Good News on Opioid Usage for a Change – it’s Down in California Workers’ Comp

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Efforts to curb the use of opioids in California’s workers’ compensation system appear to be paying off.

New research from the California Workers’ Compensation Institute on prescription drugs used to treat injured workers shows that opioids now account for less than a quarter of all workers’ comp prescriptions in the state, down from nearly a third a decade ago.

Other drugs, such as anti-inflammatories and anticonvulsants, often used as alternative painkillers, now represent a much larger share, the CWCI report shows.

Interestingly, while public attention to the national opioid epidemic began ramping up only in the past few years, the downward trend in California workers’ comp has been going on for longer than that, the report shows.

“This is an issue that has been with us for quite some time, albeit under the radar of mass media coverage until I would say the last five to seven years,” said Alex Swedlow, president of the CWCI. “This problem was some 30 years in the making. It will take a lot of time to fully resolve it.”

The CWCI studied a sample of 12.5 million prescriptions dispensed to injured California workers between 2007 and 2017, and focused its research on drugs that were used to treat injured workers with lost-time claims. The study tracks changes in the prescription and payment distributions among major therapeutic drug groups.

Opioid prescriptions fell sharply over an eight-year period – from a record 32 percent of all prescriptions dispensed on 2008 and 2009 indemnity claims to 23.2 percent of the filled prescriptions in 2017, according to the study.

The study shows that opioids’ share of the total indemnity claim drug spend fell to 18.6 percent in 2017, the lowest level in more than a decade and well below the record high of 30.5 percent in 2009.

Swedlow said the positive trend is the result of ongoing efforts by numerous stakeholders in California’s workers’ comp system over several years.

“I would say there is an association that we see in the decline of opioid use and the concerted efforts by physicians, and payors, as well as injured workers, to be more educated and more cautious about prescribing and using opioids and the level of opioids that are prescribed for occupational injury,” Swedlow said.

However, opioids remain the number one drug category for California workers’ compensation indemnity claims. Opioids, anti-inflamatories and anticonvulsants were the most common drugs dispensed on the indemnity claims in 2017, accounting for more than half of all filled prescriptions. In terms of payments, opioids, dermatological drugs, and anticonvulsants ranked as the top three drug categories, together consuming 46.5 percent of the indemnity claim drug spend.

“The study is not suggesting that the opioid epidemic has been solved,” Swedlow cautioned. “Hardly. It’s improving, but still have a long way to go.”

Key findings from the CWCI report include:

Opioids were far less prevalent in the early stages of accident year 2015 and 2016 indemnity claims in earlier accident years. Among AY 2016 lost-time claims, 21.6 percent had opioids prescribed in the first three months, down from 29.1 percent of the AY 2015 lost-time claims and down from the record 37.1 percent of the AY 2008 indemnity claims. AY 2007-2014 data show the prevalence of opioids in indemnity claims prior to AY 2015 was far more stable, as the percentage of claims involving opioids at 12 months post injury and beyond was typically around 40 percent.
Among indemnity claims, the number of opioid prescriptions per user at different levels of claim development has now been trending down for several years. For example, the average number of opioid prescriptions in the first three months post injury fell to 1.8 in AY 2016, well below the peak level of 2.5 prescriptions in AY 2009.
While both the prevalence and volume of opioid prescriptions in the early stages of a claim have declined, the average strength of the opioids dispensed in the first three months, measured by morphine milligram equivalents per prescription, has shown little change, suggesting that similar strength opioids are being used in the early stages of a claim. The average strength per opioid prescription dispensed to an injured worker continues to increase sharply within each accident year as the claims develop, often doubling between the the-month and the 60-month benchmarks.
Hydrocodone was the leading opioid dispensed to injured workers in each year of the study, accounting for between 50.1 percent and 62.9 percent of all opioids dispensed on indemnity claims during the 9-1/2 year span, followed by Tramadol and Oxycodone. Together these three chugs accounted for at least 80 percent of the opioids dispensed on indemnity claims for each year in the study.
Hydrocodone also accounted for the largest share of the indemnity claim opioid chug spend m each year of the study. However, that share has dwindled from 39.3 percent in 2009 to just 21.2 percent in 2017 the combined effect of Hydrocodone’s declining percentage of the opioid prescriptions and a 20 percent reduction in the average amount paid for Hydrocodone. Tramadol, with 19.3 percent of the payments, now ranks second among all opioids in terms of drug spend, though Buprenorphine, used as a painkiller and an alternative to Methadone for opioid addiction, surpassed Oxycodone as the third most costly opioid in 2016 and in 2017 its share of the opioid dollars continued to grow, increasing to 17.2 percent.

Full results of CWCI’s study have been published in a CWCI research update, “California Workers’ Comp Prescription Drug Distributions & Opioid Trends.” CWCI members and subscribers can access the on the CWCI website. The report can also be purchased on the site.

Swedlow said he believes the state’s workers’ comp system may see further declines in opioid usage, thanks in part to a new drug formulary.

“That and the medial treatment utilization schedule together should continue the effort to reduce unnecessary opioid utilization,” Swedlow said. “Also, payers are improving their oversight abilities by leveraging managed care principles, PBMs (pharmacy benefit management groups) and other tools.”