Since opioid prescribing has decreased over the past several years, there is no longer an overwhelmingly predominant driver of pharmacy costs in workers’ compensation. And while these potent medications rightly remain a focus for the industry — new findings from the 2023 Workers’ Compensation Industry Insights Survey revealed that 52% of participants cite opioid control and prevention as their top pharmacy program concern — pharmacy trends are dynamic. The decline in opioid utilization allows for a more diverse range of trends to emerge.

“Without one drug class disproportionately impacting the industry, there are a number of other drugs of concern that we continue to track and manage,” said Dr. Silvia Sacalis, vice president of clinical services for Healthesystems. “This includes the broader pool of controlled prescription drug substances beyond opioids, as well as other drug classes that present clinical or cost concerns.”

According to Sacalis, there are several current and evolving trends across workers’ comp medical management that bear watching, including but not limited to:

1) Dermatologicals/Topicals

Dermatologicals, and specifically topical analgesics, are pain medications applied directly on the skin. “This drug class has seen significant growth as prescribers move away from a reliance on opioids for pain management,” Sacalis said. “Topical analgesics are useful to help manage pain in injured workers, but there are efficacy, safety and cost factors.”

Dermatologicals as a whole represent a significant portion of workers’ compensation drug spend; recent WCRI data estimates these therapies represent 20% of pharmacy payments. However, these costs are disproportionately increased by some variations and nuances between types of dermatologicals.

One trend that raises concerns is private-label topicals (PLTs), which are often dispensed by physicians. Not only are these products expensive, they are not FDA-approved and there are no controlled clinical trials to support their safety and efficacy. They often contain common ingredients such as menthol, methyl salicylate and lidocaine, which are available in over-the-counter products at retail pharmacies for a fraction of the cost. Many PLTs have very high concentrations of these ingredients, which can pose patient safety risks.

A second concerning trend within dermatologicals is compounds. These products are made on demand by a pharmacist based upon a prescription. The combinations of ingredients and the dosages of these products are untested, calling safety into question. Sacalis explained, “Concurrent utilization of both topical dermatologicals and oral products containing either the same or similar ingredients in combination can present patient safety concerns, as duplication of ingredients can lead to increased toxicity and adverse effects.”

One way to mitigate the prescribing of both compounds and PLTs is to make physicians aware of the potential safety concerns associated with these products and provide safer but equally effective low-cost alternatives such as the over-the-counter generic topical diclofenac.

2) Buprenorphine

Buprenorphine, classified as a Schedule III controlled substance by the FDA, is a partial opioid agonist that is approved for chronic pain and opioid dependence. It has a more favorable safety profile and less abuse potential than full-fledged opioids, but it is not free from patient safety risks. These include cardiac concerns, respiratory depression, gastrointestinal side effects and, most notably, euphoria.

Buprenorphine is available in various strengths that differ according to the indication. Lower strengths are indicated for the treatment of opioid use disorder, while higher strengths are indicated for pain management. A notable trend of concern resulting from the cost difference between buprenorphine products is the off-label prescribing of the lower strengths instead of the higher-strength products that are specifically FDA approved for chronic pain management.

Dr. Silvia Sacalis, vice president of clinical services, Healthesystems

According to Sacalis, “One complicating matter with buprenorphine is that the Centers for Disease Control and Prevention (CDC) advises that drugs used as part of medication-assisted treatment for opioid use disorder should not be evaluated using opioid dosage indexes for chronic pain. Therefore, the CDC does not include buprenorphine in its Morphine Milligram Equivalent (MME) table. That means it does not provide a correlating indicator of opioid risk, inducing a false sense of security and potential patient safety risks. Ultimately, it can fly under the radar when prescribed to patients for pain, despite being an opioid partial agonist — leading to unfavorable downstream outcomes.”

3) Anticonvulsants/Gabapentinoids

Anticonvulsants are indicated for the treatment of seizures. In workers’ comp, they are prescribed for neuropathic pain — most notably gabapentin. While gabapentin is not federally scheduled, some states have reclassified it as a Schedule V drug due to its potential for abuse. Patient safety risks include the potential exacerbation of depression symptoms, with reported adverse effects such as suicidality.

“When prescribing for the injured worker population, this is an especially important consideration because this population sometimes has a mental health comorbidity,” said Sacalis. “We must consider patient-specific factors before prescribing to mitigate unnecessary complications.”

Another consideration with gabapentin is that it is sometimes prescribed in combination with opioids, which presents compounded adverse effects for injured workers, including increased risk of abuse and addiction. Both gabapentin and pregabalin (a federal Schedule V substance) have high rates of off-label prescribing for pain and anxiety. While off-label prescribing can be medically warranted and beneficial for some patients, it can also be clinically inappropriate and cost-ineffective.

4) Novel Migraine Agents

Migraines — headaches associated with nausea and sensitivity to light and sound — can arise when certain workplace injuries exacerbate preexisting migraine conditions. Their link to traumatic brain injury has also been debated. And growth among novel agents in this therapeutic area has been particularly rapid. In 2019, the FDA approved several products within a new class called calcitonin gene-related peptide (CGRP)-targeted agents. Since then, new agents have continued to enter the market in various formulations, including oral solutions, nasal sprays and disintegrating tablets.

“Some of these new agents, such as Nurtec ODT, may be familiar to you if you’ve seen the Kardashians and other celebrities promoting them on TV,” said Sacalis. “But it’s important to note that novel migraine products are not considered first-line treatments due to their high cost. The most common first-line prescription treatments for moderate to severe migraines are triptans. Other first-line treatments include acetaminophen, NSAIDs, beta-blockers, anticonvulsants and antidepressants. It is when these medications prove ineffective or present patient-specific concerns that newer migraine medications may be useful.”

5) Specialty Medications

Specialty medications are prescribed for rare and chronic conditions, and these drugs often require special handling and enhanced clinical monitoring. In workers’ comp, they may be prescribed to injured workers in certain instances or job classes — such as those with occupational illnesses including pulmonary fibrosis, certain cancers, or exposure to blood-borne viruses including HIV or hepatitis C.

While specialty drug spend is a small portion of total pharmacy costs, individual therapies can cost up to 40 times more than traditional medications. They are also particularly complex to manage due to a variety of factors. “There is no single, consistent definition of what designates a medication as specialty,” explains Sacalis. “But it often is a combination of factors including cost parameters, route and site of administration, and the need for enhanced clinical management of the injured worker patient.”

Sacalis added, “Some specialty medications we are seeing are categorized as infusibles, which may be administered either in a physician or office setting, in the hospital or through a home health nurse. This means a portion of specialty is not captured through pharmacy transaction data, making it important to have holistic visibility into all areas of an injured worker’s care to fully understand the impact of these therapies from a utilization and cost perspective.”

The specialty drug category most common within certain worker populations is antiretrovirals, which are prescribed for health care workers who have undergone needlestick or other sharps-related injuries and are used to manage HIV infections. Earlier-generation antiretrovirals may have more side effects than newer antiretrovirals. The severity of these side effects could keep patients from completing their drug regimens, necessitating further medications to manage the side effects.

“When selecting antiretrovirals, we should look at which medications are best tolerated and the least toxic,” said Sacalis. “Because antiretrovirals can also cause serious drug interactions, reevaluating a patient’s overall drug therapy is necessary.”

6) Emerging Psychedelics

Psychedelics are a class of psychoactive substances that produce changes in perception, mood and cognitive processes. They affect all the senses, altering a person’s thinking, sense of time and emotions. “We are not typically seeing these therapies in workers’ compensation, but there are applications being researched that are potentially relevant to injured workers, especially in mental health and pain management,” said Sacalis.

Ketamine, a dissociative anesthetic, is approved by the FDA for medical use in pain management due to its analgesic properties, although it is not a first-line therapy. Beyond that, ketamine, as well as psilocybin (the active ingredient in hallucinogenic “magic mushrooms”) and MDMA (commonly known as ecstasy) are a focus of research for applications in mental health therapy. In 2017, the FDA granted breakthrough therapy designation to MDMA-assisted therapy for the treatment of post-traumatic stress disorder (PTSD).

Ketamine and psilocybin are also being researched in depression. However, there are stringent parameters around how these therapies are intended to be administered — often with adjunctive psychotherapy, and sometimes in a controlled setting with health care supervision. In fact, recently the FDA issued an alert warning against the risk of compounded ketamine products, as well as the further elevated risk of using these products without the supervision of a medical professional.

7) Opioids

Though there has been a decrease in opioid prescribing over the past decade, opioids still have a place in therapy for injured workers. That said, even at reduced levels of utilization, they require ongoing vigilance and reassessment to ensure patient safety and manage associated costs.

“With opioids, we always like to say ‘Go low and go slow.’ They are typically recommended in the acute phase of pain management, for short durations and at the lowest possible dose,” said Sacalis. “Opioid use becomes complicated — and potentially dangerous — when it occurs on a continuing basis and more potent opioids are prescribed as chronic pain progresses.” Due to the high risk of addiction and abuse, there should always be a weaning plan in place when an injured worker is prescribed opioids. &