The Opioid Epidemic Deserves More than a Closed Formulary

We have not yet completed the first quarter of 2018 and numerous states are already engaged in vigorous debate considering the adoption of a drug formulary to help curb opioid use/abuse in their respective workers’ compensation systems. Are formularies the most effective tool state legislators and regulators can count on to support medical providers and other key stakeholders, prevent new cases of opioid dependence and wean patients at risk of dependency?

A Common Thread

There is a common thread within every state that has ongoing dialog about adopting a drug formulary, the Workers’ Compensation Research Institute (WCRI’s) studies (plural) on the “Texas-like” drug formulary model. The latest study, dubbed a “FlashReport”, focuses on how the Texas-like closed formulary could influence the prevalence and cost of prescription drugs among Louisiana’s state employee claims.

With numerous credible drug formulary models now available, I find it curious how WCRI, perhaps due to industry demand, focuses on one product (but this warrants a completely separate discussion). The Texas-like formulary story is on a proverbial loop among payer legislative advocacy discussions. Now, even I can predict the FlashReport’s results – less drugs, savings on drug prescriptions.

However, the information that the WCRI report is unable to provide is arguably more important than the information it does provide. According to WCRI, the FlashReport does not study the influence of the closed formulary on patient outcomes and overall medical costs.(1) Patient outcomes in particular are monumental when measuring efficacy in healthcare.

This begs the question: If a state’s primary goal is to reduce the number of prescribed opioids, without consideration to better (or worse) patient health outcomes, why go to the trouble and expense of adopting a drug formulary. Instead, states could consider requiring all opioid prescriptions, irrespective of medical necessity, subject to pre-authorization. A formulary that only provides guidance on FILL, or DO NOT FILL, such as the case with the Texas-like formulary is not entirely necessary to reduce the number of prescribed opioids. States can borrow from Nancy Reagan’s drug policy and JUST SAY NO.

Much-Needed Context

This entry should not be construed as anti-drug formulary; drug formularies have been used effectively throughout the American healthcare system since the 1700’s.(2) This entry is to acknowledge the importance of the clinical context in which pain medications should be prescribed in.

Johns Hopkins Bloomberg of Public Health published a paper focused on “preventing new cases of opioid addiction, identifying early opioid-addicted individuals, and ensuring access to effective opioid addiction treatment while safely meeting the needs of patients experiencing pain”.(3) Johns Hopkins cites the need for “Prescribing Guidelines” as their number one call to action.

Many might consider drug formularies to be a form of guideline. While a formulary drug recommendation provides abbreviated guidance mostly for treatment reimbursement purposes, binary drug lists like the Texas-like model lack critically important context that medical providers need to ensure the right drugs are prescribed for the right reasons at the right times.

Johns Hopkins is much more prescriptive with their recommendation for action “1.2 Require oversight of pain treatment”. The recommendation urges federal and state agencies, state medical boards and medical societies to require mandatory tracking of pain, mood and function through patient engagement.

Additionally, the paper recommends the use of patient treatment agreements, urine drug screening, use of PDMP (with long-term opioid use for non-chronic pain), and specialty consultation when more than 120 MME per day are prescribed without improving pain and function. These protocols and tools for monitoring opioid prescriptions, along with decision-making support at the point of care are “needed to improve the safety of prescribing practices”.

This more comprehensive, medically responsible approach is not new. It has been adopted by numerous entities and the guidelines they endorse including: Washington State, the Department of Defense (DoD), Veteran’s Administration (VA), the Agency for Healthcare Research and Quality (AHRQ), American College of Occupational and Environmental Medicine (ACOEM), American Pain Society (APS), American Academy of Pain Medicine (AAPM), and the American Society of Intervention Pain Physicians (ASIPP).

This much-needed context is non-existent in a draconian binary drug list who’s model is a couple of centuries old.

One of my favorite bloggers published an entry expressly warning about misconstruing savings for progress. My favorite line, “Most work comp buyers focus on the deal they get on medical expenses [savings], paying little attention to the quality of care delivered, or what care actually costs.”(4)

Is it possible that we, the national workers’ compensation community, may be overlooking the true cost of adequate medical care in pursuit of artificial savings?

 

References:

1.     WCRI. “WCRI FlashReport: Texas-Like Formulary for Louisiana State Employees”. WCRINet.org. February 2018. Web. 16 February. 2018. https://www.wcrinet.org/reports/wcri-flashreport-texas-like-formulary-for-louisiana-state-employees

2.     Kendall R., PharmD. “The Application of the Formulary Concept to Workers’ Compensation”. Healthesystems. 2009.

3.     Alexander GC, Frattaroli S, Gielen AC, eds. The Prescription Opioid Epidemic: An Evidence-Based Approach. Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland: 2015.

4.     Paduda J., “Work comp medical: cost vs “savings”’. joepaduda.com. February 2018. Web. 27 February 2018. https://shar.es/1Lf8c2



Categories: Evidence-Based Medicine (EBM), State Workers' Compensation Standards

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