Formulary in LA: Would It Help with Opioid Abuse?

Baton Rouge, LA (WorkersCompensation.com) – Louisiana leads the nation in opioid abuse with officials hoping a new drug formulary will help fix the fatal problem. 

HB 592, based on the Work Loss Data Institute’s Official Disability Guidelines (ODG) Appendix A, would restrict the use of opioids among injured workers. And that’s a good thing to some, but not for others so it seems.

With an opioid epidemic sweeping the nation, Louisiana’s lead in narcotic abuse among injured workers would make the proposed legislation, sponsored by Rep. Kirk Talbot (R-Jefferson), a positive in its review, rule and regulation of the use of narcotic pain medication.

But it’s not, according to the Director of the Office of Workers’ Compensation (OWC) Sheral Kellar, who shared her opinion on her blog about the proposed formulary restrictions and the classification of drugs.

“Prescribing decisions and medications are best left to an injured workers’ treating physician. But, if HB 592 becomes law, it would establish the Official Disability Guidelines (ODG) Appendix A as the standard of care for dispensing medication to injured workers in Louisiana,” she said, adding opioids are “N” drugs that can be given, but are most often “subject to prospective utilization review to confirm the drug is medically necessary for treatment of the injured worker before being dispensed.” 

“Experience tells us that it can often take as long as 90 days or more. An injured worker should not have to wait 90 days to receive medication to relieve pain,” she added. Kellar’s office did not respond to WorkersCompensation.com for further comment by press time.

Rep. Talbot said Kellar's response is dishonest.

"It is disingenuous to suggest that formularies applying evidence-based medicine do not affect the problem of opioid abuse. The evidence from the Texas adoption of the ODG formulary and other workers’ compensation reforms shows reduced reliance on opioids and faster return-to-work times for injured workers," Rep. Talbot said.

"Texas is much larger than Louisiana, but it shares many of the same industries such as oil and gas exploration, refineries and chemical plants, construction, and agriculture. There is no reason that Louisiana could not share in the benefits of the ODG formulary," he said.

Rep. Talbot said he first learned of the opioid epidemic in Louisiana when serving as chair of an insurance panel. "It inspired me to bring this bill to ensure that a pharmacy formulary is in place for the workers’ compensation system," he said, adding, "I believe that the weak link is through the workers’ compensation system.”

Mark Pew, RX Professor and national speaker/author on the intersection of chronic pain and appropriate treatment, authored The Louisiana Trifecta, a blog detailing the proposed drug formulary in the state. He said since Gov. John Bel Edwards came out in opposition, it’s highly unlikely that HB 592 will pass the Senate.

“I don’t think it can be argued that work comp drug formularies have been successful in changing prescribing behavior to select less dangerous drugs (or even non-drug alternatives) in Ohio, Tennessee, Texas and Washington,” Pew said in an email to WorkersCompensation.com.

“If there are less prescriptions of oxycodone and alprazolam and carisoprodol, and there is a focus on alleviating pain in alternative methods, then by definition that will yield better clinical outcomes for injured workers. And that is the goal — to enable faster return to work/function with the least dangerous/most effective treatment. If HB 592 doesn’t pass, then it is imperative that the other bills related to the opioid epidemic but not specific to work comp need to move forward,” he added.

While Rep. Talbot is basing HB 592 off researched data, so is Kellar.

“Dr. Dillender’s opinion is supported by a June 2016 Workers’ Compensation Research Institute (WCRI) study, called ‘Longer Term Use of Opioids, 3rd Ed.’ This study drew data from more than 300,000 nonsurgical workers’ compensation claims with more than seven days of lost time over the study period,” Kellar said, noting results revealed an evident decrease in long-term opioid use among injured workers in 25 states, “most of which do not utilize a closed pharmacy formulary like ODG Appendix A.”

Bottom line is: It comes down to the attitudes of prescribers, Pew said. 

“It could be lack of education/understanding of opioid dangers and non-pharma alternatives, or a long-time establishment of a ‘status quo’ that has been difficult to combat, but those are true to some degree everywhere,” he said. Pew noted the over-prescription of opioids is often seen in many cases, including the elderly and “by dentists — who routinely prescribe a 30-day supply for an episode of pain that might last two days — and certainly in work comp.”

Managed Care Matters blog post “Sheral Kellar is Right About Formularies,” by Joe Paduda comments, “Kellar’s state has the second highest rate of opioid usage among workers comp patients, she is keenly aware of the issue” and “also knows a formulary is NOT a panacea, rather just one tool in the armamentarium.” 

“When you have docs using opioids as first-line pain meds — which clearly is the case in Louisiana, and they prescribe more than twice as much as the average state (which is already too high), and they prescribe more than one opioid most of the time, a formulary that automatically allows docs to prescribe hydrocodone — the most commonly used opioid in LA — is not a part of the solution,” according to Paduda.

Rep. Talbot said the ODG formulary is the most comprehensive and most frequently updated in use. “The proponents believe it will be the easiest to implement and best supported,” he said. “It would also provide the best fit within our current medical treatment guidelines,” he added.

Esquire Jeff Napolitano with Juge, Napolitano, Guilbeau, Ruli & Frieman, out of Metairie, LA, said the proposed legislation comes down to politics. “It became a political issue when it shouldn’t have been a political issue,” Napolitano said.

“Their motivation was one thing and their stated objection was something totally different,” he said of the Republicans and Democrats involved in the bill. He said along with politics comes price; another main reason many want to see the proposed formulary not succeed. 

Be it because of politics or prescribed by a doctor, easily attaining opioids has become too dangerous for injured workers and others, according to Pew. “It is a complex societal problem and thus the solution must be multi-faceted and utilize every possible evidence-based/statistically successful tactic. Which, in my mind, includes a work comp drug formulary,” he said.

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This article was updated as of 06/09/17.

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