“Insidious Incrementalism” of Opioid Use in Workers’ Compensation
In 1991, there were 40 million prescriptions written for opioids. By 2007, that number skyrocketed to 180 million. Upwards of 20 percent of all doctor office visits include an opioid prescription. Along with the increase in prescription volume, the issue of safety has been a significant challenge. In 2009, more than 310,000 Americans were admitted to emergency rooms due to an opioid overdose, and the amount of Oxycontin dispensed in 2009 alone was enough to give every man, woman and child in America 100 mg.
When analyzing the impact opioids have had in workers’ compensation, this single drug class has become the highest utilized of all prescription drugs, accounting for 30% - 45% of most payers total annual drug spend. While the use and application of these drugs cover all claim age demographics, approximately 75 percent of opioid drug costs are generated from claims older than five years, but 75 percent of all claims are less than five years old.
“Insidious Incrementalism” — the incremental growth in opioid drug therapy costs as a claims ages
Insidious incrementalism is evident when looking at an entire population of claims and seeing the cost and utilization growth of opioids occuring between the initial year of service, after 5 years and then 13 to 15 years.
As illustrated in the “Drivers of Opioid Cost per Claim” graph, when analyzing the drivers of opioid cost over time, the major contributors are the increases in drug mix (potency) and in dosage amounts, while utilization (i.e., the number of pills dispensed per prescription), by comparison, is relatively small. For example, when comparing the opioid cost per claim for claims in service during their first year versus year 14, utilization makes the cost per claim 289% higher in year 14. Other contributors such as higher dosages and the use of increasingly more potent agents (drug mix) increase the cost per claim by 855% and 2,700% respectively. It’s the “incremental” increase in dosage and drug mix that begin manifesting during years 3 to 5 where the dramatic growth in costs per claim occur.
Other items become very apparent when analyzing the data in more detail. In 2007, opioid costs for claims 10 and 15 years old were heavily influenced by Fentanyl drugs (34.7% and 45.4% of total opioid costs respectively). This was likely due to the increased use of high priced, off label prescribed drugs like Actiq. Conversely Fentanyl represented a fairly small portion of opioid costs in the earlier stages of the claims lifecycle in 2007 at only 1.3% but increased to 9% in 2010.
The other driver impacting the total cost of opioids is the change in drug mix/potency. This can be clinically quantified by comparing the Morphene Equivalent Doses (MEDs) between drugs. For example, when comparing a 10 milligram dose of Morphine to a 10 milligram dose of Oxymorphone (Opana) or Hydromorphone (Dilaudid), both drug forms are 4 times more potent than Morphine. Also, Oxycontin is 1.5 times more potent than morphine. Therefore, the shifting in drug potency can not only be more expensive, but also more powerful.