As part of our annual drug trends series, we’re taking a deeper dive into some of the therapeutic classes showing the biggest increases among the top 10 ranked by cost from our 2019 analysis.
2019 saw a slight upward shift in overall prescription trends through retail and mail-order channels in utilization per claim (up 0.8%), cost per claim (up 1.0%), and cost per script (up 0.2%). Except for opioids, the remaining top 10 therapeutic classes experienced increased utilization per claim, however, most by 3% or less. Those that increased more include the hematological class at 13.0%, the dermatological/topical class at 11.2%, antidepressants at 4.5%, and anticonvulsants at 3.2%. We’ll examine the impacts from the specialty drug hematological class more in a later installment. For now, let’s look at the other 3 classes with higher increases highlighted below.
The continuing decline of opioids in workers’ compensation has led to an increase in non-opioid medications, especially for the treatment of pain. Topical medications are often prescribed for pain relief or wound care following an injury, and their use is becoming more and more common. Again, an 11.2% increase in utilization was seen for this class from 2018 to 2019. The top contributors to cost within the topical class include prescription topical Nonsteroidal anti-inflammatory drugs (NSAIDs), private label topical analgesics (PLTAs), and compound kits/combo packs. Let us examine some of the primary drivers categorized by the types of topical preparations:
Topical anti-inflammatory agents: These represent the largest portion of utilization and cost within the topical class and include NSAIDs such as diclofenac 1% gel (generic for Voltaren) and branded products such as Flector® or Pennsaid®. Of note, diclofenac gel is expected to become available over-the-counter (OTC) in Spring 2020, according to the manufacturer.
Private Label Topical Analgesics (PLTAs): Products like Terocin (lidocaine 4%/menthol 4%) that typically combine items that are found in OTC products (e.g., lidocaine, menthol, capsaicin, methyl salicylate) in varying strengths at marked-up prices.
Compound kits/combo packs: This category consists of branded kits or packs that combine multiple, individually available products with a disproportionately high price tag (e.g. Xrylix™ is 1.5% diclofenac packaged with kinesiology tape with a price tag of nearly $5,000 per package).
Topical anesthetics: The bulk of this category is comprised of lidocaine products in various forms (i.e., gel, ointment, patch) ranging in strength from 1-5%, with many 4% products available OTC. ZTlido™, a topical patch containing lidocaine 1.8% and first approved by the Food and Drug Administration (FDA) in 2018 for pain associated with post-herpetic neuralgia (PHN), experienced the highest percentage of total cost for this category in 2019.
Wound care products: This category ranges from more costly products like Santyl® ointment (average ~$640/script) for wound debridement to burn agents like silvadene to very inexpensive OTC moisturizing creams and ointments.
Anti-infectives: These include anti-bacterial medications like mupirocin or Neosporin® as well as anti-fungal products such as nystatin and anti-viral products like Zovirax®.
Steroidal anti-inflammatory agents: Your typical topical steroids such as OTC hydrocortisone are found in this category, along with high-potency agents like betamethasone or clobetasol.
Increasing utilization of topical agents may be due to their ease of use, the lack of drug interactions when applied directly to the skin, and comparatively lower risk when used for pain relief vs. opioids. As you can see from some of the examples above, the price associated with select agents is a growing concern. As such, First Script continues to monitor and manage these and other price opportunists to ensure appropriate use and promote recommendations for therapeutic alternatives that are readily available, clinically appropriate, and cost effective.
Note: compounded topical medications are categorized separately.
Anticonvulsants/Antidepressants & Non-Tricyclic Antidepressants (TCA):
As opioid utilization continues to fall, an associated rise in the number of prescriptions for non-opioid pain medications and opioid adjunct therapies such as anticonvulsants and non-tricyclic antidepressants (TCA) has been seen. From 2018 to 2019 there was a 4.5% and 3.2% increase in utilization per claim of non-TCA antidepressants and anticonvulsants, respectively.
These classes are commonly used with opioids to provide added pain relief, and potentially reduce the need for opioids. They may also be used to treat certain types of pain such as chronic or nerve-related pain. As with NSAIDs, a rise in these therapeutic classes is a positive shift because it may indicate adjunct therapy being used in place of escalating opioid treatment.
The most common anticonvulsants prescribed were pregabalin (generic Lyrica®, which became available as a generic in the middle of 2019) and gabapentin (generic for Neurontin®). The anticonvulsants as a class may be used to treat pain because of their ability to create effective pain relief without the cravings, tolerance, or addiction issues that are associated with opioids.
Another therapeutic class commonly used to treat chronic pain is antidepressants, which may even be prescribed when depression is not a diagnosed condition for the injured worker.
Examples of non-TCA antidepressants that are used to treat pain include serotonin-norepinephrine reuptake inhibitor (SNRI) medications such as duloxetine (generic Cymbalta®) and venlafaxine (generic Effexor®). These can provide effective analgesia in pain conditions such as neuropathic pain, musculoskeletal pain, and fibromyalgia. Additionally, typical antidepressants known as selective serotonin reuptake inhibitors (SSRIs) like Zoloft®, Celexa® or Lexapro® are still commonplace in the management of mental health disorders that may result from stress or anguish caused from the injury.
The nation’s focus on the ongoing opioid epidemic and stricter guidelines on opioid prescribing has led to an increased utilization of non-opioid pain treatments in workers’ compensation that we continue to see through our drug trends analysis. Given the unique challenges 2020 has brought in the midst of the coronavirus pandemic and other stressors, it will be interesting to see how the drug trends change, or maybe not, in next year’s report.
1 Opioid class Includes opioid dependence medications