By Nikki Wilson, PharmD/MBA, Director, Clinical Products, Mitchell Pharmacy Solutions
In last week’s column we discussed fentanyl misuse leading to overdose and death, often occurring through illicit channels. However, there are legitimate, therapeutic uses for fentanyl, specifically for pain management, which can appear in workers’ compensation claims. That said, fentanyl products make up only about 2% of the opioid class prescription volume for both in-network and out-of-network transactions and may include fentanyl products such as:
- Duragesic transdermal patches
- Actiq lozenges
- Abstral sublingual tablets
- Fentora buccal tablets
- Lazanda nasal spray
- Onsolis buccal film
- Subsys sublingual spray
Fentanyl products are not typically included on a standard workers’ compensation pharmacy benefit management drug list. Due to their risks and limitations for use, these drugs often require prior authorization. In fact, unless a patient’s cancer diagnosis is considered work-related, FDA-indicated oral fentanyl products for breakthrough cancer pain would not be recommended as a pain management option within workers’ comp.
To ensure these medications are appropriately prescribed, clinical recommendations may include step therapy protocols to further intervene at the point-of-sale to ensure safe and cost-effective uses. In addition, many state formularies require that larger doses of opioids receive additional authorization. State-mandated workers’ compensation formularies now exist in a handful of states and provide more clarity on what medications can be approved for workers’ compensation claims.
Long-Term Opioid Use Requires a Different Approach
Through a concerted nationwide effort from the medical community, policymakers and health advocates, pre-pandemic prescription opioid overdose deaths had been trending downward in the past few years. However, there are thousands of injured employees who have been taking prescription opioids for many years that require close monitoring. According to Health and Human Services, these patients may also seek out other (non-medical) sources of opioids.
As the industry has worked to corral the opioid crisis, much focus has been on newly injured employees receiving opioid prescriptions. But older, legacy opioid claims require different considerations. When dealing with long-term opioid usage, evidence-based treatment guidelines advise against simply cutting off or drastically reducing the patient’s opioid prescriptions alone because this practice can have a host of negative outcomes such as extreme withdrawal, exacerbation of pain, psychological distress, and even thoughts of suicide. Careful monitoring of use, weaning of opioids over a specific time, the application of medication-assisted treatment, holistic support, and potential recovery programs should all be considered when looking for ways to provide better outcomes for those at risk.
Identifying At-Risk Patients Requires a Full View of All Prescriptions
Another way to approach this challenge in the chronic, high morphine-equivalent-dose (MED) population begins with an in-depth data analysis to identify at-risk patients with older claims. These patients fall into a “high-risk” category with prescribed MED levels greater than 90mg per day based on prescribing guidelines. An analysis found some injured employees with prescribed MED levels well above 500 MED, which raises additional concerns for potential diversion or fraudulent filling.
Along with high-MED opioid prescriptions, many of these injured employees were concurrently prescribed drugs that could increase the potential for overdose. Several such cases involved the so-called “holy trinity” combination of opioids, benzodiazepines and muscle relaxants. Intervention was apparent, but considerations were needed regarding the consequences of merely capping each individual’s MED at a level considered appropriate by treatment guidelines. A method emphasizing a personalized approach to each patient’s care is needed.
When trying to reduce opioid use among high-risk patients, choosing a one-size-fits-all approach can be detrimental – opioid usage may decrease, but patient care and outcomes are likely to worsen, possibly leading to other drug-seeking behaviors. Instead, a personalized approach that takes into consideration evidence-based guidelines along with the individual’s treatment regimen, medical history, and unique circumstances can lead to better outcomes.
Most workers’ comp claims involving chronic pain don’t start as high-risk claims; however, as time progresses, they can become physically deconditioned and dependent on opioid medications and lapse into a long-term state of disability. This further supports the critical need for comprehensive pain management programs. A complete view of the claim is vital for achieving progress and providing an injured worker with the best possible pain management protocols. To accomplish this, strategies are needed to allow visibility into all prescriptions, whether they are filled within or outside the pharmacy network.
Early Intervention is the Best Medicine
The complex nature of opioid management presents a need for a multidisciplinary opioid strategy that identifies injured employees who may be candidates for clinical outreach, naloxone to counteract opioid overdoses, and possible referrals for opioid recovery treatment programs. Early intervention is key to minimize and prevent risk by reducing the number of patients exposed to these medications and reduce hazards for those who continue to utilize an opioid regimen.
One study highlights the efficacy of evidence-based opioid programs that significantly reduce usage among acute claims. According to the findings, the program saw a 19.8% reduction in opioid-related fatalities and a 56.4% reduction of opioids dispensed vs prescribed.
Overall, these early intervention programs aim to minimize the downstream effects of medication cascades, drug-drug interactions, and potential for misuse, opioid use disorder, and overdose.
While addiction continues to be a problem in workers’ comp as well as the country at-large, through the adoption of more aggressive clinical management programs, opioid usage has continued to decline, down 38% over the past decade. Despite this, the CDC marked a record number of 100,000 drug overdoses in the 12-month period between April 2020 and 2021.
If we have learned anything about appropriate medication management, it’s that closely following all aspects of a claim from beginning to end is one of the best ways to garner the most positive outcome and avoid medication misuse that could inevitably lead to addiction and even death.
About Nikki Wilson
Nikki Wilson is a Pharm.D. who graduated with her Doctor of Pharmacy and MBA from Creighton University. As a licensed pharmacist, Wilson has over 13 years of comprehensive industry experience through leadership roles overseeing prescription home delivery programs, clinical pharmacy operations and benefit management, and product development.
Enlyte is the parent brand of Mitchell | Genex | Coventry, a leader in cost-containment technology, independent medical exams (IME), provider and specialty networks, case management services, pharmacy benefit and disability management. The three businesses have recently aligned their joint industry expertise and advanced technology solutions into a combined organization of nearly 6,000 associates committed to simplifying and optimizing property, casualty and disability claims processes and services.
Enlyte is a WorkCompWire ad partner.
This is NOT a paid placement.