Work Comp Claims for Opioids Down Significantly

By Pat Anson, PNN Editor

Workers’ compensation claims in the U.S. for opioids and other pain relievers fell significantly in 2023, one of the largest drops the work comp industry has seen in years, according to a new report.

San Diego-based Enlyte analyzes drug utilization and spending trends annually for property and casualty insurers. The company’s Drug Trends Report for 2023 estimates that overall opioid use per claim fell by 9.7 percent, with the use of sustained-release opioids such as oxycodone down more than 10 percent.

Surprisingly, work comp claims for non-opioid pain relievers also fell, even though they are increasingly prescribed as alternatives to opioids. Claims for non-steroidal anti-inflammatory drugs (NSAIDs) fell by 3% last year, with anticonvulsants like gabapentin down 7.4% and antidepressants such as duloxetine falling 6.1%. 

"This, by far, marks one of the largest drops in opioid utilization we've seen in years," Nikki Wilson, PharmD, senior director of clinical pharmacy solutions at Enlyte, said in a press release. "In addition, opioid alternatives commonly prescribed to manage acute and chronic pain also experienced decreases in utilization per claim, although to a lesser degree than opioids."

Enlyte said the decline in opioid use was “supported by prescribing guidelines,” noting that claims for high-dose opioid prescriptions have fallen for nine consecutive years. The 2016 CDC opioid guideline urged doctors not to prescribe doses higher than 90 morphine milligram equivalents (MME) per day. Although that recommendation is voluntary, it has taken root in many laws, regulations and insurance policies governing the use of opioids.

As a result, non-opioid analgesics and muscle relaxants are used more often than opioids for pain management during the first two years of a work comp claim. Only afterwards are sustained-release opioids used more frequently for chronic pain caused by job-related injuries.

Even though opioid use has fallen dramatically in recent years, opioids remain the top therapeutic class for claims, followed by NSAIDs, anticonvulsants, muscle relaxants, antidepressants and topical medications. Those six therapeutic classes represent over two-thirds of the prescription drug claims in 2023.

Respiratory and Migraine Drugs  

While the overall cost of prescription drugs fell slightly (down 0.2%) in 2023, the price of respiratory and migraine medications rose significantly, up 14.7% and 10.2%, respectively.

Newer migraine drugs that block calcitonin gene-related peptides (CGRPs) are some of the most expensive medications, with the average wholesale price of a Nurtec prescription reaching $1,916 and $1,654 for a Ubrelvy prescription.      

"Basically, what's driving these trends are the costs of the top three medications in their respective classes," Wilson said. "For instance, for migraine medications, Nurtec ODT is prescribed about 15% of the time yet makes up more than 31% of the total drug spend in this category. Similarly, respiratory medication like Trelegy Ellipta is prescribed about 10%, but accounts for nearly 19% of all respiratory medication total costs."

Enlyte reported the number of retail and mail order prescription drug claims is trending downward due to an “evolving work environment.” More people are working from home and as independent contractors, reducing the number of on-site job injuries and employee compensation claims.  

Jumping from Fire into Work Comp Nightmare

By Ron Angel, Guest Columnist

I was injured on July 1, 2001 while fighting fire for the U.S. Forest Service in Tok, Alaska.

At the end of a long day, we were setting up camp and I was carrying heavy packs which weighed about 100 pounds.  While walking I felt pain radiating from my neck and through my shoulders. After a restless night, I woke up the next day with a stiff neck and more pain. 

Every day for the next two weeks it got steadily worse and spread down my right arm. At the end of the first week I went into a local clinic where the doctor knew right away that I had blown out a disc in my neck. He prescribed Percocet for my pain.

After I returned home, the pain continued to worsen and I ran out of Percocet; so I went to the ER in Sandpoint, Idaho. They refused to give me narcotics for pain and gave me Neurontin instead, which did nothing for pain relief.

The pain continued to increase and it was more than I could handle. It was an 11 on a 10 scale so I walked into my doctor’s office in tears and showed him I was unable to lift my arm. He set me up for an MRI, which showed I had a herniated disc and two bulging discs.

Ron Angel

I had submitted a claim to the Department of Labor’s Office of Workers’ Compensation (OWCP) immediately after returning from Alaska. I tried to get OWCP to help me, but was mostly unable to contact them. When I did get a hold of someone, they had no sympathy and were extremely adversarial. 

I consulted with a neurosurgeon and he said I needed surgery immediately. I called my health insurance, but they said it was work related so they would not cover it. I still had no response from federal OWCP. 

After not being able to sleep for nine days due to the pain, I could no longer take it. I got my pistol and had it on my lap. I called Blue Cross Blue Shield and told them that if they didn't help me I was going to kill myself immediately. They begged me not to and said they would cover the costs and deal with Federal OWCP. I had my lifesaving neck surgery on August 9, 2001.

I finally received a letter from OWCP dated Oct. 16, 2001 telling me they decided to accept my claim. I would have been dead had I not had the surgery to relieve my neck and arm pain. 

Federal OWCP does not accept back injuries, brain injuries or heart injuries for a settlement, but if an injury of one of them affects an accepted body part they will pay a settlement for the loss of use. Due to the loss of strength, mobility and the continuing pain, they rated my right arm a 23% loss.

During a follow up with the surgeon in 2004 he noticed that I had some movement of an adjacent disc that was causing me some discomfort. He said this is common with fusion patients and that we should just monitor it. If it started to cause me more problems he would have to go back in and fuse the next segment. This is called adjacent segment disease and it occurs in about 25 percent of fusion patients.

I am now retired and a couple of months ago I began to lose strength in my right arm, which I can't raise above my shoulder.  Pain is now radiating from my shoulder down to my elbow. I would rate my pain at a level of 4 today.  I contacted OWCP for authorization to get a new MRI, but they informed me that due to the lack of activity they had closed my case in 2013.

I explained they should have provided notification because my surgeon had said that eventually I would need another fusion. They told me that since they closed it, I will have to file another work comp claim for a re-occurrence of the injury. 

In order to re-open my claim, OWCP requires a narrative from the doctor that states the new symptoms are connected to my original injury in 2001. They also require all of my medical records since 2001, five other requirements for the doctor, and three pages of questions that I have to answer. 

My surgeon says the bulge in my disc is severe and another fusion is necessary, but he won’t provide a statement to OWCP because he is tired of dealing with them. He said he has another patient who has been trying for approximately two years to get his claim reopened, unsuccessfully. He doesn't have time to play their games. 

Since my doctor will not give me a statement, the only way I can get it fixed is if my health insurance will cover it. I'll be responsible for 20% of the cost!  This could have been avoided if OWCP had contacted me before arbitrarily closing my case. 

Now it looks like I get to go through the same trials to fight for my next fusion, which OWCP claims was not caused by the original injury. It looks like my bureaucratic nightmare with federal work comp is starting all over again.    

Ron Angel lives in Idaho.

Pain News Network invites other readers to share their stories with us.

Send them to:  editor@PainNewsNetwork.org.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Pain Meds Top Concern of Work Comp Industry

By Pat Anson, Editor

The use of opioid pain medication is the number one issue faced by the worker’s compensation industry, according to a new survey that calls the long-term use of opioids in the U.S. an “extremely significant problem” for insurers and employers.

The annual survey of nearly two dozen insurers, state worker compensation agencies and self-insured employers was conducted by CompPharma, a consortium of pharmacy benefit managers that helps members develop procedures to control work comp costs.

The survey found that drug spending by the worker compensation industry increased by 6.4% last year, the first increase since 2009. Pharmacy spending in work comp cases was estimated at between $5 and $7 billion in 2014.

“During the past several years long-term opioid use has become the single biggest concern identified by respondents. While program managers and work comp executives have long known about the relatively high usage of narcotics in work comp, the depth and breadth of understanding of the issue continues to increase. Throughout the survey, respondents mentioned narcotics, opioids, addiction, specific drugs, dependency, and related terms, even when responding to other questions,” CompPharma said in a report on the survey.

Asked to rate the severity of the opioid problem on a scale of one to five, respondents gave it an average ranking of 4.75, which was called “a clear indicator of the level of the industry’s anxiety over a problem that it was somewhat slow to fully grasp.”

Payers also expressed concern about the cost of new opioids and abuse deterrent opioids, which are formulated to make it more difficult for the drugs to be snorted or injected.

“They say follow the money well here you go,” said Lynn Webster, MD, past president of the American Academy of Pain Medicine. “If patient well-being and safety were the concern of payers they would rapidly adopt abuse deterrent formulations and lobby Congress to find safer and more effective therapies.  Neither are occurring.”

Webster said the cost of opioids was the “genesis for the anti-opioid movement” and claimed the work comp industry was fueling efforts to limit opioid prescribing.

“We need to ask why cost to payers trumps patients reporting effectiveness,” Webster said in an email to Pain News Network.  “There should be a Senate investigation to see if this has been an orchestrated attack.  If so it should be criminal.” 

Payers who were surveyed said they had developed a variety of ways to limit the cost of opioids or make them harder to get.

“Respondents noted several approaches to controlling cost, with a more diverse range of solutions and more specificity in solutions than we’ve previously seen. The majority of the respondents implemented programs, upgraded approaches, hired staff, or altered DUR (drug utilization review) processes pertaining to opioids. This shows how seriously these respondents take the issue,” the report states.

Payers were also concerned about physicians dispensing opioid pain medications out of their own offices, which often cost more than opioids obtained at a pharmacy.

“Physician dispensing also drastically and artificially inflates the cost of workers’ compensation pharmacy costs. Physician-dispensed prescriptions typically cost three to ten times the amount of the same prescription filled by a retail pharmacy. More recent studies point to longer claim duration, more claimants prescribed opioids for longer periods, higher overall medical costs, higher indemnity expense, and poorer outcomes associated with claims with physician-dispensed drugs,” the report said.

The survey also found a greater willingness on the part of the work comp industry to utilize urine drug testing. Four years ago, half of the survey respondents said they were using drug tests to monitor employees who had filed work comp claims. The 2014 survey found that three-quarters of respondents have implemented or will implement a drug testing program.