By Dr. Mitch Freeman, Pharm.D., Senior VP and Chief Clinical Officer, Mitchell
Being aware of emerging trends in drug therapy is important for the successful management of any workers compensation program. Opioids and medical marijuana are the two topics that seem to dominate conversation, and this past year continued that trend. As an industry, what are the key facts we need to know about these issues and what were major changes that occurred in 2019?
Let’s take a look at the three clinical trends from 2019 that will likely continue into 2020.
1. Opioids in 2019
Opioids continued to be a national issue and 2019 saw several bills related to the prescribing of the drug. Nationally, the Food and Drug Administration (FDA) announced changes to opioid analgesic labeling for tapering the drug. The changes underline the importance of gradually tapering patients who are dependent on opioids and monitoring for potential withdrawal symptoms. These changes came in conjunction with a Drug Safety Communication to educate providers and patients on how to safely taper.
Several states also passed opioid prescribing limit laws in 2019, a trend that has increased over the past few years. However, a few states, including New York and Maine, pushed back against these limits, instead proposing bills that would increase the days’ supply limit of opioids for certain patients. Maine’s proposed bill did not pass.
Naloxone and the Opioid Crisis
Naloxone, the drug used to reverse the effects of opioid overdose, is not a new drug nor concept. In fact, the FDA approved the brand name Narcan in 1971. Recently, however, the drug has become central to the discussion on how to prevent opioid overdose deaths. In 2019, the FDA approved a generic version of Narcan nasal spray in an effort to make the drug more accessible.
This year also saw a flurry of legislation related to the drug. Many states considered bills requiring co-prescribing of antagonist prescriptions. Among the states requiring physicians to offer antagonist prescriptions when prescribing opioids to high-risk patients are California, Ohio, Rhode Island, Vermont, Virginia and Washington. The FDA has also taken steps to encourage the development of over-the-counter naloxone products. In the United States, naloxone is available without a prescription in every state except Hawaii.
The FDA is continuing to spread awareness about and increase availability of naloxone (whether in the injectable, auto-injector or nasal spray form), and we expect these efforts to continue into 2020.
2. Medical Marijuana
In our previous post, “Pondering Pot”, we explored recent research and legislative updates related to medical marijuana in 2019. Despite a very active legislative session related to marijuana, only one state – Illinois – passed a bill legalizing the drug for recreational use. Most other legalization-related bills did not pass; however, some states are now considering voter initiatives for 2020.
On the federal level, the U.S. House passed the SAFE Banking Act, which would allow for financial institutions to provide services to cannabis-related businesses. This Act is awaiting action from the Senate.
Recent research has been conflicted on the potential benefits of marijuana, especially in relation to its potential to replace opioids in the treatment of pain. Some studies show that marijuana may be effective in treating pain. Other studies have shown that opioid use and overdose may not actually decrease with legalization of marijuana.
Although research has been limited to this point, the DEA announced in August that it is expanding access to and facilitation of medical research into marijuana.
As we move into 2020, we expect this topic to continue in discussions among state legislators and at the federal level. Of note are two bills running simultaneously in the U.S. Senate and House – S 2227 and HR 3884. These two bills, sponsored by several Democratic presidential candidates, seek to decriminalize cannabis at the federal level and impose a five percent tax on all cannabis products, among other regulations.
Regardless of the outcomes of these bills and upcoming research efforts, 2020 is sure to be an eventful year for marijuana. For the workers’ compensation industry, this means keeping apprised of any new legislation or state court rulings that may affect how we manage medications for injured workers. As more research becomes available, it will help us to navigate how the drug may or may not be used for treatment in our industry.
Another consideration for workers’ compensation insurers is the increase in utilization of gabapentinoids. In recent years, the use of gabapentin (brand name Neurontin) and pregabalin (brand name Lyrica) has increased dramatically. Prescribing of gabapentinoids increased 64% from 2012 to 2016, while opioid prescribing has been declining since 2012.
According to NCCI, Lyrica was the top drug (PDF), in terms of cost, prescribed in workers’ compensation in 2016. However, in 2019, the Lyrica patent expired, allowing for generic versions of the drug to enter the market and likely reduce costs.
Although gabapentinoids have become a consideration in the treatment of certain types of pain, there are risks to consider with these drugs. In particular, the use of gabapentinoids in conjunction with opioids is a major concern, as gabapentinoids can increase the risk of respiratory depression. Several studies have found that gabapentinoid abuse in conjunction with opioid abuse is rising.
With this in mind, some states have taken steps to limit the potential negative impact gabapentinoids could have. Gabapentin is listed as a controlled substance in five states and North Dakota implemented dosage limits for pregabalin in 2019.
We expect more states to look at the prescribing of pregabalin and gabapentin in 2020, whether that be to implement prescribing limits or to reclassify the drugs.
2020 Clinical Vision
The upcoming year will likely see similar focuses on clinical issues, including opioids, marijuana and gabapentinoids. As the election ramps up and the workers’ compensation industry looks toward the next decade, we will be monitoring trends and issues that may impact our industry. It’s sure to be an exciting year!
About Mitch Freeman
Mitch Freeman is the Chief Clinical Officer for Mitchell International, Pharmacy Solutions. Prior to joining Mitchell, Freeman was the CEO of First Coast Health. He has a wealth of industry expertise and leadership in the workers’ compensation industry including the chief sales and marketing officer of PMSI, vice president of sales at Ameritox, vice president and general manager for ExpressScripts, and president of pharmacy services for MSC.
Freeman is a frequent guest speaker and author. Freeman is a graduate of Florida A&M University where he received his doctorate of pharmacy.
Headquartered in San Diego, California, Mitchell International, Inc. delivers smart technology solutions that simplify and accelerate claims handling and repair processes, driving more accurate, consistent and cost-effective resolutions. Mitchell integrates deep industry expertise into its workflow solutions, providing unparalleled access to data, advanced analytics and decision support tools. Mitchell’s comprehensive solution portfolio and robust SaaS infrastructure connect its customers in ways that enable tens of millions of electronic transactions to be processed each month for more than 300 insurance companies, over 30,000 collision repair facilities and countless other Property & Casualty industry supply partners across the Americas and Europe. For more information, please visit mitchell.com.
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