Every day, more than 115 people in the United States die after overdosing on opioids, according to the National Institute on Drug Abuse. Moreover, “the CDC estimates that the total economic burden of prescription opioid misuse alone in the U.S. is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement.”

Given the prevalence of pain as a symptom among injured workers, the workers’ compensation industry is heavily affected by inappropriate prescribing of painkillers — and the secondary medications that treat their side effects. According to NCCI, injured workers who received at least one prescription in 2016 received three times as many opioid prescriptions as the average.

Thanks to public awareness of the crippling dangers of opioid addiction, as well as a shift in workers’ comp toward patient advocacy, inappropriate prescriptions of high-risk or costly drugs have trended down over the past five years.

But incentives to close claims quickly and at minimal cost can still compromise the mission to, first and foremost, achieve the best clinical outcome possible for the patient.

“That’s a challenge in workers’ comp. People can have a very myopic perspective. The focus can persistently be on the cost of drugs and erring on the side of less expensive treatment even if it’s not the optimal treatment that could most effectively deliver quality care for the injured worker patient in the long run.,” said Silvia Sacalis, PharmD, VP, Clinical Services, Healthesystems.

According to Dr. Sacalis, six classes of drugs should raise red flags any time they appear on a workers’ compensation patient’s file:

1. Opioids

By now opioids’ addictive properties are well known, but that’s not their only downside.

Silvia Sacalis, PharmD, VP, Clinical Services, Healthesystems

“Opioids have a myriad of side effects, including constipation and gastrointestinal discomfort. They can also cause erectile dysfunction for men who use them long term,” Dr. Sacalis said. Long-term opioid use may also cause serious cardiac side effects including slow heart rate, low blood pressure, rapid irregular heart rhythm and depressed function of the heart muscle leading to heart failure, stroke or heart attack.

People with existing cardiovascular disease are especially at risk.

“There can be contraindications not just with other medications, but with conditions that a patient already has. One of the challenges in workers’ comp is that unfortunately, there isn’t always a complete patient history, so the treating physician may or may not be aware of things like chronically high blood pressure, diabetes or a family history of heart disease,” Dr. Sacalis said.

“Treatments should always take into consideration aspects of the injured worker’s health beyond the injury itself in order to prevent unnecessary harm from a prescription drug.”

2. Skeletal Muscle Relaxants

Muscle relaxers block transmission of pain signals from nerves to the brain, and they can be just as addictive as opioids. Some patients may be prescribed both opioids and muscle relaxants, which increases the risk of getting hooked or overdosing.

“Some skeletal muscle relaxants pose a higher risk than others, but one of the most offensive is Soma, due to its addictive properties both alone and when used in combination with opioids,” Dr. Sacalis said. “Patients are usually prescribed additional medications to counter these side effects, and they can be very costly.”

3. Benzodiazepines

Used to treat anxiety, benzodiazepines “quiet” the nerves and have a sedative effect. Used in combination with muscle relaxants and opioids — which also depress the central nervous system — that synergistic effect is dangerously magnified to the point where patients could have trouble breathing.

Even the FDA cautioned explicitly against using benzodiazepines concurrently with opioids, issuing a Drug Safety Communication in 2016 warning physicians and patients of their additive effect. According to the notice, “from 2004 to 2011, the rate of emergency department visits involving non-medical use of both drug classes increased significantly, with overdose deaths… nearly tripling during that period.”

4. Compound Creams

Custom formulations of topical analgesics gained popularity as a way to treat pain without taking a pill. But these concoctions mix drugs in ways that were never intended.

“Compounds have hampered our industry significantly,” Dr. Sacalis said. “The ingredients were never FDA-approved to be utilized that way. So combining different oral agents into a topical format poses a safety risk to patients, especially if they are taking the same medication orally, due to the duplicative effects of these drugs used in combination.”

In many cases, over-the-counter pain creams are a safe alternative to compounds. “We have started to see a positive shift to over-the-counter options that contain lower concentrations of active ingredients such as menthol, like Bengay,” Dr. Sacalis said.

5. Specialty Agents

The category of ‘specialty agents’ encompasses a range of primarily biological medications including oral, injectable, and infusible products that may require special handling, distribution, and patient management.

Hyaluronic acid injections fall under this umbrella — these are prescribed to treat joint pain in patients for whom other pain relievers haven’t worked, but are not necessarily FDA-approved for these indications. As do prophylactic agents, which are meant to be used immediately, on the site of the injury, to treat needle-stick injuries to prevent HIV, Hepatitis C and other infections.

“These medications aren’t necessarily bad, it just depends where in the course of treatment they’re administered,” Dr. Sacalis said. “Depending on the nature of the injury, they may pose an issue when they are used long-term or for off-label purposes, and we do see a lot of off-label use.”

Long-duration use of some of these types of drugs may be necessary but can pose safety concerns, especially if inappropriately administered or ineffectively treating an injured worker patient’s condition. These drugs can also be very expensive, hence the need for proper oversight and management.

6. Polypharmacy

Perhaps more so than any individual drug, a laundry list of medications sparks major concern for case managers as it increases the risk of adverse drug interactions and distracts physicians from the underlying problem at hand.

“Most opioid pain medications have a variety of side effects, and once you start to see two, three, four additional medications tacked on to the original treatment to mitigate the side effects of the opioids, it just lumps on new groups of potential side effects from those secondary medications,” Dr. Sacalis said.

This could indicate that there are multiple treating physicians who aren’t communicating with each other, but it often signals the need for a closer look to ensure that the patient’s primary condition is being addressed effectively.

“The solution shouldn’t be to keep treating side effects by adding more and more drugs. It should be addressing the underlying issue. Treat the injury, not just the pain associated with it.”

Alternative Treatments and Intervention

Proactive management of these higher-risk prescriptions can prevent some of the worst consequences. Patient education about the risks, regular monitoring of the patient’s adherence and progress, and clear communication among treating physicians, PBMs, case managers and payers can prevent treatment from spiraling out of control.

There are also lower-risk and lower-cost alternative treatment options available to replace these dangerous drugs.

“We are seeing positive prescribing shifts toward more appropriate therapies,” Dr. Sacalis said. Anticonvulsant agents like Lyrica, for example, have become more common for the treatment of neuropathic pain. Over-the-counter options like Tylenol can also be suitable.

Getting the right treatment options in front of patients requires understanding the nature and severity of their injury and the level of risk posed by various treatments. Some might do fine on a short course of opioids. Others — say, those with a history of addiction — should know their alternatives.

A variety of formulary management, patient monitoring and physician outreach tools can facilitate treatment interventions.

“We use analytics to stratify patients into high, moderate or low risk severity categories, which indicates what level or type of intervention is warranted. Some are focused on the patients, while others are targeted toward the prescribers and the pharmacies,” Dr. Sacalis said. “At the end of the day, our goal is to change inappropriate prescribing behavior and positively effect better quality care for the injured worker patient.” &