Often the signs that opioids are being abused or misused can go undetected in a workers’ compensation claim because critical trends and information may not be easily visible. As a result, missing the various red flag situations can have serious safety consequences for the injured worker and negatively impact the outcome of the claim, highlighting the criticality of knowing what to monitor.
Top 5 Red Flags
According to Robert Goldberg, MD, FACOEM, an occupational medicine specialist and chief medical officer at Healthesystems, “Early warning signs of potential abuse or misuse frequently go unnoticed because some characteristics seem insignificant when considered in isolation. However, when multiple attributes are combined, they can reveal serious risks for inappropriate drug utilization. In order to identify characteristics that should raise red flags, the prescription data must be monitored from multiple perspectives.”
Adding to the challenge is that prescription data is received from disparate sources —paper bills and prescriptions processed electronically from network pharmacies – and requires a much more comprehensive data analytics approach.
There are a number of behaviors and events in opioid therapy that should prompt immediate intervention. The current issue of the RxInformer clinical journal published by workers’ comp PBM Healthesystems provides a comprehensive guide to help claims professionals quickly identify opioid misuse. The article, titled “Red Flags in Opioid Therapy,” is authored by industry-leading clinical pharmacists. It identifies the signs claims professionals should monitor, and recommends intervention strategies to help manage this complex issue. Several key scenarios are analyzed including the following top five red flag situations:
- A claimant receives various prescriptions for opioids, carisoprodol and benzodiazepine – a dangerous combination often acquired for illicit purposes.
- A claimant has a consistent pattern of attempting to strategically process their opioid prescription within the narrow allowable refill timeframe. If successful, after six months the pattern can yield an additional month supply, which is a signal of misuse or abuse.
- A claimant obtains opioid prescriptions from multiple physicians that are part of different physician practices. This can indicate an unauthorized dose escalation or doctor shopping.
- A claimant frequently changes pharmacies to obtain opioids — especially when the pharmacies are not part of the PBM network.
- A claimant receives prescriptions for four or more medications concurrently (polypharmacy).
Robert Goldberg, MD, FACOEM, is a board certified occupational medicine specialist and chief medical officer at Healthesystems, a leading PBM and ancillary medical benefits manager serving workers’ compensation payers. A past president of the American College of Occupational and Environmental Medicine, Dr. Goldberg is a nationally recognized authority on occupational medicine and musculoskeletal injuries.
Learn More
Read Dr. Goldberg’s Leaders Speak article on WorkCompWire for additional insights on the use of data to detect emerging prescription drug therapy risks.
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To read more about red flags in opioid therapy and other workers’ compensation-related topics, request a copy of RxInformer.
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