Prescribing Pain Medications for Workers' Compensation Patients

LAS VEGAS — As many as 10% to 20% of patients who enter the worker's compensation system due to physical trauma go on to develop chronic pain due to either progression of the injury or the initial injury being severe in nature.

Patients who require long-term treatment may have started on typical medications, such as anti-inflammatory drugs and muscle relaxants, but in the long run these patients often have higher use of antidepressants, anticonvulsants, and long-acting opioids, according to Matthew P. Foster, PharmD, a senior clinical pharmacy manager with Helios. 

The most common injuries associated with the worker's compensation program include sprains, strains, burns, lacerations, and punctures, Dr. Foster explained, and some of these injuries go on to become chronic pain issues.  

“The top medication classes in workers' compensation are drastically different than group health,” Dr. Foster noted. For worker's compensation cases, opioids, anticonvulsants, nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, and muscle relaxants top the list of medications that are prescribed, whereas group health medications are more likely to include lipid regulators, antidepressants, beta-blockers, and antidiabetics.1

Currently, opioids are responsible for 30.9% of the total medication spend in workers' compensation. Overall, the top 10 therapeutic classes account for nearly 86% of the total spend, Dr. Foster noted.These prescribing trends can be influenced at least in part with the use of legal changes and treatment guidelines, he said.

One example of how prescriber behavior was influenced occurred when hydrocodone changed from a schedule III to a schedule II controlled substance.

“[Workmen's compensation patients] did see a drop in the number of prescriptions, but there was an increase in other medications, like oxycodone/APAP. Most disturbing was that the quantity per prescription of hydrocodone products went up by 15% to 20%,” Dr. Foster said. 

He noted that this most likely had to do with the physicians not being able to see their patients consistently every 4 weeks, and instead writing prescriptions for longer periods of time to hold patients over until their next visit. “This is one of the more troubling trends we're monitoring […] that there are more of these products being used based on the presumption that there will be a longer period of time in between refills.” 

The purpose of treatment guidelines is to establish evidence-based information that provides clarity for clinicians and patients, and to assist patients with functional improvement, returning to work, and keeping them informed, Dr. Foster explained. 

Currently, 3 main guidelines govern Workman's Compensation: Official Disability Guidelines (ODG), American College of Occupational and Environmental Medicine Guidelines (ACOEM), and individual state guidelines. 

Dr. Foster explained that the ODG guidelines detail specific work flows for clinicians, including detailing what pain complaint the patient has, the initial therapy prescribed, and other aspects of the individual patient. 

Some states have adopted legislation that adopt one or a hybrid of these guidelines, Dr. Foster said, adding that “more and more states are picking up this process of having their own guidelines.”

At the state level, Dr. Foster noted that the use of treatment guidelines for pain management has been shown to be very effective, with Texas showing a 76% decrease in nonformulary medication use, which includes a 65% decrease in opioid prescriptions. 3 

Discussing recently adopted ACOEM changes, Dr. Foster explained those specifically pertaining to morphine equivalency dosing (MED). After a review of several studies last year, the ACOEM recommended that “in most cases MED should be limited to 50 mg, particularly in the acute setting, although subacute and chronic pain patients may require higher doses.” 

Dr. Foster said the effect of this change is mainly on chronically injured workers. “This targets claimants for an earlier intervention to address ongoing pain management before doses continue to escalate.”  

However, even with treatment guidelines, there is still room for improvement. Dr. Foster noted that even though most treatment guidelines recommend urine drug testing at least once a year, compliance is still only approximately 30% to 40%.  

Disclosure: Dr. Foster reports he serves on the Workers' Compensation Advisory Board for Iroko Pharmaceuticals. 

Reference

  1. IMS Institute for Healthcare Informatics. National Prescription Audit. https://www.imshealth.com/ims/Global/Content/Insights/IMS%20Institute%20for%20Healthcare%20Informatics/IHII_Medicines_in_U.S_Report_2011.pdf. December 2010. Accessed September 9, 2015
  2. Helios. 2015 Workers' Compensation Drug Trend Report. http://www.helioscomp.com/insights/2015-drug-trends-report. Accessed September 9, 2015.
  3. Texas Department of Insurance. Worker's Compensation Research and Evaluation Group. https://www.tdi.state.tx.us/wc/regulation/roc/. Accessed September 9, 2015.
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