In New Jersey, a Topical Analgesic Costs $139. In Illinois, It’s $2,712. See the Problem, Workers’ Comp?

Pay attention workers’ comp payers — if you’re in multiple states, you may be paying more for the same drug in one than you do in the other.

At least that’s the case with topical analgesics and gabapentinoids. Two recent studies by the Workers Compensation Research Institute (WCRI) examined prescribing practices and prices for the two drug groups across 28 states. 

In the case of topical analgesics the research found a 20-fold variation in average payments per claim.   

“Topicals and gabapentinoids are among the top three drug groups in terms of prescription cost-share in many of the states that we examined. We are taking a closer look at the utilization patterns of these drug groups today. We will see where prescribing is more frequent, and where payments are higher,” said Dr. Vennela Thumula, author of the two reports.

In a recent webinar, “Prescribing of Topical Analgesics and Gabapentinoids for Work-Related Injuries,” Thumula discussed the findings of her research. The webinar looked at high drug prices, off-label use and whether the drugs were being used in ways that are recommended by treatment guidelines.  

Here are the major findings from the two studies.

Topical Analgesics Study

The topical analgesics study found that the prevalence of the drug and its price varied widely between states.

“The percent of workers that had topical analgesics ranges from three to 17% across the 28 states we examined,” Thumula said.

“In New Jersey we see the average payment was $139 whereas in Illinois, it was $2712, which is 20 times higher.”

She attributed the difference to the type of topical analgesics being prescribed, with some states leaning towards cheaper versions and others to more expensive ones.

The states that had the highest topical analgesic payments were Illinois, Louisiana, South Carolina and Pennsylvania.

The study found that high-priced private label topicals were dispensed at physician’s offices to nearly a third of claims with topicals in Illinois, Lousiana, Maryland, New Mexico and South Carolina, and to nearly two-thirds in Delaware.

The average topical analgesic payment per claim with a prescription ranged from $6 in Iowa to $277 in Illinois.

Looking at the types of topical analgesics dispensed, the study found that prescription strength topicals such as Lidocaine or Diclofenac Dodium were the most dispensed followed by private-label topicals, over-the-counter topicals, custom compounds and compound kits.

Private-label topicals are independently manufactured products with common over-the-counter ingredients such as menthol, capsaicin, and lidocaine. They are not FDA approved and are not recommend by evidence-based guidelines as first-line therapy.

Thumula outlined concerns about private-label topicals including a lack of evidence of clinical benefits of private label topics over comparable over-the-counter products.

She also said there are safety concerns about topicals that have higher concentrations, and that workers with private-label products were more likely to be dispensed multiple private-label prescriptions over time or to simultaneously receive other topical analgesics.

The study concluded that expensive and non-recommended topical analgesics are often prescribed to workers with injuries in some states, resulting in higher topical analgesic payments per claim and that, in other states, lower-cost over-the-counter and prescription topicals were often prescribed, keeping payments for topical analgesics lower.

Gabapentinoids Study

When it comes to gabapentinoids, WCRI’s study found that between three percent and 12% of workers with a prescription received gabapentinoids across the 28 states studied and half of them had multiple prescriptions.

Gabapentinoids are almost always dispensed for off-label uses in worker’s compensation. According to the study, two-thirds of workers with gabapentinoids had a diagnosis for neuropathic conditions and one-third did not have a diagnosis with neuropathic involvement.

The study found that about half of the workers received less than the recommended daily dose of gabapentin and that concomitant prescribing of gabapentinoids and opioids is common among workers with injuries.

Potential reasons for lower than recommended doses of gabapentin include clinicians trying to find a balance between maximizing pain relief and minimizing adverse events, lower initial doses that are recommended for patients with renal impairment and because lower doses of gabapentinoids may be prescribed to workers with injuries when in combination with opioids.

The states where gabapentinoids were more frequently dispensed include New York, Massachusetts and Louisiana. The state where it was lowest was California.

The study also examined prevalence and payments for gabapentin and for pregabalin, with gabapentin being the predominantly prescribed between the two. Pregabalin accounted for less than one percent of claims with prescriptions in most study states.

Again, however, the study found great variation among the states in payment data. The average gabapentinoid payment in Louisiana per claims with prescription was $50. It was $3 in California.

The study found that gabapentinoids, which are FDA approved for seizures and a finite list of pain conditions, are rarely prescribed for the FDA approved conditions.

According to the study, 64% of claims with gabapentinoids prescriptions have a documented diagnosis for neuropathic conditions and include a broad range of conditions such as sciatica or carpel tunnel syndrome. The other approximately one-third did not have any neuropathic conditions and included such complaints as sprains and strains.

In regard to gabapentinoids being prescribed concomitantly with opioids, she said that other studies have shown that concomitant use of these two drugs leads to respiratory depression resulting in overdose deaths.

Near the conclusion of the study period, she noted that the FDA issued a warning that serious breathing issues may occur when gabapentin (Neurontin, Gralise, Horizant) or pregabalin (Lyrica, Lyrica CR) is taken with other medicines that depress the central nervous system (CNS) such as opioids, in those patients who have underlying respiratory problems, or in the elderly.

The study showed that concomitant prescribing of these two drug types is prevalent, she said. &