Posted by Jeffrey A. Jacobs, M.D., M.P.H., Associate Medical Director
Last week I testified before the Pennsylvania House Labor and Industry Committee on the use of drug formularies in the workers’ compensation system.
It was the first time I have had the opportunity to testify before a government body and express my opinion about an issue I feel strongly about – the need for legislation to control over-prescribing of opioids and curb misuse and abuse.
In a memorandum, Rep. Ryan E. Mackenzie, author of the bill under consideration (HB 18), said the intent is to “reduce instances of opioid abuse and addiction stemming from our workers’ compensation system.” The proposed legislation would require the Pennsylvania Department of Labor and Industry to adopt an evidence-based drug formulary and establish certain standards for utilization review.
I was only allowed five minutes to speak, but my written testimony, which features a detailed analysis of the opioid epidemic, also became part of the record. I was able to touch on the three key points that I wanted the committee members to understand:
First, opioids have a role in the treatment of pain, but they are not the first-line medication in most situations.
- Available studies do not support the belief that opioids are better at pain relief than non-steroidal anti-inflammatory medications.
- Opioids have a high-risk profile relative to other analgesics.
- Opioid use delays recovery, increases the likelihood of chronic disability and raises costs.
Second, no one ever became a chronic pain patient without first going through the acute and sub-acute treatment phases.
- Front-line providers (primary care, occupational medicine, hospital emergency department, urgent care, and in some situations, orthopedic surgeons) bear the responsibility for promoting recovery in the first two to three months following an injury. Since the majority of individuals recover from musculoskeletal complaints in days to weeks with conservative treatment, decisions to use opioids in the acute phase of treatment at best are unnecessary and at worst may be the gateway to chronic use.
Third, there are non-pharmacologic tools available to the primary care provider that optimize the well-being of their patients with acute or chronic musculoskeletal pain.
- State prescription drug monitoring programs, opioid treatment agreements, urine drug monitoring and evidence-based drug formularies have shown success in reducing overprescribing of opioids and overdose deaths. In addition, non-pharmacologic treatments such as physical therapy and cognitive behavioral therapy for opioid addiction and dependence have shown success in improving chronic pain patient function and providing significant pain relief. They should be available and funded as an alternative to continuation of opioids.
Drug Formularies in Workers’ Compensation Systems, the American College of Occupational and Environmental Medicine suggests that “a decision to include, exclude or otherwise restrict certain medications in a formulary should optimally follow principles of evidence-based medicine, including a ranking of the strength of medical evidence about a drug’s efficacy and safety.” The college also recommends that states include specific provisions to measure a broad range of outcome variables in order to assess the impact, efficacy and cost of formulary adoption. Outcome measures may include total claim costs, rates of delayed return to work or delayed claim closure, utilization review costs, and patient and provider satisfaction.2016 position paper on
My remarks appeared to be well-received by the committee – after all, who could be against reducing death and disability from opioids? However, I observed powerful constituencies represented in the room that vociferously disagreed with the vehicle for achieving this reduction (evidence-based drug formularies).
I am not sure whether the Pennsylvania bill will make it out of committee, but as an introduction to the legislative process, I consider the Labor and Industry Committee hearing a small but positive step.