In a study published last month, the California Workers’ Compensation Institute found that the top 10% of doctors who prescribe extremely potent, highly addictive Schedule II opioids for injured workers in California account for nearly 80% of all workers’ compensation prescriptions for these narcotic drugs, and that nearly half of the prescriptions were for minor back injury claims. In a follow up to that study, CWCI examines the prescribing patterns for fentanyl, the most potent of the Schedule II opioids. Using the claim sample from the earlier study, the new report analyzes prescription data from the 16,890 California work injury claims in which Schedule II drugs were prescribed, as well as from the 5,253 non-surgical medical back claims from the sample, to measure the extent to which fentanyl is being used in California workers’ compensation. Among the key findings:

   • Overall, more than 1 out of 5 injured workers who received Schedule II opioids were prescribed fentanyl. Among those with non-surgical medical back problems (strains and sprains) who received Schedule II opioids, more than 1 out of 4 were given fentanyl; 
   • Fentanyl accounted for 20.3% of all Schedule II opioid prescriptions given to injured workers, and 21.8% of the Schedule II prescriptions dispensed to non-surgical medical back claimants; 
   • More than a quarter of the doctors who wrote Schedule II opioid prescriptions for injured workers prescribed fentanyl, while 3 out of 10 doctors who wrote Schedule II prescriptions for non-surgical medical back patients prescribed fentanyl.

As in the earlier analysis, the new study found that most of the fentanyl prescriptions for injured workers were written by a small percentage of the Schedule II opioid prescribers, with the top 10% accounting for 84% of the prescriptions. Use of fentanyl to treat non-surgical medical back problems was more widespread, however, as the top 10% of Schedule II prescribers accounted for 72% of the fentanyl prescriptions written for these claimants.

Most of the fentanyl prescriptions were transdermal patches, which have limited FDA approved uses and have been the subject of multiple FDA warnings. California workers’ compensation pain management guidelines also say the patches should only be used for chronic pain patients requiring round-the-clock therapy, who have developed a tolerance for other opioids, and whose pain cannot be managed by other therapy. Furthermore, there was no evidence of cancer-related illness or injury among any of the injured workers in the study sample, indicating that off-label use of fentanyl lozenges or tablets, which are only FDA approved for breakthrough, chronic cancer pain, has become an issue in the California system. The study found that off-label use of fentanyl was concentrated in the 10% of the claims (1,690 cases) with the highest volume of Schedule II opioid prescriptions, where nearly 12% (199 cases) had prescriptions for lozenges or tablets. A closer look showed the rate of off-label use was even higher for the top 10% of non-surgical medical back cases with the most Schedule II opioid prescriptions – where 77 of the 525 patients, or nearly 15%, were prescribed fentanyl lozenges or tablets.

More results, graphics, and commentary on the study are available in the CWCI Research Spotlight Report, "Prescribing Patterns of Schedule II Opioids Part 2: Fentanyl Prescriptions in California Workers’ Compensation," posted under Research on the Institute’s website, which can be accessed by clicking here.