By Brian Carpenter, R.Ph., Vice President of Pharmacy, Coventry Workers’ Comp Services
“Did you take your pills today, dear?” The image of a member of the AARP generation lining up the day’s medications is almost a cliché. It’s a picture we need to look at more closely as workplace demographics change and employees stay on the job beyond traditional retirement age. As the workforce ages, it’s important to be aware of the impact of medications in older individuals in order to reduce the likelihood of injuries and to promote optimal outcomes when an injury does occur.
Drugs, dizziness and danger
Drug metabolism changes with age. Drugs stay in the body longer or are present in higher-than-average concentrations. Although the most marked decreases in drug metabolism occur after the age of 60, some data suggest that the decline begins as early as age 40. These results are significant as the Bureau of Labor Statistics has reported that one in five workers are over the age of 55 and by 2030 that number is expected to be one in four. When drugs stay in the body longer, they are more likely to cause unwanted side effects, or for side effects to have greater impact. For example, research data from New York University School of Medicine and from Albert Einstein College of Medicine show a significantly increased risk of falls and fractures for older adults individuals taking narcotics rather than non-narcotic pain relievers. Both opioids and anticonvulsants, often prescribed for chronic pain, can cause dizziness—a double danger when balance is declining. Citing data from the Centers for Disease Control and Prevention’s National Center for Health Statistics, a recent Los Angeles Times article notes that older workers may be more likely to take sleeping pills, which can cause next-day drowsiness, placing these individuals at higher risk of injury. The decrease in muscle mass and/or bone density that comes with age can mean that falls may be more likely to result in fractures, and that injuries may be more severe and take longer to heal.
To further complicate matters, older workers are more apt to have comorbidities or chronic conditions, such as diabetes, that can affect organ function. Most medications are eliminated through the liver or kidneys, so liver or kidney disease can impact drug metabolism and even limit the choice of medications. For example, non-steroidal anti-inflammatories (NSAIDs) can stress the kidneys, and acetaminophen can be hard on the liver. As a result, narcotics are often selected for pain management in older adults with poor liver or kidney function, but as noted above, opioids come with their own risks.
In addition to increasing injury risk, medications taken for chronic conditions and comorbidities are more likely to contribute to drug interactions in older adults. This is of particular concern in the event of an injury. Providers must take into account current medications when prescribing drugs for an injury. Muscle relaxants and narcotic pain medications must be prescribed with caution for individuals who are already taking sleep aids, certain antihistamines, anticonvulsants for depression, or pain medications for arthritis or other chronic conditions. It is especially important to recognize that older workers may be treated by multiple providers, each of whom is prescribing a different set of medications. A complete drug history is essential to providing the best outcomes.
Steering toward safety
All of the factors above can make prescription drug management more critical when the injured worker is older. Fortunately, tools are available to help promote drug safety in an aging population. In 1991 geriatrician Mark Beers developed a list of drugs—known as the Beers Criteria—with a high likelihood of serious side effects in patients over 65. Expanded in 2003 and updated regularly, the Beers list is well known and widely used today. It includes many medications commonly used in workers’ comp, including zolpidem (Ambien®), many NSAIDs and muscle relaxants, and long- and short-acting benzodiazepines.
A pharmacy benefit management (PBM) system should implement drug utilization edits based on the Beers list and evidence-based criteria for other demographic groups to generate intervention alerts at the point of sale. Before filling a potentially problematic prescription, the pharmacist can reach out to the prescriber to discuss concerns or treatment options. This prospective drug utilization review helps the pharmacist provide the best care possible.
From the case manager or adjuster perspective, prescription drug profiles can be useful tools. These reports can be triggered by a claim risk model based on claimant demographics, prescriber patterns, drug utilization and drug combinations. Such profiles can alert case managers and adjustors to potentially dangerous drugs or drug combinations. A 90-day medication history creates more context than a conventional alert and provides the workers’ comp team with the information necessary to support timely interventions on the front end.
One such intervention could be to initiate claim-specific drug utilization assessments, which take the injured worker’s age and comorbidities into account when reviewing appropriateness, drug interactions, dosing, morphine equivalency dose (MED) and number of prescriptions in order to optimize the current drug regimen. The profiling process may identify potential cases for assessment, with the goal being to simplify and minimize medications while ensuring that the injured worker receives necessary therapy. Such a review may prompt a peer-to-peer discussion with the prescriber to encourage safer medication choices. As a result of such discussions, in three out of four cases, the prescriber makes the necessary changes to the drug therapy following the discussion. When this information is made available to the case manager, he or she is able to confirm that the prescribing changes continue.
Shape a strategy
An aging workforce presents unique challenges. Aging bodies may be more vulnerable, and many popular medications increase the risk of injury, age-related side effects and undesirable drug interactions. Unfortunately, the answer is not always as simple as taking a particular drug or drug class off the table as an option. The optimal approach will depend on each individual’s health and other factors. 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. As older workers are projected to be a significant part of the workforce for decades to come, it makes sense to have a strategy in place to address these demographic changes—for everyone’s benefit.
About Brian Carpenter
Brian Carpenter, R.Ph., is vice president of pharmacy for Coventry Workers’ Comp Services. A registered pharmacist in several states, Carpenter has both workers’ comp and group health expertise in pharmacy benefit management (PBM) programs. He has been instrumental in bringing to market unique solutions to help payers with drug utilization management by focusing on claimant safety and creative drug management programs.
About Coventry WCS
Coventry Workers’ Comp Services, a division of Aetna, is the leading provider of cost and care management solutions for property and casualty insurance carriers, (workers’ compensation and auto insurers), third-party administrators and self-insured employers. We design best-in-class products and services to help our partners restore the health and productivity of injured workers and insureds as quickly and as cost effectively as possible. We accomplish this by developing and maintaining consultative, trusting partnerships with our clients and stakeholders, built on a foundation of innovative and customized solutions that support the claims management process.
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This is not a paid placement.