California workers’ comp prescription formulary took effect Sunday for pre-2018 injuries. Under the Division of Workers' Compensation regs, doctors are to have filed reports by April 1, 2018, detailing weaning and tapering plans for non-exempt, unlisted or compound drugs.

Julius Young

It is not clear that these weaning and tapering plans have been filed in most cases as the deadline approached.

The formulary bill was enacted in 2015, but implementation was not immediate. The California DWC missed a July 1, 2017, implementation deadline. After extensive rule-making, final formulary regs were adopted in late 2017.

Accompanying the promulgation of a formulary were new Medical Treatment Utilization Schedule guidelines, also adopted in the latter part of 2017.

The MTUS guidelines now incorporate chronic pain and opioids guidelines developed by the American College of Occupational and Environmental Medicine. This was after controversy as to whether the DWC should use ACOEM’s guidelines, those set by Official Disability Guidelines or other sources.

The new MTUS regs and formulary regs will clearly make it more difficult for injured workers to receive opioids, though guidelines are in place for the acute injury phase and perioperative use.

Concern has been building for years across the country about opioid addiction and opioid deaths. Many now believe the country is in the throes of an opioid epidemic. So it is not surprising that the tide has changed in California workers’ comp.

Some pain management physicians and their patients may be unhappy with this, but whether they agree or not, the ground has shifted a bit.

It’s unclear whether there will be widespread drug crises as the shift in prescribing is mandated under the new formulary.

It’s also unclear whether there will be widespread refusals to honor weaning and tapering plans, leaving workers in the lurch. That’s a story we will continue to monitor.

But in the meantime, what have the opioid trends been in California workers’ comp over the past few years?

That is a topic that was recently tacked by the California Workers’ Compensation Institute (CWCI) in a March 2018 study. CWCI had issued a 2016 opioid study, but the recent study updates the prior study, based on data through 2017.

Clearly, the opioid tide has receded somewhat, and this is even before the new MTUS guidelines and the start of the formulary. 

I’ll detail some of the numbers from the 2018 CWCI study (a word of caution: Note that CWCI looks at stats from a database generated by its insurance company members, so while I don’t have reason to doubt that these numbers might apply to self-insureds and non-CWCI third-party administrators, they are not necessarily indicative of the whole California system).

In terms of volume, 2008 opioids were 32.1% of indemnity claim prescriptions filed. As of 2017 that has dropped to 23.2%.

In terms of spending, in 2009 opioids were 30.5% of indemnity claim pharma spending. That fell to 20.4% in 2016 and 18.6% in 2017.

Stats reveal that opioid use in the early stages of claims is down and that the number of opioid prescriptions per user is down. Use of generics increased and brand-name opioids declined.

The study does claim that “the average potency” dispensed “increased dramatically” over the time of longer-term claims. As a result, CWCI concludes, “This pattern of increasing the quantity and/or strength of the drugs given to injured workers who remain on opioids for chronic pain suggests that these workers often develop a tolerance to these drugs and must rely on increasingly higher dosages or stronger medication if they are not weaned off of the opioids.”

As far as specific drug names, comparing 2017 to 2008, tramadol use was up (35.9%) as was buprenorphine (1046.7%) and oxycodone (82.5%). But hydrocodone decreased (down 44.1%), along with morphine (down 55.6%) and fentanyl (down 66.5%). The study notes that Darvon/Darvocet, frequently used a decade ago, has been taken off the market.

As opioids are used less, other categories of meds appear to be used more, including anti-inflammatories, antidepressants and anticonvulsants.

The study notes that these trends reflect multiple factors, singling out several, including “the growing awareness (and wariness) of the longterm risks of opioids and the desire to find alternative treatments for chronic pain, including off-label use of other medications,” and “the impact of UR and IMR (where half of the disputed medical requests are for prescription drugs and 92% of the denials or modifications are upheld)."

Julius Young is a claimants' attorney for the Boxer & Gerson law firm in Oakland. This column was reprinted with his permission from his blog, www.workerscompzone.com.