By Silvia Sacalis, PharmD, Vice President of Clinical Services, Healthesystems
Workers’ comp has grown more complex as the care and conditions we manage continue to evolve, and industry professionals are taking notice.
Healthesystems partnered with Risk & Insurance magazine to conduct the 2020 Workers’ Comp Industry Insights Survey, collecting the opinions of 669 workers’ comp professionals across diverse roles and organizations to understand what challenges most concerned our industry.
A major insight from the survey is that workers’ comp professionals expressed great interest in new and emerging trends in care, which warrants a closer look into the clinical impact of these trends.
Survey respondents ranked population trends and the changing workforce as the biggest challenge facing the workers’ comp industry in 2020.
It’s no secret the aging workforce has been a subject of discussion for the last several years, and survey respondents ranked them the #1 population challenge across all roles and organizations. And when further questioned which populations might have the biggest impact on workers’ comp programs, survey responses led to this ranking:
- Aging workforce
- Millennials/younger workers
- Temporary/gig workers
- First responder coverage
- Racial, ethnic, and gender diversity
Clinical Considerations for Population Trends
Unique populations have unique health concerns that can impact workers’ comp claims. Among the aging workforce, this can include comorbidities – as 3 in 4 workers over 55 have at least one chronic health condition1 – and biologic changes that occur with age and impact how the body metabolizes and responds to medications.
But what clinical considerations come with other populations?
An estimated 32-40% of millennials prefer alternative therapies such as acupuncture, herbal remedies, and massage therapies to traditional prescription drugs,2 and roughly 1 in 5 millennials smokes marijuana regularly.3 Habits such as these can impact care following a workplace injury, making it imperative we engage these populations to address potential concerns.
In regard to first responders, the discussion has mainly focused on providing benefits related to post-traumatic stress disorder, though many states have also passed legislation to expand the various types of occupational cancers which fire fighters may be covered for under workers’ comp. Both of these trends reflect the need for updated formularies to provide access to adequate care, as well as programs tailored to illnesses not previously managed in workers’ comp.
And what concerns are associated with racial, ethnic and gender diversity? Members of different socioeconomic groups experience different health risks that could impact drug therapy. For instance:
- Black populations are 2x more likely to die from heart disease4
- Latino populations are 50% more likely to die from diabetes or liver disease5
- Women are 2x likely to be diagnosed with depression6
All of these patient populations may be at increased risk for drug interactions with medications they are taking for their chronic conditions if they are concurrently prescribed some of the more common medications used to treat workplace injuries.
There are various other factors that can impact injured workers and as such, workers’ compensation pharmacy programs must be flexible enough to address a wide range of potentialities.
Shifts in Chronic Pain Drug Therapy
Survey respondents ranked chronic pain as the top health risk concerning workers’ comp professionals, yet interestingly enough, opioids have become less of a concern for industry professionals, ranking them as the #4 health risk.
While the opioid epidemic has caused a remarkable level of damage, recent data indicates that healthcare professionals have begun to shift their prescribing habits. Not only has the CDC reported declines in opioid overdose deaths,7 prescribing,8 and average daily morphine milligram equivalents (MME),9 but other data indicates that prescribers are increasingly prescribing different types of pain medications.
California’s Workers’ Compensation Institute (CWCI) reported that nonsteroidal anti-inflammatory drugs (NSAIDs) surpassed opioids as the most common drug group among injured workers in 2019,10 and the Workers’ Compensation Research Institute (WCRI) reported that in 27 states the utilization of non-opioid pain therapies are on the rise.11
Clinical Considerations for Chronic Pain
While it’s great we’re shifting away from opioids, it is important that our industry understands there are still risks involved with other pain medications, some of which are controlled substances.
NSAIDs, typically used for aches and pains associated with various conditions, bring increased risks of high blood pressure and heart attacks, as early as the first few weeks of use,12 along with gastrointestinal concerns including stomach ulcers and intestinal bleeding.
Acetaminophen, which can also treat minor aches and pains, can cause liver toxicity over time, especially when used along with alcohol, and overdoses can be fatal. The risk of overdose is particularly concerning, as acetaminophen is also present in various combination drugs, meaning patients could unknowingly be taking large amounts of acetaminophen. An estimated 56,000 emergency department visits occur due to acetaminophen every year, along with 500 deaths.13
Gabapentinoids, which can be used to treat neuropathic pain, come with a multitude of risks including mood alterations, suicidal thoughts, difficulty breathing, potential for abuse, and overdose. The FDA recently warned against using gabapentinoids in patients with breathing disorders,14 and approximately 74,000 gabapentin exposures were reported to the U.S. Poison Centers from 2013-2017.15
Muscle relaxants, which can alleviate pain, carry the risk of mood changes and impaired thinking, paralysis, central nervous system (CNS) depression, respiratory failure, heart failure, and the potential for addiction and abuse. Toxic exposure to a single muscle relaxant, baclofen, increased 36.2% from 2014-2017.15
Because these medications contain unique risks, pharmacy programs must holistically and vigilantly monitor and manage injured workers and their patient-specific risk factors to prevent dangerous consequences and promote recovery.
One of the most significant and top of mind concerns for workers compensation professionals.
We’ve known for years that comorbidities significantly impact workers’ comp claims, and our survey respondents ranked comorbidities as their #1 program challenge overall.
It’s not surprising, considering 1 in 3 Americans has high blood pressure,16 and that over 30 million Americans have diabetes.17 Comorbidities are so prevalent that back in 2012, the NCCI reported comorbid diagnoses nearly tripled in workers’ comp over a decade, and that such diagnoses can double medical costs in claims.18
Clinical Considerations for Comorbidities
There are two main clinical strategies for addressing comorbidities: ensuring that pharmacy programs are built to accommodate patients with comorbidities and coordinating care between all providers that are involved in treating and caring for patients, inside and outside of workers compensation.
Pharmacy programs can be tailored to patients with comorbidities by combining clinical expertise with advanced algorithms and analytics to create better risk-detection tools. When pharmacy programs target a wider range of high-risk claim activity in workers’ comp populations, the detection of comorbid drug concerns can prevent previously unmanaged complications by flagging risks before they become problematic.
And when a patient with a comorbidity enters the workers’ comp system it is important to coordinate care between providers managing the workplace injury and providers managing the comorbidity. Having multiple prescribers can lead to drug-drug interactions, polypharmacy, therapeutic duplication, and worsening outcomes for injured workers.
A strong pharmacy program can detect these numerous and serious situations. Some of these include:
- Patients with respiratory comorbidities that are prescribed opioids for their pain; opioids increase the risk of respiratory depression, which can be fatal
- Patients with psychosocial disorders and high blood pressure; patients that are taking antidepressants and prescribed NSAID pain medications can experience increased blood pressure
- Patients with diabetes who are already at an increased risk for kidney complications; the prescription of NSAID pain medications can further impact the kidneys
The list goes on.
Pharmacy programs must be comprehensive, taking into consideration not just the drug therapies that are being used for the workplace injury, but also other treatments injured workers may be concurrently taking, as well as the various characteristics of the patients who receive them. This not only keeps patients safe and improves recovery efforts, but it reduces long-term medical costs by preventing complications that require additional care.
About Silvia Sacalis
Silvia Sacalis, BS, PharmD, provides clinical leadership and strategic direction as Vice President of Clinical Services at Healthesystems. Her healthcare 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 clinical services teams, the development of clinical programs, and integration of analytics technology coupled with clinical consultative support. Dr. Sacalis is a national thought leader and contributor to various industry presentations, publications and interviews.
Dr. Sacalis received her Bachelor of Science in Computer Science and Doctorate of Pharmacy degrees from the University of Illinois at Chicago.
Healthesystems 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 increasing the quality of care for injured workers. To learn more about Healthesystems, visit www.healthesystems.com.
Healthesystems is a WorkCompWire ad partner.
This is NOT a paid placement.
1Productive Aging and Work: Safety & Health. CDC/NIOSH. https://www.cdc.gov/niosh/topics/productiveaging/safetyandhealth.html
2Millennials are seeking the fountain of youth through healthy aging. Nielsen. http://www.nielsen.com/us/en/insights/news/2014/millennials-are-seeking-the-fountain-of-youth-through-healthy-aging.html
3One in eight U.S. adults say they smoke marijuana. Gallup Poll. http://news.gallup.com/poll/194195/adults-say-smoke-marijuana.aspx
4African American Health – Creating equal opportunities for health. CDC. https://www.cdc.gov/vitalsigns/aahealth/index.html
5Hispanic Health – CDC Vital Signs. CDC. https://www.cdc.gov/vitalsigns/hispanic-health
6Zhong W, Kremers HM, Yawn BP, et al. Time trends of antidepressant drug prescriptions in men versus women in a geographically defined US population. Archives of Women’s Mental Health. 2014;17(6):485-492. doi:10.1007/s00737-014-0450-7
7Hedegaard H, Minino AM, Warner M. Drug overdose death in the United States, 1999-2018. CDC/NCHS. https://www.cdc.gov/nchs/data/databriefs/db356-h.pdf
8Opioid Overdose: Prescribing practices. CDC. https://www.cdc.gov/drugoverdose/data/prescribing/prescribing-practices.html
92018 Annual surveillance report of drug-related risks and outcomes – United States. CDC. https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf
10Young B, Hayes S. California workers’ compensation prescription drug utilization & payment distributions, 2009-2018: Part 1. CWCI. https://www.cwci.org/document.php?file=4190.pdf
11Wang D, Thumula V, Liu TC. Interstate variations in dispensing of opioids, 5th edition. WCRI. https://www.wcrinet.org/reports/interstate-variations-in-dispensing-of-opioids-5th-edition
12FDA Drug Safety Communication: FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes. FDA. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-strengthens-warning-non-aspirin-nonsteroidal-anti-inflammatory
13Agrawal S, Khazeni B. Acetaminophen toxicity. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK441917/
14FDA warns about serious breathing problems with seizure and nerve pain medicines gabapentin (Neurontin, Gralise, Horizant) and pregabalin (Lyrica, Lyrica CR). FDA. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-serious-breathing-problems-seizure-and-nerve-pain-medicines-gabapentin-neurontin
15Reynolds K, Kaufman R, Korenoski A, et al. Trends in gabapentin and baclofen exposures reported to U.S. poison centers. https://doi.org/10.1080/15563650.2019.1687902
16More than 100 million Americans have high blood pressure, AHA says. American Heart Association. https://www.heart.org/en/news/2018/05/01/more-than-100-million-americans-have-high-blood-pressure-aha-says
17National diabetes statistics report 2020: estimates of diabetes and its burden in the United States. CDC. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
18Comorbidities in Workers’ Compensation. NCCI. https://www.ncci.com/Articles/Pages/II_research-brief-comorbidities-in-workers-compensation-2012.pdf