Pain is one of the most common reasons adults seek medical care in the United States. According to the Centers for Disease Control and Prevention (CDC), American healthcare providers write 259 million prescriptions for opioid pain medication each year — enough for every adult in the country to have their own bottle of pills. Meanwhile, there is insufficient evidence to support the long-term benefits of opioid therapy for chronic pain.
This longtime rise in opioid prescriptions has occurred in tandem with sharp increases in opioid-related overdose deaths and widespread opioid use disorder (OUD). Due to alarming reports regarding this epidemic, opioid use is finally trending down, according to the CDC — except for synthetics like fentanyl. Guidelines have changed in recent years to curb the use of opioids as a first-line approach to pain treatment not associated with cancer.
Prescribers are moving away from opioids and searching for safer pain treatment options. At the same time, patient prescriptions and workers’ compensation claims are seeing an uptick in opioid dependency management medications.
From opioids to alternatives: trends
As prescribers shift to alternative pain management methods, opioid prescription trends are moving in the right direction, as suggested in a 2023 Enlyte LLC report. From 2021 to 2022, the proportion of opioid scripts and costs dropped 1.3% and 2.5%, respectively. The number of injured employees using opioids has continued to decline (down 2.7%) as well.
Opioid potency in prescriptions has also dropped. Morphine milligram equivalents (MME) and morphine equivalency doses (MED), values used to compare the potency of an opioid dose relative to milligrams of morphine, determine a person’s cumulative intake of opioids in 24 hours and are helpful indicators of dose-related risk for adverse reactions, including overdose.
Dosages higher than 50 MME per day increase the risk of overdose at least twofold, compared to smaller ones, says the CDC. Importantly, opioid claims with high MED decreased from 2021, and average daily MED levels per script decreased as well (down 5.3% and 2.8%, respectively).
Opioid dependency/reversal medications on the rise
Even as workers’ comp claims involving opioid decline, there has been a notable rise in prescriptions for managing opioid use disorder (including in workers’ comp). These drugs, commonly referred to as medication-assisted treatment (MAT) or medications for opioid use disorder (MOUD), do not cure OUD — there is no known cure. It merely quells withdrawal symptoms. The drugs are, however, demonstrably safe and effective in treating OUD in combination with psychotherapy, such as cognitive behavioral therapy (CBT).
For patients using MAT, there is no real “exit plan” once beginning the treatment and no clear guidelines on how long to continue taking such medications. The Enlyte report found that claims involving prescriptions of MAT medications increased 11.6% from 2021 to 2022, while costs fell during that period. The increase can be attributed in part to injured workers staying on those medications indefinitely and the subsequent push for MAT treatment to be part of their workers’ comp benefits. It also reflects healthcare providers’ efforts to take a proactive and preventive stance on opioid dependency.
Naloxone, a drug used to reverse opioid overdose, is also on the rise in workers’ compensation claims. In 2022, 7.3% of injured workers prescribed opioids with MED>50 (an opioid dosage that increases the risk of overdose twofold) received naloxone, up from 2.5% since the year prior.
Recent regulatory changes likely influenced this trend. In some states, providers are now required to prescribe the drug anytime a high-dosage opioid prescription is filled. This is positive news. Naloxone can act as a safety net for patients — including injured workers — if they do overdose on opioids, and at the very least prevent the financial burden of an emergency room visit.
Effective pain management options
Solutions that have emerged to replace opioids include anti-convulsants (the generic prescription medications gabapentin and pregabalin), nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen, acetaminophen (i.e., Tylenol) and anti-depressants (duloxetine, for one). These medications have proven effective at improving symptoms of chronic pain and garner less dependence, which explains the significant increase in prescriptions.
There is still, however, potential for misuse or abuse. Use of gabapentinoids, specifically gabapentin and pregabalin, have raised concerns — even being FDA approved to treat neuropathic pain — that the medicines are being overprescribed. Both medications can be taken recreationally to produce a high. Some misuse the medications alongside opioids, which significantly increases the risk of unintentional opioid poisoning and death. Still, clinicians are increasingly prescribing both drugs for pain instead of opioids. A 2021 Workers’ Compensation Research Institute (WCRI) report explored the growing use of gabapentinoids for managing pain arising from work-related injuries, and according to a 2022 WCRI study, anti-convulsants are one of the top-three categories of medications by payment share that are prescribed to injured workers.
It is best to consider every patient holistically, as there are often psychological comorbidities that underlie pain and interfere with its resolution. Extensive evidence points to the benefits of nonpharmacologic treatments, such as behavioral health, coupled with non-opioid pharmacologic treatments. Exercise or stretching can increase function, and CBT has been shown to reduce pain intensity in chronic-pain sufferers.
Other types of pain management treatments, such as spinal cord stimulation and nerve blockers, come up in the context of workers’ comp claims, but few studies support their medical use.
Safety, regulatory concerns
Since opioids have fallen out of favor, some physicians have begun prescribing and dispensing over-the-counter, private-label topical medications that are not just expensive and contain higher than recommended strengths of active ingredient; they are also not FDA-approved. Private label topicals are considered specialized products and bypass established pharmacy safety measures with little-to-no utilization review. Drug companies are marketing directly to providers to dispense and prescribe their products — posing a clear financial conflict of interest and safety risk. Many states do not have regulations in place to address these concerns, and any state allowing physician dispensing cannot control how these medications are distributed.
To address such concern, Sedgwick’s dedicated and highly trained team of nurses and pharmacists uses our established proprietary risk analysis indicators and evidence-based medical treatment guidelines to identify unsafe medications, drug combinations and dosages. They utilize evidence-based practices to evaluate medication regimens and collaborate with prescribers to ensure patient safety and medication compliance on our clients’ workers’ compensation claims. Our team of pharmacy experts is here to help employers protect injured workers from harmful medications, treat their symptoms safely and effectively, and control prescription drug costs.
> Learn more — read about Sedgwick’s pharmacy solutions for U.S. workers’ compensation claims.