By Dr. Mitch Freeman, Pharm.D., Chief Clinical Officer, Mitchell Pharmacy Solutions
Pain is one of the most frequently occurring and challenging aspects of treatment observed in workers’ compensation claims. The experience of pain is extremely individual and safe, effective treatments for any person can be difficult to predict. Opioids, while offering some relief for many with moderate to severe pain, come with a set of very serious predictable risks that leave many pain treatment professionals wanting alternatives that are equally effective and safer.
Pharmaceutical pain management options that have gained increased consideration in recent years include gabapentinoids, skeletal muscle relaxants and medical marijuana. What are some of the benefits and drawbacks of each? Let’s explore the key points below.
Gabapentinoids are a sub-class of anticonvulsant medications, with some demonstrated effectiveness for treatment of neuropathic pain. The two main drugs in this category are gabapentin (Neurontin®) and pregabalin (Lyrica®).
ODG Guidelines describe conditional recommendations for gabapentinoids as an option for treatment of neuropathic pain. The guidelines state, “The patient’s diagnosis should include evidence of a neuropathic etiology. There are multiple causes of neuropathy outside of that related to injury/trauma/surgery.” In targeted conditions with neuropathic etiology, such as spinal stenosis, gabapentin is a recommended agent, but it is not recommended in conditions, such as chronic, non-specific, low back pain.
Gabapentinoids are frequently prescribed in workers compensation settings. In 2018, anticonvulsants were the third most-prescribed therapeutic class of medications in California, and pregabalin and gabapentin were the #1 and #3 drugs, respectively, by spend in 2016 (PDF).
Although their use has increased, there are concerns about gabapentinoid abuse along with additional risks when used concurrently with opioids. Gabapentinoids have been shown by some studies to have a potential for abuse, especially in those with a history of opioid or substance abuse, and the FDA warns of serious breathing problems associated with gabapentinoids when used with opioids. Several states have also moved to up-schedule gabapentin as a controlled substance, and pregabalin is listed as a Schedule V controlled substance federally.
Whether gabapentinoids are a viable adjunct to opioids in mixed pain conditions is unclear. Though prescribing has increased and they may be effective for specific types of pain, it is important to monitor your claims for any signs of abuse or concerning drug combinations.
Skeletal Muscle Relaxants
As we discussed in last week’s Leaders Speak, skeletal muscle relaxants (SMRs) have seen a rapid increase in prescribing in recent years, with a study from JAMA finding that, between 2005 and 2016, continuous SMR prescribing tripled from 8.5 million to 24.7 million. An overwhelming majority of these patients also received a concomitant opioid prescription.
ODG Guidelines also list SMRs as a third-line medication option, but are not recommended for most patients with chronic low back pain and should only be considered “as-needed”. The guidelines also state that SMRs are not proven to be any more effective than NSAIDs.
SMRs raise concerns about co-prescribing with opioids, as this combination places the patient at higher risk of overdose. They should also not be prescribed to patients over the age of 65, as their use can increase the likelihood of falls.
Overall, SMRs offer a potential short-term option (2 weeks) for relief of pain related to muscle spasticity or spasm, but are not recommended for longer-term use and would not be appropriate for chronic pain issues that other pain medications can help alleviate.
Marijuana continues to gain traction across the United States, with several states joining a group that has already legalized its medical or recreational use during the 2020 elections.
In some reports, marijuana has shown promise in the management of pain. Additionally, marijuana components CBD and THC, alone or in combination, have been investigated and FDA approved for several targeted conditions, including nausea of chemotherapy, childhood epilepsies and spasticity in multiple sclerosis. As well-designed studies of marijuana progress, its safety and effectiveness in pain conditions and as an opioid alternative will be better understood.
Though legalization continues to expand, the effects of long-term use, drug interactions, product standardization and effectiveness of the drug are still not well known. Marijuana remains a federally controlled substance in Schedule 1, infringing access to it for research studies. Any action taken at the federal level to down-schedule may enable and accelerate studies that will bring greater understanding of the true effectiveness of marijuana in the treatment of pain and other conditions.
Overall, it’s clear there is no silver bullet for pain management. For many claimants, non-opioid treatment is often the best option, or a mix of pharmaceutical and non-pharmaceutical strategies may be best. As the industry continues to help injured workers recover in the best way possible, it is vital to work with your PBM to identify risk in your claimants’ prescription regimen and manage intervention appropriately.
About Dr. Mitch Freeman
Dr. 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, repair processes and pharmacy transactions, 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 providers, over 70,000 pharmacies and 30,000 collision repair facilities, as well as countless other Property & Casualty industry supply partners across the Americas and Europe.
Mitchell, Genex, and Coventry have recently combined their joint industry expertise and advanced technology solutions into one organization to simplify and optimize property, casualty and disability claims processes and services. For more information, please visit Mitchell.com.
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This is not a paid placement.