Safe and appropriate use of opioids begins at the moment of injury

The use of opioid analgesics is prevalent in the workers’ compensation population with nearly 70% of injured workers taking opioids. There is considerable concern about the safe and effective use of opioids, as so much focus is on abuse, misuse, addiction, dependence, and diversion of the medication. However, managed proactively with the assistance of a pharmacy benefit manager (PBM), opioids can be a safe and appropriate part of an injured worker’s medication therapy regimen.

Why the concern

Drug abuse is the leading cause of accidental death in the United States—ahead of both car and gun accidents. Prescription medications, especially opioid analgesics, have increasingly been the cause, now accounting for at least 60% of overdose deaths (Centers for Disease Control and Prevention, 2014). It’s a balancing act for employers to protect their injured workers and provide access to medication, such as opioids. A proactive PBM can help employers by providing tools that facilitate safe and appropriate use of opioid analgesics. Some of these tools are briefly outlined below:

Medication plans and formularies

Customized formularies based on body part, nature of injury, injury date, and state of jurisdiction can ensure that injured workers receive the right medication at the right time. For example, long-acting opioid analgesics might not be appropriate for a laceration or during the acute phase of an injury. By applying formularies at the time of dispense, oversight of the injured worker’s therapy can begin as early as the first fill and continue until closure/settlement.

Medication review

In situations where therapeutic issues regarding a claimant’s therapy do not resolve in a timely manner or in cases where a claims adjustor or nurse case manager would like a second set of eyes on a file, a PBM’s clinical service team can be invaluable. Their review of the injured worker’s medication profile and medical records compares actual use versus recommended use and can identify potential therapeutic duplications and drug-drug interactions, as well as other therapeutic concerns and intervention needs. The review findings are then discussed with the prescriber of record, helping foster an environment of open communication and collaboration that benefits payers and injured workers alike.

Clinical escalation alerts

At any given time, many claim professionals manage more than a hundred claims. Knowing when and which claims could benefit from a bit more attention can have a direct impact on outcomes – both clinically and financially. Alerts sent by the PBM to the claims professional, often facilitated via a claim management portal, do just that. They raise awareness of potential therapeutic concerns as well as identify possible misuse and abuse situation so that action may be taken.

Multiple prescriber service

An injured worker may have an existing prescription with his regular doctor for a condition unrelated to the injury and then receive another in the same class from the doctor treating the workers’ compensation injury, putting him at risk for over-utilization, drug-drug interactions, and misuse and abuse. This is particularly concerning when opioid analgesics are involved. Working with a PBM, payers can identify claims involving multiple prescribers and should it be necessary, intervene.

Early intervention and high-risk profiling

Certain factors in an injured worker’s profile, such as high doses of medications, duplication of opioid therapy, and the use of multiple pharmacies, can be indicators of potential misuse or abuse. The use of analytics, whether as part of an early intervention program or a high-risk profiling service, can identify possible therapeutic concerns earlier in the claim and facilitate communication with the prescriber to optimize therapy, if needed.

Drug testing and monitoring

Drug testing and monitoring can be useful in confirming adherence with the medication therapy regimen; potentially revealing long-term use of opioid medications, high-risk therapies, misuse, abuse, and diversion. A PBM and their urine drug testing and monitoring services can not only help facilitate cost-effective testing but also assist with communicating inconsistent results to the prescriber. A PBM’s clinical service team can also play an important role in creating an action plan with the payer and prescriber to monitor the injured worker’s ongoing therapy.

The aforementioned, combined with a PBM’s ability to capture prescriptions in-network, provide excellent (and accountable) service, deliver information timely and securely, and advocate for positive change are shown to effectively control pharmacy cost and utilization. The integration of a PBM’s tools, resources, and expertise into a payer’s claim management process can also effectively bend the curve away from the misuse and abuse of opioid analgesics, reducing risk to achieve better outcomes.

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