March 15, 2018

Dr. Silvia Sacalis: Women and Prescription Pain Meds – A Risky Proposition?

By Silvia Sacalis, PharmD, Vice President of Clinical Services, Healthesystems

Silvia SacalisThe phrase “injured worker” might bring to mind an image of a rugged, male construction worker. But this stereotype overlooks a significant portion of the injured worker population – women. With 40% of nonfatal occupational injuries reported in female workers,1 women represent a significant portion of the workers’ compensation population.

National Women’s Health Week was celebrated earlier this month, kicking off on Mother’s Day, May 8th. In light of this, I wanted to take the opportunity to speak about the female segment of the injured worker population. Specifically, I wanted to address the potential risks that women face when it comes to pain management.

Gender and Prescription Medication Misuse
There is broad public awareness that overdose deaths due to prescription pain medications, including opioids, have continued to increase over the last 15 years. But what may not be as widely understood is that the rate of increase has been disproportionately high among women. While men are still more likely to die from overdose, women are catching up, and the consequences are devastating2:

  • Overdose deaths from prescription pain medications have increased more than 400% among women over the last 15 years, compared to 265% among men
  • Every 3 minutes, a woman visits the emergency department due to prescription pain medications
  • Women between the ages of 25-54 – an age range that represents the working population – are the most susceptible
  • The risks aren’t limited to opioids. Emergency department visits due to antidepressants or benzodiazepines – two drug classes also commonly seen prescribed within workers’ compensation – are more frequent among women

While data from the Centers of Disease Control and Prevention (CDC) demonstrate a trend in the broader U.S. population, Healthesystems’ analytics confirm a consistent trend among injured workers. An analysis of more than 40,000 claims found that female gender was associated with elevated risk for prescription opioid misuse, along with certain socio-demographic, age, occupational and lifestyle factors3.

Two questions immediately come to mind in light of these statistics. First, why is this happening? And more importantly, how can we begin to combat this alarming trend?

Nature vs. Nurture?
One explanation put forth to explain the rapidly rising rates of prescription drug misuse in women focuses on biological and behavioral differences between genders. Studies have demonstrated that women are more susceptible to opioid cravings than are men.4 Research also suggests that women cope with pain differently than men and are more likely to turn to narcotics for similar pain levels. They are also more likely to misuse prescription opioids for conditions other than pain, such as anxiety.5 The CDC cites studies that indicate women may become dependent on prescription pain medications more quickly than men, and that they are also more likely to seek prescriptions for these medications through multiple physicians – a behavior known as “doctor shopping” that is a red flag for potential opioid misuse.2

But one can also make the case that these outcomes and behaviors are a product of the prescribing trends. The CDC also reports that women are more likely to be prescribed prescription pain medications, at higher doses, and for longer durations than men. If a higher volume and higher dosages of opioids are prescribed in the female population, statistically it would follow that higher rates of dependence and misuse would also occur in this population.

Why exactly are women being prescribed these medications more often? It may be because women are more likely to seek the care of a physician,6 creating opportunity for a prescription in the first place. In addition to the higher rates of opioid prescribing, in general, women are significantly more likely to use a prescription drug to manage health concerns when compared with men (56% vs 37%).7

Data also show that women are more sensitive to pain and are more likely to experience chronic pain. However, if evidence-based guidelines are followed, this shouldn’t explain the higher rates of opioid prescribing, because evidence-based medicine strongly advises against opioid treatment in the chronic long-term setting. Unfortunately, those of us involved in the management of workers’ compensation claims know this not to be the case. Nationally it remains a problem as well, with 9 million people in the United States reporting long-term medical use of opioids.8

Realistically, the trend of prescription pain medication misuse and overdose in women results from a combination of all of these factors. Regardless of causality, there is an opportunity to take these learnings and apply them to clinical decision making as it relates to the prescribing and management of drug therapies.

Managing Drug Therapy Risk
If gender itself is indeed a factor, should we start assuming that a female injured worker on prescription narcotics is likely to become dependent and addicted? Absolutely not. But it would be equally damaging to make clinical decisions that are gender-blind. Determining the most appropriate treatment for a patient requires taking into consideration individual patient characteristics – and gender is one of those considerations.

So, what does this mean for workers’ comp? There are certain gaps in healthcare that the workers’ compensation industry simply does not have the means to address. When it comes to female patients, the field of medicine has traditionally fallen short in understanding and meeting their specific needs. Historically, women have been underrepresented in clinical trials, meaning that much of medicine practiced today is based on experiences in men, despite biological and chemical differences between the genders that should be taken into account.9

However, as stewards of care in the injured worker, we can still strive to mitigate drug therapy risks in ALL injured worker patients, including those who are women. First and foremost, evidence-based medicine must guide prescribing. This includes using more conservative treatment approaches for managing pain before high-risk prescription medicines – such as opioids or benzodiazepines – are even considered. It also means screening for risk factors upfront, such as treatment history and a history of substance abuse.

Finally, truly effective patient management requires taking a holistic look at a claimant – including patient characteristics such as comorbidities, psychosocial concerns, and yes, gender. While being a woman should in no way become synonymous with risk, the trend of increasing misuse among this population is something that treatment providers, case managers, and others involved in her care would be wise to keep in mind.

About Silvia Sacalis
Silvia Sacalis, PharmD, provides clinical leadership as Vice President of Clinical Services at Healthesystems. Her experience and clinical expertise span the PBM, retail pharmacy and managed care environments. Leveraging her technology background, clinical skills and management expertise, she helps develop and operationalize strategic clinical initiatives to help workers’ compensation insurance payers maximize the impact of a pharmacy benefit management program. Throughout her career, she has held various leadership roles in which she provided oversight of the development of clinical services programs, and integration of analytics technology with clinical consultative support. Dr. Sacalis received her Bachelor of Science in Computer Science and Doctorate of Pharmacy degrees from the University of Illinois at Chicago.

About Healthesystems
Healthesystems LS LogoHealthesystems is a specialty provider of innovative medical cost management solutions for the workers’ compensation industry. The company’s comprehensive product portfolio includes a leading pharmacy benefit management (PBM) program, expert clinical review services, and a revolutionary ancillary benefits management (ABM) solution for prospectively managing ancillary medical services such as durable medical equipment (DME), home health, transportation and translation services. By leveraging innovation, powerful technology, clinical expertise and enhanced workflow automation tools, Healthesystems provides clients with flexible programs that reduce the total cost of medical care while improving the quality of care for injured workers. To learn more about Healthesystems visit

Healthesystems is a WorkCompWire Ad Partner.
This is not a paid placement.

1Bureau of Labor Statistics. Nonfatal occupational injuries and illnesses requiring days away from work, 2013 [news release]. December 2014.
2Centers for Disease Control and Prevention. Vital Signs: Prescription Painkiller Overdoses.
3Goldberg R, Manhertz H, Willis A. Estimating potential misuse of prescription opioids by injured workers in workers’ compensation. Poster presented at the American Academy of Pain Medicine 2016 Annual Meeting; Palm Springs, CA.
4Back SE, Payne RL, Wahlquist AH, et al. Comparative profiles of men and women with opioid dependence: results from a national multisite effectiveness trial. Am J Drug Abuse. 2011;37(5):313-23.
5McHugh RK, DeVito EE, Dodd D, et al. Gender differences in a clinical trial for prescription opioid dependence. J Subst Abuse Treat. 2013;45(1):38-43.
6Centers for Disease Control and Prevention. Variation in Physician Office Visit Rates by Patient Characteristics and State, 2012.
7Kaiser Family Foundation. Gender differences in health care, status, and use: spotlight on men’s health.
8Centers for Disease Control and Prevention. CDC grand rounds: prescription drug overdoses – a U.S. epidemic. MMWR Morb Mortal Wkly Rep. 2012;61(1):10-3.
9The Society for Women’s Health Research; U.S. Food and Drug Administration Office of Women’s Health. Dialogues on Diversifying Clinical Trials. September 2011.

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