State Fund Looks to Put Soma Use to Bed
http://www.wcexec.com/state-fund-looks-to-put-soma-use-to-bed.aspx
Nearly 80 years ago, Aldous Huxley wrote in Brave New World about the wonders of a fictional drug called Soma and its benefits for society, but a real modern-day drug with the same name is anything but a benefit for society and the workers’ comp community, says one prominent medical director. With a host of other drugs available that carry far less baggage, he hopes to get Soma out of the California workers’ comp system, and he’s starting with his own claims first.
Gideon Letz, M.D., medical director for State Compensation Insurance Fund, and a respected leader in California’s workers’ comp medical community, is not necessarily a crusader in the traditional sense, but he is on a mission to end use of the drug Carisoprodol in the California workers’ comp system. Better known by its brand name Soma, the drug is not only one of the most commonly prescribed muscle relaxants, especially for back and neck injuries, it’s also one of the most commonly prescribed drugs overall.
That’s a problem, says Letz, because the drug has a high incidence of abuse and addiction.
“The problem with Soma is that it’s metabolized into another drug called Meprobamate, which has a lot of problems with it, but the primary one is that it’s very addictive,” Letz noted in an exclusive interview with Workers’ Comp Executive. “Meprobamate isn’t used anymore, but when you take Soma it is immediately metabolized in your liver into this Meprobamate drug.”
While it’s termed a muscle relaxant, Letz says it works more like a sleeping pill acting as a central nervous system depressant. “They work, because if you have muscle spasms and you take a central nervous system depressant, it basically makes you so sleepy that you relax,” he noted. But these depressant effects have also created a black-market demand for the drug, which now has a street value of $5 to $10 per pill.
“ … and this is a policy of our UR [utilization review] department, is that we’re not going to authorize any more of this Soma drug.”
— Dr. Gideon Letz,
State Fund
With estimates that 20% of all disability claims in California with a prescription have at least one for Soma — a rate that puts the Golden State among the highest Soma use rates in the nation — Letz says he’s working to reverse the trend.
“Basically, what we have said, and this is a policy of our UR [utilization review] department, is that we’re not going to authorize any more of this Soma drug,” he said. “We will allow for some taper because some of these people have been on it for years and are very addicted to it, but we’re not going to authorize it anymore.”
Alternatives Exist
Letz maintains that a number of other muscle relaxants on the market can do the job without the dangers associated with Soma. He named Flexeril as one likely substitute, pointing out that it’s commonly used “and has zero street value.”
While lauding it as a worthwhile goal, Alex Swedlow is not convinced that a total ban can be implemented under the current rules of engagement in California’s workers’ comp system.
Swedlow, researcher with California Workers’ Compensation Institute, notes that implementing the program is one thing, but getting denials to stand up in a dispute process might prove more difficult to sustain.
“We now have two sets of treatment guidelines and they don’t necessarily agree with each other,” Swedlow says, noting the Division of Workers’ Compensation’s decision to move beyond the American College of Occupational and Environmental Medicine (ACOEM) guidelines to also adopt the ODG chronic-pain guidelines. “How do you run an adjudication system when you have one set of guidelines saying one thing and the other something else?”
But Letz is not dissuaded, maintaining that State Fund’s position is supported by both sets of guidelines.
“As of this moment, I don’t know that we’ve made a dent in it yet. We just started this UR program. This is very recent,” he said. “But I think the word will get out and that within a year or two we’ll see this drug basically disappear.”
He’s already got one convert.
Bill Zachry, vice president of risk management for Safeway Inc., and a member of State Fund’s board, caught a recent presentation by Dr. Letz on the subject and was impressed.
“I wasn’t aware of how the drug metabolized. It may have been part of [Safeway’s] formulary, but to the extent that it was, it won’t be going forward, if there’s no ethical or moral reason for providing it,” he told Workers’ Comp Executive. “What an idea!”
Call Out the Docs
Beyond the UR process, Letz is bringing other pressures to bear to lower use rates not only for Soma but for all narcotics.
“It may have been part of [Safeway’s] formulary, but to the extent that it was, it won’t be going forward, if there’s no ethical or moral reason for providing it.”
— William Zachry,
Safeway
“Soma and narcotics are a major contributor to delayed recovery,” he told Workers’ Comp Executive, noting that studies have shown the longer that workers are off on workers’ comp, the less likely they are to ever return to the job. “ When you take these drugs, you don’t want to do anything, and the best treatment for patients with musculoskeletal pain conditions is activity and exercise, for many reasons, including psychosocial, but also physical.”
He maintains that these drugs, plus drugs such as Valium and Xanax, can be a short-term help, but he maintains that too many injured workers are kept on them for far too long. And to fix that, he says he’s going to target doctors.
Letz says the carrier is beginning to use its prescription benefit manager to help find high-risk cases with a lengthy pattern of prescriptions for Soma and other narcotics, and other counterproductive treatment patterns. In these cases, they’ll target doctors for an intervention to discuss their prescribing habits and treatment patterns.
“The thinking should be that the prescription isn’t working, so we should be trying something different instead of just upping the prescription,” he maintains, noting that many doctors prescribe drugs such as Soma out of habit and aren’t even aware of problems with it.
If the gentle nudges aren’t enough, Letz says State Fund is prepared to notify the Drug Enforcement Agency, the Medical Board of California and the Division of Workers’ Compensation. But such drastic measures are expected to be an uncommon occurrence. “I do know that whenever someone is watching them, then behavior changes,” Letz says of physicians.
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