Workers' Compensation

6 Drugs That Should Raise Red Flags on Any Workers’ Comp Claim

A variety of painkillers make the list, but they aren’t the only drugs that threaten patient safety and compromise outcomes.
By: | October 3, 2018 • 7 min read

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.” &

Katie Dwyer is an associate editor at Risk & Insurance®. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

4 Companies That Rocked It by Treating Injured Workers as Equals; Not Adversaries

The 2018 Teddy Award winners built their programs around people, not claims, and offer proof that a worker-centric approach is a smarter way to operate.
By: | October 30, 2018 • 3 min read

Across the workers’ compensation industry, the concept of a worker advocacy model has been around for a while, but has only seen notable adoption in recent years.

Even among those not adopting a formal advocacy approach, mindsets are shifting. Formerly claims-centric programs are becoming worker-centric and it’s a win all around: better outcomes; greater productivity; safer, healthier employees and a stronger bottom line.


That’s what you’ll see in this month’s issue of Risk & Insurance® when you read the profiles of the four recipients of the 2018 Theodore Roosevelt Workers’ Compensation and Disability Management Award, sponsored by PMA Companies. These four programs put workers front and center in everything they do.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top,” said Steve Legg, director of risk management for Starbucks.

Starbucks put claims reporting in the hands of its partners, an exemplary act of trust. The coffee company also put itself in workers’ shoes to identify and remove points of friction.

That led to a call center run by Starbucks’ TPA and a dedicated telephonic case management team so that partners can speak to a live person without the frustration of ‘phone tag’ and unanswered questions.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top.” — Steve Legg, director of risk management, Starbucks

Starbucks also implemented direct deposit for lost-time pay, eliminating stressful wait times for injured partners, and allowing them to focus on healing.

For Starbucks, as for all of the 2018 Teddy Award winners, the approach is netting measurable results. With higher partner satisfaction, it has seen a 50 percent decrease in litigation.

Teddy winner Main Line Health (MLH) adopted worker advocacy in a way that goes far beyond claims.

Employees who identify and report safety hazards can take credit for their actions by sending out a formal “Employee Safety Message” to nearly 11,000 mailboxes across the organization.

“The recognition is pretty cool,” said Steve Besack, system director, claims management and workers’ compensation for the health system.

MLH also takes a non-adversarial approach to workers with repeat injuries, seeing them as a resource for identifying areas of improvement.

“When you look at ‘repeat offenders’ in an unconventional way, they’re a great asset to the program, not a liability,” said Mike Miller, manager, workers’ compensation and employee safety for MLH.

Teddy winner Monmouth County, N.J. utilizes high-tech motion capture technology to reduce the chance of placing new hires in jobs that are likely to hurt them.

Monmouth County also adopted numerous wellness initiatives that help workers manage their weight and improve their wellbeing overall.

“You should see the looks on their faces when their cholesterol is down, they’ve lost weight and their blood sugar is better. We’ve had people lose 30 and 40 pounds,” said William McGuane, the county’s manager of benefits and workers’ compensation.


Do these sound like minor program elements? The math says otherwise: Claims severity has plunged from $5.5 million in 2009 to $1.3 million in 2017.

At the University of Pennsylvania, putting workers first means getting out from behind the desk and finding out what each one of them is tasked with, day in, day out — and looking for ways to make each of those tasks safer.

Regular observations across the sprawling campus have resulted in a phenomenal number of process and equipment changes that seem simple on their own, but in combination have created a substantially safer, healthier campus and improved employee morale.

UPenn’s workers’ comp costs, in the seven-digit figures in 2009, have been virtually cut in half.

Risk & Insurance® is proud to honor the work of these four organizations. We hope their stories inspire other organizations to be true partners with the employees they depend on. &

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]