A Revealing Look at Florida Workers' Compensation Drug Trends

Compared to the nation as a whole, Florida experienced a much lower total spend and transactions associated in this category in 2009. Spend on narcotic analgesics in Florida was 25.5 percent of total pharmacy spend compared to 34.7 percent nationally.

Also compared to national trends, Florida experienced an overall decrease in price and utilization of narcotic analgesics in 2009. The largest impact was the number of prescriptions per claimant, which accounted for a majority of the 13.1 percent reduction in total spend per claimant. When looking at injury dates on a national level, narcotic analgesics had a 7.8 percent reduction in the first year of injury. This trend appears to be occurring in Florida as well, with narcotics experiencing a 5.6 percent decrease, which was balanced by an increase in the use of both non-steroidal anti-inflammatory drugs (NSAIDs) and skeletal muscle relaxants by 4.1 percent and 1.4 percent, respectively.

Skeletal Muscle Relaxants

Skeletal muscle relaxants are typically used in the treatment of muscle spasms that are a frequent component of occupational injuries, such as sprains or strains.

Total spend on skeletal muscle relaxants was higher in Florida at 8.7 percent of total pharmacy spend compared to 7.9 percent nationally, despite a nearly equal number of prescriptions.

Overall, there was an 8.8 percent decrease in prescriptions per claimant and a 3.9 percent decrease in the days of supply per prescription, yet there was a 10.4 percent increase in the total billed per day of supply. This was due almost entirely to the use of Amrix, a once-a-day formulation of Flexeril (cyclobenzaprine), and the lower dose Soma (carisoprodol) that are only available in brand formulations. Amrix, the extended-release formulation of cyclobenzaprine, is approximately 525 percent more expensive than the generic, immediate-release formulation. In the case of the Soma 250 mg dose, this medication is 480 percent more expensive, on a price per prescription basis, than the generic 350 mg formulation. These higher medication costs, coupled with a 38 percent increase in utilization of Amrix, helped drive the overall increase in price per day of supply for skeletal muscle relaxants, despite the overall decrease in utilization for the class overall.

NSAIDs

Anti-inflammatory medications are used in workers' compensation for the treatment of pain and inflammation caused by physical injuries. NSAIDs had an overall decrease in utilization (less prescriptions per claimant and shorter durations of therapy) resulting in an overall decrease of 13.3 percent in total billed per claimant. However, this does not reflect the increased use of anti-inflammatories in the acute phase of injury. Additionally, although the "older" drugs in this class (e.g. ibuprofen, naproxen) may have had decreases in utilization, the brand-name only Celebrex had an increase of 7 percent in the number of prescriptions per claimant, similar to the 8 percent increase nationally for Celebrex.

Dermatologics

Dermatologics include all medications that are applied externally to the skin for the treatment of infection, inflammation and, most commonly in workers' compensation, pain relief.

Nearly 95 percent of the total billed amount for dermatologics are for Lidoderm (topical anesthetic), Flector (anti-inflammatory patch), and Voltaren Gel (anti-inflammatory gel).

Although Lidoderm utilization did not change significantly in the number of prescriptions or the duration of therapy, the total billed per day of supply increased due to average wholesale price (AWP) increases approaching 8 percent. Lidoderm remains the drug with the second highest expense in workers' compensation both in Florida and nationally.

The other two main products in this category, Flector and Voltaren, are two different formulations of anti-inflammatory medications applied directly to the site of pain or inflammation. This increased utilization may be due to promotion of these brand-only formulations by their manufacturers and the perception that topically applied products are safer than those taken orally, although there is no evidence that topically applied products are safer or more effective. Although these topical anti-inflammatory drugs were used by a smaller proportion of the population, the increase in utilization most likely influenced the overall decrease in other anti-inflammatory drugs.

Additionally, it should be noted that these two products carry a substantially higher price than traditional anti-inflammatory drugs. For example, the average cost per day of supply is $3.68 for an oral anti-inflammatory, compared to $9.92 for a Flector patch. This increased price contributed significantly to the increase in spend for these agents.

In Summary:

• The AWP increases of medications were balanced out by a decreasing age of claim and increased use of generic medications in Florida.
• In Florida and nationally, narcotic analgesic spend and utilization decreased due to less use of narcotics in the first year after injury in favor of anti-inflammatory medications and skeletal muscle relaxants.
• Skeletal muscle relaxant spend, which accounted for a greater percentage in Florida than the nation, increased due to the use of the brand name only formulations of Amrix and Soma.
• Anti-inflammatory utilization decreased overall in Florida, but Celebrex continues to have increased utilization rates both in Florida and nationally.
• The dermatologics used in the treatment of pain and inflammation may also account for the decreased utilization of NSAIDs, albeit at a higher cost per day of therapy.

As evidenced by the high utilization of medications to treat pain and the complexity of therapeutic regimens, a clear need exists in workers' compensation for pharmacy benefit management (PBM) programs that not only focus on controlling costs, but also on the management of pain. A clinically based PBM pain management program can positively impact the use of pain medications by injured workers.

Matt Foster, PharmD, is the clinical pharmacy manager for PMSI, one of the nation's largest providers of specialty managed care services and products for workers' compensation. PMSI provides a best-in-class integrated portfolio of clinically based services in pharmacy, medical services and equipment, and settlement solutions. www.pmsionline.com.