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.