1186/s12913-015-0830-3
  20. Foster NE, Mullis R, Hill JC, et al. Effects of stratified care for low back pain in family practice (IMPaCT Back): a prospective population-based sequential comparison. Annals of Family Medicine. March/ April 2014. (12)2:102-111. doi: 10.1370/ afm.1625
  21. Lipton B, Robertson J, Corro D. Medical services for claims 20 or more year old. NCCI. Jan 2013. https://www.ncci.com/Articles/Pages/II_Med-Svcs-20yrs.pdf
  22. Zhang J, Yu Y, Sabiniano E. Physical medicine treatments and their impact on opioid use and lost time in California workers’ compensation. WCIRB. Jan 2020. https://www.wcirb.com/sites/default/files/documents/physical_medicine_research_report_0.pdf
  23. Leung N, Tao XG, Bernacki E. The relationship of the amount of physical therapy to time lost from work and costs in the workers’ compensation system. Journal of Occupational and Environmental Medicine: August 2019 - Volume 61 - Issue 8 - p 635-640. doi: 10.1097/JOM.0000000000001630
  24. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. JAMA. 2015;313(24):2456–2473. doi:10.1001/jama.2015.6358
  25. Arizona medical marijuana program November 2017 monthly report. Arizona Department of Health Services. Nov 2017. https://www.azdhs.gov/documents/licensing/medical-marijuana/reports/2017/2017-nov-monthly-report.pdf
  26. Office of Medical Marijuana Use Weekly Updates – September 6, 2019. Office of Medical Marijuana Use. Sep 6, 2019. https://www.knowthefactsmmj.com/wp-content/uploads/ommu_updates/2019/090619-OMMU-Update.pdf
  27. Brisbo A. Medical marihuana act statistical report with program information and financial data for fiscal year 2017. Bureau of Medical Marihuana Regulation. Nov 28, 2017. https://www.michigan.gov/documents/lara/2017_Section_507_Medical_Marihuana_Act_Report_608184_7.pdf
  28. Medical Marijuana Identification Card Program – Patient, Primary Caregiver, Medi-Caland CMSP Card Data. California Department of Public Health. Sep 2019. https://www.cdph.ca.gov/Programs/CHSI/Pages/MMP-Card-Data.aspx
  29. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American college of physicians. Ann Intern Med. 2017;166(7):514-530. DOI: 10.7326/M16-2367
  30. Skelly AC, Chou R, Dettori JR, et al. Noninvasive nonpharmacological treatment for chronic pain: a systematic review. Agency for Healthcare Research and Quality – U.S. Department of Health and Human Services (HHS). June 2018. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/nonpharma-chronic-pain-cer-209.pdf
  31. Wiederhold BK, Gao K, Sulea C, Wiederhold MD. Virtual reality as a distraction technique in chronic pain patients. Cyberpsychol Behav Soc Netw. June 2014; 17 (6): 346-352. https://dx.doi.org/10.1089%2Fcyber.2014.0207
  32. Gartt B, Taverner T, Masinde W, Gromala D, Shaw C, Negraeff M. A rapid evidence assessment of immersive virtual reality as an adjunct therapy in acute pain management in clinical practices. Clin J Pain. Dec 2014; 30 (12) 1089-98. doi: 10.1097/AJP.0000000000000064
  33. Jones T, Moore T, Choo J. The impact of virtual reality on chronic pain. PLoS One. Dec 2016; 11 (12). http://dx.doi.org/10.1371/journal.pone.0167523
  34. The evolution of alternative medicine. The Atlantic. June 25, 2015. https://www.theatlantic.com/health/archive/2015/06/the-evolution-ofalternative-medicine/396458
  35. Millennials are seeking the fountain of youth through healthy aging. Nielsen. May 13, 2014. https://www.nielsen.com/us/en/insights/article/2014/millennials-are-seeking-the-fountain-of-youth-through-healthy-aging/
  36. FDA education blueprint for healthcare providers involved in the management or support of patients with pain. Food and Drug Administration. May 2017. https://wayback.archive-it.org/7993/20170112130317/http:/www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM515636.pdf
  37. ACOEM Chronic Pain Guideline. May 2017. https://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Chronic-Pain-Guideline.pdf
  38. Lee JH, Choi TY, Lee MS, et al. Acupuncture for acute low back pain: a systematic review. Clin J Pain. 2013 Feb;29(2):172-85. doi: 10.1097/ AJP.0b013e31824909f9

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RxInformer

Since 2010, the semi-annual RxInformer clinical journal has been a trusted source of timely information and guidance for workers’ comp payers on how best to manage the care of injured worker claimants and plan for the challenges that lay ahead. The publication is an important part of Healthesystems’ proactive approach to advocating for quality care of injured workers while managing the costs associated with treatment.