It’s Always Something in Workers’ Comp. Enlyte’s Latest Report ID’s Topicals as a Bigger Pharmacy Spend Than Opioids

A new series of reports from Enlyte analyzing pharmacy spend and utilization data from 2022 has found that topicals have knocked opioids off of the top spot in terms of overall cost, even as pharmacy costs and utilization generally have remained relatively flat.

“This publication, with the 2022 data, was the first time we saw a jump and a flip flop of opioids with number one overall spend for a therapeutic category, and that tells the story pretty well,” said Nikki Wilson, senior director of clinical pharmacy services at Mitchell.

“Topicals have taken over that top spot and become an area of focus. There aren’t the same safety concerns as an opioid, where we’re worried about overdose and addiction, but this class has its own challenges.”

According to the report, the proportion of total scripts in the topical class increased 0.8% from 2021 to 2022, while the cost of these drugs jumped 2.3%. They were also more commonly used earlier in a claim, prior to the two year mark, as opposed to opioids and anticonvulsants, which were more common as claims aged.

Other Key Findings

The numbers for topicals are in stark contrast to the general picture for pharmacy in 2022, which according to Enlyte, saw prescriptions per claim fall 1.2%, and costs per script nudging up just half a percentage point. Total pharma cost per claim fell 0.7%.

“The drop across the board has a lot to do with what we’re seeing across the industry, which is, in general, script and claim volumes have been going down over the last few years, and so has pharmacy spend,” Wilson explained.

“It’s a reflection of that, and then the programs we have in place, that are looking to drive appropriate utilization. It’s part of the bigger picture, but there’s nothing specific in the data.”

Despite their ranking by cost, topicals are still well under the mark for opioids in terms of utilization.

“They’re ranked number one by spend, but number five by total volume of scripts; opioids are number two for spend and number one for volume, still,” Wilson clarified.

The Conversation on Opioids Continues

Opioids remain a central part of Enlyte’s research, and opioids occupy the entirety of a recently released third part of the study.

Joe Paduda, principal, Health Strategy Associates

Opioids ranked No. 2 in 2022, with prescriptions per claim falling 7.7%. Although they remain first in utilization at 18.7% of the total, costs per claim and per prescription both fell as well, 14.7% and 7.5%, respectively.

Wilson noted that a future report will break down more of the topical data in a similar fashion to the opioids-specific report, focusing on the different drugs in the class and the drivers behind their costs, but she cited physician dispensing as a significant factor in the creeping cost of the medications.

“When we pull in our out-of-network and physician dispensed data, private label topical analgesics start filtering in,” she said.

“We don’t see those in the retail space; they’re marketed directly to physicians, so that creeps into the data.”

Wilson noted most of the drugs in the class are FDA-approved prescription topical products, about 70%. However “they’re often being used off label and their cost is disproportionate to the volume.”

Private Label 

The other category within topicals causing concern is private label topical analgesics.

Wilson explained that Enlyte’s data has them at about 11% of volume, but about 27% of spend.

“They’re very costly drugs, and that category in particular isn’t reviewed or approved by the FDA for safety and efficacy, and they contain the same or similar ingredients as common over-the-counter drugs,” she said.

These ingredients include menthol, methyl salicylate and capsaicin. These ingredients in and of themselves are not particularly dangerous. However, according to a report from RxInformer (a publication by Healthesystems), the concentrations in some cases are troubling.

They cited their data in finding that “of the 22 private-label topical analgesics Healthesystems has observed being prescribed for injured workers, 19 contain menthol and/or methyl salicylate, and 74% contain these ingredients at concentrations twice or even three times higher than the recommended FDA thresholds.”

Indeed, the FDA did issue a warning about rare but serious burns associated with these ingredients in 2012.

According to industry veterans, however, the issue isn’t only safety and efficacy — it’s also simple greed.

“There is no credible evidence that these topicals do anything but transfer money from taxpayers and employers to ethically-challenged dispensers,” explained Joseph Paduda, principal, Health Strategy Associates, LLC.

“Unfortunately insurers and employers have failed to take meaningful steps to address this profiteering, allowing it to proceed and grow in several states.”

He also noted that in states where employers/insurers can direct care, it’s an important first step to steer claimants away from doctors that physician dispense.

Managing More Migraines 

The final standout drug class in Enlyte’s 2022 data is a new one for workers’ comp to monitor, despite its relatively infrequent use across the wider subset of claims. Migraine medications had the largest observed utilization increase at 14.8%.

“What’s driving that is a newer therapeutic class that has been released to market,” Wilson explained. “They all fall in the bucket of calcitonin gene-related peptide drugs, the CGRPs. They’re new, so it’s a novel way of prevention and treatment of migraines.”

The medications are certainly meeting a need. The National Institutes of Health indicates in an information paper about the class that migraines are “the sixth-highest cause worldwide of years lost due to disability as per the Global Burden of Disease Study (2013).”

However, given generics of these drugs won’t be available for years, management for appropriateness is essential.

“There’s three that come to the surface and that we’re seeing in the book and they’re all only available as a brand name medication,” said Wilson.

Wilson named the top three: Nurtic, for preventative treatment, Ubrelvy and Aimovig injectible, explaining that all of these drugs carry high monthly costs.

“So if it’s a patient that has a head injury or something else where a migraine is accepted on the claim, we’re seeing those being used because it’s a novel therapeutic class that’s really good at what it does, but it does carry that hefty price tag.”

She noted that the use she’s seeing is appropriate, unlike some other drug classes in the workers’ comp arena.

“They’re used on label and used for their FDA approved indications primarily, but they are addressing pain so it’s possible they’re replacing opioids in some cases, although we don’t have a direct tie to that in our data.” &