Alternatives to Opioids When Addressing Pain Management in Workers' Compensation

A fuller awareness of the risks, costs, and consequences of opioid medication use in pain management for injured workers has been growing for some time, and the search for safe, effective, and affordable alternatives has taken on greater urgency. The quest for alternatives that offer a measure of effective analgesia (without tolerance, craving and/or addiction) is taking on an increased priority in discovery laboratories and across the ranks of practicing clinicians and other health care professionals. Beyond new discovery, another potential source of opioid alternatives are medications approved for other uses, and that may also hold promise for pain management.

If you have ever wondered why a medication that is assigned to a  different therapeutic category is used to treat pain, it is often because the assigned category is based on the first approved indication for its use and not the full appreciation of how it might actually be used in clinical practice.

When a medication is prescribed for a use that is not in the Food and Drug Administration (FDA) approved label, it is called “off-label” prescribing and happens when physicians expect or understand that a drug may be useful for a condition that isn’t listed. Off-label prescribing is a common practice.

A good example of this is anticonvulsant medications, which first came forward on applications for FDA approval based on studies that described their effectiveness and safety in seizure disorders. The known pharmacologic activity of anticonvulsants suggested a “calming” or “damping” effect on nerve transmission activity that might also be useful in reducing the sensation of pain. This formed a rational basis for studies that followed to validate their use in certain pain conditions.

Lyrica® (pregabalin) is FDA labeled both for partial onset seizures in adult patients and for several neuropathic pain conditions such as diabetic peripheral neuropathy, herpetic neuralgia, fibromyalgia, and nerve pain related to spinal injury.

Lyrica experienced significant growth in utilization and expenditures from its U.S. launch in 2004, and until recently, represented the leading branded medication for utilization and costs in the workers’ compensation pharmacy setting.¹ Mid 2019 saw the introduction of its first generic equivalent with numerous approved generic pregabalin products launching in the first months following patent expiration.²  Robust price competition soon followed and has resulted in significantly lower pricing for pregabalin.

Medications in other therapeutic categories also share this “crossover” effectiveness from one targeted condition to another, namely nonsteroidal anti-inflammatory drugs (NSAIDs) and certain antidepressant medications that have been studied and demonstrated to be effective in pain management.

Alternative prescribing constitutes the majority of antidepressant drug utilization in workers’ compensation settings. Antidepressants used to treat pain can provide effective analgesia in pain conditions such as neuropathic pain, musculoskeletal pain, and fibromyalgia. The pharmacological mechanism of these medications is not fully understood but is believed to work through the increase of neurotransmitters in the spinal cord that may reduce the conduction of pain signals to the brain.  

One antidepressant example is Cymbalta® (duloxetine), which the FDA approved in 2004 for the treatment of major depressive disorder. In addition to this first approved indication, the FDA has since added indications for the treatment of generalized anxiety disorder, fibromyalgia, chronic musculoskeletal pain, and neuropathic pain. Generic duloxetine became available in 2013 and is in the class of antidepressants known as the serotonin and norepinephrine reuptake inhibitors (SNRIs). This drug works by influencing the level of specific chemical messengers in the brain.

The use of duloxetine for pain treatment has received a boost with the FDA noting that it was effective for reducing pain in patients with or without major depressive disorder. Additionally, the degree of pain relief may have been greater in those with comorbid depression. Utilization in workers’ compensation has increased due to the fact that the same dose used to treat pain is the effective dose for treating depression and/or anxiety.

It should be acknowledged that antidepressants don’t work immediately to alleviate pain and most patients experience only moderate pain relief. However, antidepressant medications may be used safely in conjunction with other drug classes with faster onset of pain relief, such as NSAIDs.

The use of these “alternative” medications in the treatment of certain types of pain may have an impact in reducing the use, and thereby the risks, associated with opioids. These medications provide options in pain management because of their ability to provide effective pain relief without the cravings, tolerance, or addiction issues that are typically associated with opioids. That said, relief of pain and related suffering in any individual should be accomplished in keeping with their response to treatment. Expert industry guidelines, such as the Official Disability Guidelines (ODG) and American College of Occupational and Environmental Medicine (ACOEM), also support the use of some antidepressant and anticonvulsants to treat pain on a case-by-case basis. Stricter guidelines on opioid prescribing in initial treatment and continuing pain care may be contributing to increased utilization of these and other non-opioid pain treatments in workers’ compensation.

References:

1. First Script - 2017 Drug Trends Compilation – Published November 2018 - https://teams.sp16.aetna.com/sites/workerscomp/Marketing/Drug%20Trends/ DrugTrendsSeries-Compilation-20181109.pdf#search=Drug%20Trends 

2. https://drugstorenews.com/pharmacy/nine-generic-firms-get-fda-approval-for-generic-lyrica

By Craig Prince.

Craig Prince R.Ph. is a clinical pharmacist with First Script®, the pharmacy benefit management solution offered through Coventry. Craig supports pharmacy marketing communications, pharmacy and therapeutics (P&T) Committee operations, and opioid mitigation projects, as well as being a contributing author to Coventry’s Blog The Sounding Board.

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