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Experts question motive behind changes to Calif. comp drug formulary

The California Division of Workers’ Compensation’s recent changes to the nine-month-old drug formulary specifically list several newly named drugs as prohibited for pain management — baffling experts who say some of these drugs are unusual for treating pain and wonder why they are being introduced into the new formulary language.

The changes, set to go into effect Oct. 1, now lists additional “nonexempt” opioids — as all opioids are listed as such and require a utilization review for prescribing usually after the first, limited fill — and a host of other substances that include vitamins, minerals, supplements and other pharmaceuticals outside the usual pain-management platform of drugs.

Estrogen is one example experts cited, as the hormone-replacement pharmaceuticals have rarely if ever been prescribed for pain stemming from a workplace injury. Others now on the list — from the body-building supplement creatine monohydrate to dehydroepiandrosterone, or DHEA, touted in medical journals as a muscle-builder and sex-enhancer — are also under scrutiny as to why they are necessary to list as prohibited on the comp formulary. Common pharmaceuticals such as antiviral drugs used to fight viruses are also a confusing new entry to the “nonexempt” list for chronic pain.

Experts say the introduction of such drugs into the formulary language begs the question: Have doctors in California treating injured workers in pain tried to prescribe such drugs and supplements?

“Antivirals?” Silvia Sacalis, a Tampa-based licensed pharmacist and vice president of clinical services for Healthesystems LLC, said, questioning the listing of two antiviral drugs on the revised list of banned drugs. “Maybe someone tried to use that for neuropathic pain. It would be very strange. Doctors may have tried to prescribe these in some instances,” leading to the revisions and additional language in the formulary, she said.

A spokesman for the division said the revised Medical Treatment Utilization Schedule Drug List is based on the American College of Occupational and Environmental Medicine Practice Guidelines, which uses an evidence-based approach in its recommendations for treating pain. The 2016 version of those guidelines — the most recent — already contained language stating that drugs such as the antivirals, creatine and vitamins now listed on the revised California formulary are not proven to be effective for pain management. Such medications and supplements were not included in the original California formulary, but are now added as “nonexempt,” in line with the ACOEM guidelines.

“My speculation is that (these drugs are) becoming an issue from a medical necessity perspective and a billing and prescribing pattern perspective; (claims adjusters) needed clarity on whether these (drugs) are appropriate for these kinds of conditions,” said Joe Paduda, Skaneateles, New York-based president of CompPharma LLC.

The shift away from opioids in comp has created a need for alternatives — even if they are unproven, he said. “I pity the adjuster who gets a script for estrogen” to treat chronic pain, he said.

The division spokesman wrote in an email that “physician/dispensing habits are not a factor in the MTUS Drug List updates” but did not answer follow-up questions regarding why the state did not initially include the medications from the 2016 guidelines in its formulary, which was finalized in 2017 and went into effect this year.

Mr. Paduda said the likely answer is that such drugs and substances have been prescribed and that “this is providers looking for alternative ways to deal with pain” and that the other rationale for addressing certain substances is the result of what he called a problem in workers compensation: physician dispensing.

“Is this profit seeking in the physician-dispensing industry?” he said of the practice of physicians selling and billing drugs at higher prices in their offices.

“I am sure doctor dispensing has something to do with it (and) I appreciate it being addressed in this way,” said Ms. Sacalis. “This list is going to keep growing and growing, while it is strange to see some of these listed (as not proven to treat) chronic pain.

“(The division is) taking a firm stance on it and I am sure it has to do with physician trends: that they are seeing these drugs coming through” the comp system, she said. “The only way they know what to address is to see the patterns.”

The division said in a statement on Sept. 6 that further updates to the drug list will be made “on a quarterly or more frequent basis.”