Shifting Focus: Addressing Overlooked Medication Challenges in Workers’ Compensation

A narrow focus on the opioid epidemic may overlook the risks of non-opioid prescriptions and draw crucial resources away from proactive monitoring and interventions.

By: Dr. Devon Mahaney | November 9, 2023

Close up of a prescription pad showing an order for duloxetine

The opioid epidemic, which gained attention in the 1990s, has led to a significant focus on monitoring and managing opioid medication use. Even today, we continue to practice vigilance in opioid prescribing practices.

However, this sustained emphasis on opioids may have unintentionally shifted attention from other classes of medications that can also lead to unfavorable circumstances, potentially creating problems on a larger scale.

Here, we draw attention to one such medication — duloxetine, brand name Cymbalta, an SNRI antidepressant that is becoming a more prevalent concern in the workers’ compensation sector.

A recent assessment conducted by Broadspire using pharmacy benefit manager (PBM) data has uncovered a noticeable trend in high-dose¹ duloxetine prescriptions among injured workers. We’ll delve into the findings of the survey, shed light on the potential risks posed by these prescriptions and outline the proactive measures that claims managers and their risk management partners should be taking to address this critical issue.

The Opioid Era and Its Implications

According to the Center for Disease Control and Prevention (CDC), the onset of the opioid epidemic in the 1990s² prompted a widespread focus on opioid medication utilization.

This intensified scrutiny aimed to address the risks associated with opioid dependence, addiction, misuse and related adverse outcomes.

Over the years, monitoring opioid use has remained a priority in health care settings and in the management of workers’ compensation claims.

While the focus on opioids has undoubtedly been necessary, it may have inadvertently diverted attention from other classes of medications that could pose significant challenges and risks to injured workers.

The limited attention given to these medications may lead to missed opportunities for early intervention and the prevention of adverse outcomes.

It is incumbent on health care professionals and insurance adjusters to broaden their perspective beyond opioids and remain vigilant about the potential dangers associated with other medications.

Unveiling the Duloxetine Dilemma

Dr. Devon Mahaney, clinical pharmacist, Broadspire

Duloxetine, a selective serotonin and norepinephrine reuptake inhibitor (SNRI), garnered attention for its efficacy and frequent use in treating depression and various types of pain.

The medication is commonly prescribed for the management of various conditions, including major depressive disorder, generalized anxiety disorder, diabetic peripheral neuropathy (nerve damage causing pain) and fibromyalgia (a widespread chronic muscle pain condition).

While the recommended daily dosage of duloxetine³ typically does not exceed 60 mg, our data survey revealed a shocking truth: Approximately 20% of injured workers prescribed duloxetine are receiving doses that exceed the established limit.

Navigating Uncharted Territory

In the context of injured workers, managing pain and functional impairment is crucial for advancing their recovery and return to work.

Work-related injuries often result in acute and chronic pain, which can significantly impact an individual’s ability to perform job-related tasks and engage in daily activities. Effective pain management strategies are therefore essential in optimizing functional outcomes and promoting successful rehabilitation.

Despite duloxetine’s potential as an effective treatment for chronic pain, its specific efficacy and safety profile in the context of injured workers remain an area of interest. Best-practice clinical interventions should aim to support safe prescribing practices that align with published guidelines while ensuring optimal patient outcomes.

Balancing Benefits and Risks

The underlying mechanisms of neuropathic pain involve irregular signaling and processing of pain signals within the nervous system.

Duloxetine, as an SNRI, exerts its therapeutic effects through the modulation of both serotonin and norepinephrine neurotransmission in the central nervous system, thereby influencing pain perception and mood regulation.

While clinical studies have explored the potential benefits of duloxetine at higher doses⁴ (>60 mg per day) in patients with major depressive disorder, it is crucial to weigh these benefits against the associated risks.

Research suggests that higher doses may provide additional relief for those who have not adequately responded to lower doses, but they also bring an increased risk of adverse events. Therefore, a prudent approach is necessary when considering the initiation of treatment with high-dose duloxetine.

Approved by the U.S. Food and Drug Administration in 2004, duloxetine was first used to treat major depressive disorder (MDD) in adults.

Common side effects with duloxetine at doses of 60mg per day are nausea, dry mouth, dizziness, constipation, difficulty sleeping, excessive sweating, persistent weakness or fatigue, and high blood pressure.

The use of high-dose duloxetine prescriptions poses a significant concern, potentially amplifying the risks of adverse effects⁵ and drug interactions. Excessive doses and combinations of medications that affect serotonin (such as tramadol) can lead to a life-threatening condition known as serotonin syndrome, while combining duloxetine with benzodiazepines can make the effects of benzodiazepines even stronger.

A Proactive Response

By performing an evaluation of PBM data that manages medication utilization in workers’ compensation cases, we captured insights into the frequency and trends of duloxetine usage.

To ensure patient safety and adherence to established guidelines, Broadspire has embarked on a comprehensive safety project initiative to monitor and reduce the incidence of high-dose duloxetine prescriptions among injured workers. We suggest that others do the same.

To address the pressing issue of overutilization, our team has developed and implemented targeted interventions. Clinical communication to health care providers emphasizes the importance of adhering to recommended dosages and monitoring patient safety.

Additionally, we have established clinical alerts to serve as a tool to address the overprescription of high doses of duloxetine, polypharmacy and drug interactions. These interventions not only enhance awareness but also promote evidence-based prescribing practices and encourage appropriate utilization of duloxetine among injured workers.

In Conclusion

As we continue to address the opioid epidemic and strive to enhance opioid safety in workers’ compensation, it is equally important to widen our gaze and acknowledge the potential risks associated with medications beyond opioids.

Duloxetine, an SNRI antidepressant, serves as a compelling example. By maintaining a comprehensive approach that encompasses various medication classes, including duloxetine, we can better safeguard injured workers, minimize their risks and optimize their outcomes.

A proactive approach of monitoring and targeted clinical interventions can impact the percentage of injured workers receiving medication doses exceeding recommended limits. By prioritizing patient safety, promoting evidence-based prescribing and fostering awareness among health care providers, strides can be made toward mitigating the risks associated with high-dose duloxetine utilization.

It is our collective responsibility to stay vigilant, address emerging trends and take preventative measures that contribute to the wellbeing of injured workers. By actively engaging in efforts to optimize medication safety, we play a crucial role in facilitating their recovery, supporting their return to work and ultimately improving their overall quality of life. &

[1] High-dose duloxetine is defined as >60 mg per day.

[2] Center for Disease Control and Prevention. 2022, June 1. Opioid Data Analysis and Resources.

[3] Nelson C. Serotonin-norepinephrine reuptake inhibitors (SNRIs): Pharmacology, administration and side effects. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed December 17, 2020.

[4] Smith, J., & Johnson, R. (2006). The Impact of Medication Utilization on Patient Outcomes in Workers’ Compensation: A Comparative Analysis. Journal of Medical and Insurance Adjuster Research, 24(3), 123-136. Retrieved from https://pubmed.ncbi.nlm.nih.gov/16845641/

[5] Micca JL, Ruff D, Ahl J, Wohlreich MM. Safety and efficacy of duloxetine treatment in older and younger patients with osteoarthritis knee pain: a post hoc, subgroup analysis of two randomized, placebo-controlled trials. BMC Musculoskelet Disord. 2013;14:137. doi: 10.1186/1471-2474-14-137. PubMed 23590727

Dr. Devon Mahaney, PharmD, is a clinical pharmacist with Broadspire. She can be reached at [email protected].

Why Insureds Might See an Uptick in M&PL Claims

George Schalick, Jr., Senior Vice President of the Management and Professional Liability Division, Philadelphia Insurance Companies

The current soft market might come as a bit of a surprise as it does not track with previous underwriting cycles and economic conditions. Afterall, many privately held and non-profit organizations struggled during the early days of the pandemic with shutdowns and rapidly declining revenues. But the Government assistance programs, like the Paycheck Protection Program loans, helped keep many afloat during the tough times.

“During COVID many organizations stopped doing business until they were able to sort out all of the health and safety challenges,” Schalick said. “They were forced to lock down, but then all the government assistance programs allowed them to keep people employed. The increased volume of claims we anticipated we would see coming from the lockdowns and restrictions that were imposed upon businesses in the U.S. didn’t manifest at first.”

“Just because there wasn’t an onslaught of reported claims at the beginning of the pandemic, doesn’t mean the circumstances that would give rise to a claim being reported didn’t occur. Courts and the judicial system were closed or slowed and now that they are back open, we’re starting to see the circumstances that occurred during the COVID lockdowns becoming claims today,” Schalick said. “Litigation is progressing.”

Added to the delayed pandemic litigation is a concern over newer claims that might be filed as the country inches toward an economic downturn. Though a recession was avoided in 2023, experts think a soft dip could occur in 2024, with 76% of economists saying there’s a 50% or less chance of an economic downturn this year — that almost always results in more management liability claims.

“During the Great Recession in 2008, we saw an almost immediate spike in claims because of the economic conditions and the pressure it placed on organizations. They were making personnel changes with significant belt tightening almost immediately.” Schalick said.

What’s in Store for M&PL Policy Rates in 2024?

Despite an uptick in claims and increased economic uncertainty, management liability rates haven’t increased, resulting in market-wide pricing levels that may not meet the increased pressure of rising settlements and jury verdicts.

“Rates are going the other direction and settlement values are not falling,” Schalick said.

The mismatch between rates, claim frequency and severity is, in part, because carriers experiencing the dramatic soft market in the public D&O market are seeking premium gain in the private and non-profit market.

“In the public company market, the rates have been decreasing significantly. The rates were increasing in the private, not-for-profit market, and rightfully so, but there’s a desire to supplement overall mid-size D&O for carriers who also write private not-for-profit, and they see that as an opportunity to aggregate premium,” Schalick said. “So the always competitive landscape in the private, not-for-profit market has dramatically increased in the last 18 to 24 months.”

Still, companies of all sizes and types should be concerned about management liability rates in the future. Legal system abuse is resulting in increases in both the amount of litigation and the size of verdicts plaintiffs are receiving.

Certain areas of the country are particularly vulnerable to this type of legal system abuse. As a result, insureds in these localities are likely to be vulnerable to rate increases.

“The environment is so positive for the plaintiff that forces premium increases so carriers are able to stay in that market long term,” Schalick said.

Why a Tenured Carrier Partner Can Help Insureds Navigate An Uncertain Market

It’s clear that insureds are facing an uncertain M&PL market over the next few years. Fortunately, carriers with a long history in the M&PL space will be there to offer stability.

Philadelphia Insurance Companies has been supporting this market for 35 years. PHLY is committed to offering long-term rate stability, even as economic and claims trends start to push premiums upwards. They have an appetite for all sorts of companies, large and small, for-profit and nonprofit alike.

“We’ve been at this game for a long time and are one of the most tenured underwriters in this space,” Schalick said. “We like to stay very consistent.”

PHLY has worked with both for-profit and non-profit on management liability policies. With dedicated M&PL teams throughout the company’s 13 regions, PHLY provides the support agents and brokers are looking for on behalf of their clients. The teams know their regions well and can respond to local trends. They’re also dedicated to making the renewal process as easy as possible for their partners and policyholders.

“We have real confidence in our results, so we focus a lot on making the renewal experience as painless as possible for all agents and insureds,” Schalick said.

The company is also investing in tools to help insureds avoid losses. Earlier this year, they launched a new online risk management platform, PHLYGateway, which offers resources for insureds on how to create an employee handbook and trainings on issues such as recognizing workplace sexual harassment and discrimination.

If insureds have questions, they can consult a Best Practices Help Line, provided via the platform. That way, they can get on the spot risk management guidance to help them prevent claims.

To learn more, visit: https://www.phly.com/mplDivision/managementLiability/default.aspx.

This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Philadelphia Insurance Companies. The editorial staff of Risk & Insurance had no role in its preparation.

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