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Workers comp’s top problem drug

Actiq, the lollypop pain killer, is rapidly becoming the biggest problem drug in workers comp. FDA approved only for treating cancer pain, the potent narcotic is now on most payers’ top 5 drug list (ranked by dollars spent).
There are likely several factors that have enabled a drug clearly not approved for musculo-skeletal conditions to achieve this high “honor”.

Actiq’s premise is a rapid delivery of an opiod (fentanyl) to the pain centers via absorption through the mouth. It appears to work quickly and is quite effective. According to Cephalon (the drug’s manufacturer), Actiq’s ability to address pain is not specific to cancer, and it can be effective in addressing pain with other origins.
That effectiveness is likely a primary reason for the drug’s growing popularity. But so is the inability of many physicians to adequately deal with pain. From reviews of many workers comp case files, it is evident that many claimants receiving Actiq are being treated by primary care physicians, orthopods, and other specialties that do not traditionally have significant expertise in pain management. As a result, when confronted with a patient complaining of excessive pain, physicians appear to keep upping the ante, adding ever-more powerful drugs to the patient’s treatment plan.
Conversations with pharmacists, including Jim Andrews of Cypress Care (an HSA consulting client and workers comp Pharmacy Benefit Manager) support this view. Jim’s company has developed and implemented a sophisticated peer review approach to managing Actiq, resulting in termination of fully two-thirds of Actiq scripts. WIth a monthly cost in excess of $1200 (depending on dosage strength), that’s a lot of money.
Actiq will be going off patent in the near future. While that’s good news, it is not likely to reduce either the incidence of usage nor have a significant impact on price. Over the last year, Cephalon has raised Actiq’s price several times, resulting in a total effective price increase of over 40%. While a generic version is likely to hit the shelves this year, early indications are prices for the generic will be 10% below the brand.
What does this mean for you?
Workers comp payers have almost no ability to address drug pricing. If they are going to have any chance to gain control over drugs costs, payers will have to adopt intelligent, pro-active, clinically-based utilization control programs.

14 thoughts on “Workers comp’s top problem drug”

  1. So, again as usual, a useful legally prescribed procedure/medication is going to be second guessed by “Doctors” who are under the employ of the big insurance carriers. These paople constantly “Peer-Review” outrside their own specialty and since they have an opinion, of course, paid for again by the big guns, it will to be to AXE the procedure/medication for somebody who just really might need the prescription. Of course you are going to say “what about all of the mis-directed prescriptions… BLAH BLAH BLAH,,, ” There will always be bad apples,
    BUT, to allow off discipline peer reviews, coupled with paid for opin ions, and “WOW ” we have a single opinion against the patient, “NO POSSIBLE WAY ARE WE GOING TO PAY FOR THAT HORRIBLE STUFF” and another patient goes untreated. Maybe Dead… from his own hand from the frustration of dealing with the most recently profitable industry in the system… Insurers… Why is that???

  2. I have been successfully using Actiq for several years. My first ins. company covered it after a proir authorization. Then Medicare part D came into effect. They had to cover it for 60 days no questions asked. Then they refused because i don’t have cuurent cancer and was using it for severe migraines and back pain. So the doctor provided coupons for me. Today i went to refill my script and the coupons expired as of 9/30/06 due to the new generic version being available. And yes, the generic is very close in price. The pharmacy offered me a “deal” of $168.86 for a 2 week 6 unit supply. No go for me for I am on social security with income of $704 per month. Now due to my other drug failures and allergies i have nothing for break-through pain. Does anyone know of any help out there? perscription assistence programs won’t help because “i do have a script plan, they just don’t cover that drug”. Well, thanks for nothing PAPs.

  3. I too am being effected by the Actiq/Generic situation. For the past 7 yrs. I have been dealing with severe back and leg pain. I’ve had 2 surgeries, every procedure available and feel like I’ve tried EVERY medication available. I even resorted to an implanted pain pump whch has given me some relief but certainly not anything to be excited about. Actiq is the first and only medication I have taken that has given me adequate pain relief and allows me to have some normalcy to my life. Now all of a sudden my doctor says he wants me to try a different med -Fentora. It still cost me a small fortune and it has the effectiveness of a fizzy alkaseltzer would for pain. I’m sure the change has something to do with insurance politics, pharmaceutical politics and the FDA. As usual the “rules” and guidelines only apply and effect the people who really need the medication and now can not get it. So insurance companies and the FDA set guidelines that are made to keep the drug abusers and addicts from having access to the medication. Unfortunately a blind eye is turned to the patients that truly benefit from medications like Actiq and the abusers and addicts will simply obtain the drug illegally and go “happily” on their way and the rest of us will continue to suffer.

  4. I suffer from 4 herniated discs, 2 levels of stenosis. Scoliosis. Schmorls endplate, facet aerthritis. And a deformed thecal sac.
    Currently I Am using a 100 mcg fentanyl patch, and 30 mg Roxicodone for bt. The patch does nothing and I have to rely on the roxi.
    Thanks to you abusers out there, I Can’t get other LMeds that might work for me. Keep in mind how your decision to abuse opiates hurts otrher people!

  5. I have been unable to find a single medical website that doesn’t stress Actiq is intended for BREAKTHROUGH pain only, not for short or long term pain control. No one has any idea what the long-term effects of a drug like this are and anyone taking it on a regular basis are likely doing themselves more harm than good in the long run.

  6. ok first of all poster named AL you must not suffer from cronic pain like alot of us do !!!!!!!
    well Actiq is the only med that really works for me now “after yrs of narc meds” but now like many live in lots of pain and have thought about suicide even cause of the pain if not for wife and kids i might be “gone” by now. but i cant get it cuz ins. dont pay for it and cephilon “the maker” wont give it to me free cuz i dont have cancer so i suffer with lesser meds and only somany a month so i have to take 2-3x what the dr tels me to so my meds last me 1-2 weeks and im in pain again for 2-3 weeks with no meds =8-( well to cut this short the FDA sucks and the big business we call health care will not let DR. prescribe what they know patients need cuz they need to control things they think will help us

  7. I have been taking Actiq a number of year’s and was so greatful with the pain releif. I also take 200mg Fentinal Patch which helped some but with the Actiq for break through I was able to function again as a business woman, mother and homemaker. Since all this my Insurance Company (United Health Care) refuses to pay since I do not active cancer. I have been in two major auto accidents with broken bones and fractures all over my body. My noise has exposed nerves from the accident which is like the worst toothach you ever had times 10 every day of my life since I am without actiq. I don’t know how long I can survive like this? I now remain in bed almost 24 hrs a day I cannot work, take care of my home, or even sit and talk with my children and family I stay locked in my room in pain. It makes a person only wish to get cancer to get rid of the current pain. YOU GUYS DID A GREAT JOB I’M SURE YOUR MOMMA IS PROUD OF YOU

  8. I had three back surgeries and the third one is a two spinal fusion. Now i have nerve damage in my legs. The pain is very servere. Acitq works at times but Fentora works better. W/C has disapproved me from that. And now disapproving anything the doctors are giving me. What am i to do. The pain is killing me. Fentora is the only med out of all the meds i have that gives me some relief then no relief. The cost of fentora is high, so i guess thats why i can’t get it again. I am in a mess.

  9. I’ve had 4 back surgeries and am fuzed between L3-4 and L5-S1 and have taken Actiq for 5 years. All the sudden Aetna has decided to not cover Actiq, unless your a cancer patient. It seems, even though this has been covered for so many years without issue, the Aetna doctors and staff that review medications have decided what’s best for the patient. If this doesn’t reek of a big insurance company finding a way to save money, I don’t know what does. What gives them the right to know what’s the best treatment for me, when they’ve never seen me and have no idea what pain I live with on a daily basis. Actiq is the only pain medication I’ve taken that gives me relief and allows me to function without having that slowed down mental buzz feeling. It’s also amazing that Aetna knows better than a Pain Managment doctor who specializes in treating patients that live in pain. It’s pretty sad when I have to pay the premiums that I do, see a doctor that’s a specialist and Aetna can tell me what’s best for me. Again, it comes down to the dollar and not what’s best for the patient.

  10. Hello,
    I too have taken actiq for many years and it has been paid for all this time with aetna, I even switched to the generic and now I get a letter in the mail last month saying they will only cover 15 lollipops a day which is one every 1 every two days??? wtf??? they are even doing this with the new drug Fentora that my doctor wsnted me to switch to?? I hate health insurance companies. What am I going to do?????? without this medicine my pain will for sure be unbearable and nothing compares to the relief I get from this great medication!

  11. Hi everyone,
    Boy, I read all yor stories and it sounds like i’m reading about myself. I too am being tortured by the wounderful Work Comp System. I was injured in 1991, 2 ruptured thorasic discs, had all the norms, injections, stims, spinal fusion, trigger pts. you name it They did it. While all this was going on I was given a variety of meds by different Drs. until the Dr. would release me because they got fead up with W/C telling them how to do there job. Long story short turns out I am allergic to every medicine except fentanyl (Actiq) and Demeral. Also tape which left the Fentanyl patches out. Now in Texas W/C has a list of meds not allowed in the w/c system. Surprise, Actiq, the only med that not only helps me, but litteraly the only med I can take at the top of the list. So they have cornered me. I am now forced to have a pump put inside me to have my fentanyl put directly into my spinal fluid. I have to take the risks that go along with surgery and the pump itself to save Liberty Mutual the all Mighty Dollar. Real Bunch of Caring people there. you can tell real quick who they aren’t looking out for !!Good Luck to you all, I wish I could give you more. Your friend through pain, Cindy

  12. All I can say to the above comments is, “Amen”. I’ve also been using Actiq for chronic intractable pain for more than 4 years now, including an entire year of paying for Actiq completely out of pocket. It started off as $600.00/week, and before the year was out, it was up to $1,200.00/week. Yes, that’s right, a more than 100% price increase inside of one year from Cephalon, and over $60,000.00 out of pocket for this ONE medication. As you can probably surmise, Actiq is the ONLY medicine that has had any success with controlling my pain. This medication is what allowed me to even hold a job – but without insurance coverage, my entire salary went to pay for it.
    When I checked around the web looking for some justification for the tremendous and rapid price increase, the only thing I found was a transcript of a Cephalon quarterly investor’s conference call. The Cephalon managers were positively cackling that they were able to more than double the price of Actiq in less than one year and only loose 4% of their prescriptions. And then the government allows Cephalon to buy the only other company on earth that was making a similar, fentenyl based transmucosal break-thru pain medication. They approved that transaction because Cephalon told the government regulators that granting an exclusive license to manufacturer and distribute Actiq to Barr would ensure “competition”. Since when do the words “generic” and “exclusive” even show up in the same day??!? Basically, we have Cephalon and the government telling us, “Screw you while we get paid.”
    When asked by Doctors if I have ever considered suicide, I tell them that if a chronic pain patient tells you they have not thought of ending their own lives, they are either lying to you or lying about being in pain. Maybe we should start a trend: Walk into the insurers/doctors/governments office, whichever one is most responsible for ignoring our medical needs, explain our pain and our problems with not being able to get or afford the medication we need to lead some semblance of a normal life, then blow our brains out right there in front of them. Maybe if that starts happening 4 or 5 times a week, something might FINALLY get done that actually helps us.
    Can you tell I’m frustrated?

  13. I had cancer. So, getting Duragesic or Actiq was easy. For the first year, it was not a big deal. The pain clinics made sure I had plenty of everything. After a year, they cut everything as I no longer had cancer. The pain sure wasn’t gone….. It was an ugly
    several years before the pain went away – with inadequate pain control and meds. Makes one wish they got the cancer back to have access to whatever.

  14. Wholesale cost of fentanyl citrate is $100/GRAM. That is 10c for 1000 mcg. The rest of the lollipop is sugar. If this isn’t a rip-off, I don’t know what is.

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Joe Paduda is the principal of Health Strategy Associates



A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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