Pharmacy Trends

Reports Shed Light on Latest Targets of PBMs

Pharmacy benefit managers are looking beyond opioids to identify other key risks negatively impacting costs and outcomes.
By: | June 23, 2014

Comorbidities, aging workers, and acetaminophen overuse are among the growing concerns in the workers’ comp system, according to several pharmacy benefit management companies. Three of the larger pharmacy benefit management companies have released data on costs and outcomes among their databases. While opioids continue to dominate the PBMs’ attention, the companies are also looking at several other emerging trends that impact costs and/or outcomes.


“Acetaminophen — Tylenol, other brands, generics — is one of the most commonly used drugs in the U.S.,” according to Express Scripts. “Effective in reducing pain and fever, acetaminophen is available in both prescription and OTC-strength products that often are used by injured workers.”

Because they are often combined with other ingredients, especially opioids, acetaminophens are sometimes taken by injured workers in doses that exceed the recommended 4,000 mg per day. Even a single overdose can cause permanent liver damage or even death.

“As a result of safety concerns, effective Jan. 14, 2014, the Food and Drug Administration requires manufacturers of prescription combination products that contain acetaminophen to limit the amount of acetaminophen to 325 mg in each dosage unit,” the report says. “In addition, the FDA plans to withdraw approval for any prescription drugs that continue to contain more than 325 mg.”

A review of approximately 400,000 injured workers last year found nearly 55 percent of the narcotic medications prescribed contained acetaminophen, according to Express Scripts. Hydrocodone-acetaminophen medications accounted for 75 percent of them.

The company says it has a program to identify injured workers who exceed the approved dose and relay the concerns to the prescribing physician.

“Results indicate that daily acetaminophen intake decreased to below 4,000 mg per day for 85.1 percent of the injured workers whose prescribing physician received an acetaminophen education letter,” according to the report.

Older Workers

“An aging workforce is the new norm,” states the drug trend analysis from Coventry/First Script. “As the workforce ages, First Script considers the age of the injured worker as a risk factor and is paying close attention to the impact medications have on older individuals in order to reduce the likelihood of injuries and to promote optimal outcomes when an injury does occur.”

Since older workers are more likely to have chronic conditions that may affect organ functions, drug metabolism can be an issue, as most medications are eliminated through the liver or kidneys. “As a result, other medications or alternative pain management modalities are often selected for pain management in older adults with poor liver or kidney function,” the Coventry/First Scripts report says.

The report also notes that medications taken for chronic conditions and comorbidities are more likely to contribute to drug interactions, and current medications must be considered when prescribing drugs for an injury. Care must be taken when prescribing muscle relaxants and opioids for older workers who are also taking sleep aids, certain antihistamines, anticonvulsants, or pain medications.

With the U.S. Bureau of Labor Statistics estimating that one in four American workers are likely to be at least 55 years of age by 2020, the company says a focus on prescription drug management for older workers is critical. The company uses various tools such as the Beers Criteria — a list of drugs with a high likelihood of serious side effects in patients older than 65.

“Ex­panded in 2003 and updated regularly, the Beers list is well-known and widely used today,” the report says. “It includes many medications commonly used in workers’ comp, including zolpidem (Ambien), many NSAIDs and muscle relaxants, and long- and short-acting benzodiazepines.”

The company uses the Beers list and evidence-based criteria to identify drug-age interactions and generate intervention alerts prior to the medication being dispensed. Also, prescription drug profiles can be triggered based on claimant demographics, prescriber patterns, drug utilization, and drug combinations.

“Prescription drug management in older workers requires informed choices and careful monitoring in order to increase safety, to encourage optimal treatment outcomes, and to help avoid re-injury,” the report states. “As older workers are projected to be a significant part of the workforce for decades to come, Coventry/First Script has a strategy in place with our clinical and pharmacy resources for this specific population.”

Comorbid Conditions

Depression, insomnia, and obesity can complicate and extend workers’ comp claims, explains Progressive Medical and PMSI. Each condition may prolong treatment or become compensable itself.

“Proactive management of these influences at every stage of the claim is therefore important to achieve better outcomes,” the company’s drug trend report says.

As one of the more common and disabling comorbid conditions, depression can also intensify the pain sensation. Some injured workers rely on pain medications to enhance their mood. “Unfortunately, opioid analgesics can further potentiate depressed feelings as a result of their frequent and well-known side effects, including but not limited to fatigue, nausea, and decreased libido,” according to the report. “Since depression usually has a multi-factorial origin, the key strategies to its successful treatment are early identification, eliminating or minimizing the effects of contributing factors, and establishing a multifaceted treatment program consisting of behavioral therapy and pharmacologic management. If underlying depression is not identified early and treated effectively, adequate pain relief can be hindered.”

Pain can create sleep difficulties for injured workers, which can prevent the body from getting restorative sleep. “One strategy is to ensure that the therapy regimen, both pharmacologic and non-pharmacological, accurately treats the underlying condition,” the report says. “A review of our transactional data from 2013 suggests that the use of sedatives and hypnotics is experiencing a downward trend, as the therapeutic class fell to the number eight position based on total spend.”

A higher incidence of pain, prolonged healing rates, increased depression, and anxiety are associated with obesity in the workers’ comp system, the report explains. Obesity may increase the predisposition for injury and negatively impact workers’ comp costs and lost workdays.

Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at [email protected].

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