By Dr. Mitch Freeman, Pharm.D., Chief Clinical Officer, Mitchell Pharmacy Solutions
Drug overdoses accelerated in 2020, with the Centers for Disease Control and Prevention (CDC) reporting more than 81,000 overdose deaths occurring in the twelve month period ending in May 2020, with (non-prescription) synthetic opioids leading the increase. With these staggering numbers in mind and an eye toward limiting the impact of prescription opioids on addiction and overdose, the workers’ compensation industry continues to look for alternatives to treat pain. One drug category that is finding increased use in pain treatment is skeletal muscle relaxants (SMRs).
As we consider the ramifications of a year of increased overdose deaths and try to find the best pain treatment for our patients, what do you need to know about SMRs? Are they a viable alternative to opioids? How should you manage these drugs in your pharmacy program?
SMR Prescribing Patterns
SMR prescribing is increasing in the U.S., with a June 2020 JAMA study finding that continued SMR prescribing from U.S. physicians tripled between 2005 and 2016, from 8.5 million to 24.7 million. The study identified a number of concerning prescribing patterns, including:
- Nearly 70% of those patients receiving SMRs were simultaneously prescribed an opioid, a potentially dangerous combination that could cause increased risk of overdose.
- A significant observed increase in “continuing” SMR prescriptions. Chronic or continuing use of SMRs (over 2 weeks) is not recommended, as there is little evidence to support their effectiveness beyond this and their prolonged use may lead to dependence.
- Finally, the study found that a majority of these patients were over the age of 65, an age group that is considered high-risk due to the increased potential for sedation and related falls when taking SMRs.
SMRs and Workers’ Comp
In workers’ compensation, SMRs are frequently prescribed to manage workplace injuries. ODG Guidelines state that less sedating skeletal muscle relaxants are conditionally recommended for use as a “second line option for short-term treatment of acute [Low Back Pain (LBP)] and for short term treatment of acute exacerbations of chronic LBP.” The guidelines additionally state that there is no evidence that skeletal muscle relaxants are more effective than NSAIDS, which are listed as a first-line option.
In comparison to opioids, SMRs may be more advantageous in treating short-term issues, but lose their advantage in the long-term when it comes to work disability. A May 2019 study of workers’ compensation disability found that workers who received a short-term prescription for a skeletal muscle relaxant or NSAID were at lower risk for work disability compared to those who received a short-term opioid prescription. However, the study also found that an increase in days’ supply of any of these drugs was associated with work disability, supporting the ODG Guidelines recommendations to limit SMR prescriptions to short-term.
Additionally, SMR use can be particularly concerning in workers’ compensation claims as more serious injuries that may require long-term prescriptions often occur among older populations.
SMRs and Your Pharmacy Program
When evaluating SMR prescribing in your pharmacy program, make sure to look at a few key questions:
- Are these short-term prescriptions or longer-term?
- Are they being prescribed to an older or younger population?
- Are SMRs being co-prescribed with opioids or other medications that could cause health complications?
- Are there alternatives that your injured workers could be using?
Short-term use of skeletal muscle relaxants may be an effective alternative to opioids for selected patients, but continuing pain management is a complex issue that requires careful consideration of available treatments and the unique presentation of each patient to optimize best health outcomes. Continue to work with your pharmacy benefit manager to identify areas of concern and develop strategies to mitigate risk for your injured workers.
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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