Reformulated Opioids: Are Abuse Deterrents Losing Their Promise?
No one can argue that opioid abuse — the focus of countless articles, debates and discussions — is not a concern in workers’ compensation.
For starters, estimates for this very specific patient population indicate that potent and highly addictive opioids account for approximately 25% of a payer’s total prescription costs. More specifically, oxycodone-based products, primarily OxyContin®, account for a large percentage of the total opioid spend for many workers’ compensation payers.
When considering that approximately one-third of all claimants who begin using an opioid for three or more consecutive months will continue using the drug for longer than one year, the situation gets even more worrisome. Also, research shows that continued opioid therapy is often associated with delays in returning to work and settling claims.
Taken together, those factors clearly pointed to the notion that something needed to be done to slow the growing opioid abuse trend, especially in workers’ compensation. One such effort occurred in August of 2010, when OxyContin OP, a crush-resistant and abuse-deterrent reformulation of OxyContin (oxycodone extended-release), entered the market, ostensibly to replace OxyContin OC, the original and highly abused formulation.
Unfortunately, the promise of abuse-deterrent forms of OxyContin may be more wishful thinking than reality. Certain segments of Healthesystems data shows that as time has passed, and after an initial spike in use of OxyContin OP, there have been many instances where physicians have shifted prescribing away from the OP formulation to other non-abuse deterrent opioid preparations, primarily Oxycodone IR and Opana ER (oxymorphone).
When analyzing the shifts in opioid utilization after the release of the abuse-deterrent OxyContin 18 months ago, Healthesystems reviewed prescription activity data for thirteen different opioids (see Table Below).
Of the opioids Healthesystems reviewed, the use of oxycodone immediate-release (IR) and OxyContin accounted for approximately 89% of the total opioids prescribed in 2011. Interestingly, in the months after the release of OxyContin OP, there was an almost 9% decrease in all types of OxyContin prescriptions (See Chart 5). Conversely, over the same time period, there was over a 5.3% increase in oxycodone IR prescriptions and a 2.1% increase in Opana ER (oxymorphone).
While this unfortunate trend was happening, much debate and discussion focused on OxyContin OP, questioning its effectiveness compared to the more abuse-prone version. Also, widely published information on the internet from illegitimate users have described OxyContin OP’s unfavorable characteristics and identified the obstacles that exist in trying to extract the active ingredient to get the same “high” experienced with the original formulation.
Clearly, something was driving this unexpected shift in prescribing away from the abuse-deterrent OxyContin OP. And while there may be a number of valid reasons, the trend from OxyContin OP to other, non-abuse deterrent opioid products points to a potential motivation driven by those who abuse opioids in workers’ compensation. For example, could the possibility exist that complaints by abusers to their medical prescriber influenced the prescription to move from OxyContin OP to another non-deterrent alternative?
Currently, with the impending release of the crush-resistant Opana ER, approved in December 2011 and expected to be available this spring, there is another potential opportunity for monitoring similar shifts in prescribing. Will there be an early spike and then decline in Opana ER prescriptions, similar to what happened with OxyContin OP? It remains to be seen, but should be monitored. With the development of abuse-deterrent formulations there was hope that a decrease in opioid abuse among workers’ comp claimants would follow. But so far, according to Healthesystems’ analysis, there seems to be a shift — even if unintended — toward more easily abused formulations.
One strategy for payers to employ is ensuring that injured workers using opioids participate in a pain management agreement with their prescriber and be subject to random urine drug screens. Also, PBMs and payers should initiate programs that encourage following up with prescribers in regards to an opioid exit plans is also recommended.
Whether abuse-deterrent opioid products end up having their intended effect is still unknown. For its part, Healthesystems will continue to proactively monitor and analyze prescription data to provide workers’ compensation payers with the insight necessary to stay ahead of the prescription drug curve, especially in this case where so much is at stake – for both payers and patients.