The Perils of Pain Management

Barry experienced strain in his back, and before too long his doctor was prescribing upwards of $10,000 a month in medication. His case shows how a huge amount of drugs can be consumed to manage a pedestrian, non-surgical condition, without the treating doctor practicing abuse or fraud.

Rather, the doctor appears to have been trying to control his patient's pain, and depression arising from pain and disability, by adding drugs as the patient's symptoms evolved.

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Jim Andrews, a pharmacist and executive at Cypress Care, brought Barry's case (not his real name) to my attention. When an insurer engaged the firm's pharmacy benefit managers, Barry was taking six different narcotic analgesic drugs including two different strengths of Actiq lozenges, one muscle relaxant, one non-steroidal anti-inflammatory drug (NSAID), one medication for insomnia, one medication to combat daytime drowsiness, three medications used for depression, one drug to combat decreased mental ability, one drug for fluid retention or hypertension and one drug used for acid reflux--possibly the side effects of long term NSAID therapy, and several drugs to combat side effects from multiple opioid drugs.

This brew was costing between $6,000 and $10,000 a month.

As a layman, I envision someone with a hammer, blindly trying to hit every nail in sight. Andrews, more thoughtfully, sees a clinician in search of a medical solution. The clinician's challenge was, inch by inch, to find out what worked to control Barry's pain. Overmedication came about when the patient's volatile, migrating subjective pain perceptions were met with a practically unlimited number of specific solutions in the drug cabinet.

The goal of pain therapy, Andrews told me, should be to maximize function, reduce pain and improve quality of life. Opioids may not be the only pharmacologic medications utilized. There may be a requirement for adding "adjuvant analgesics." These are agents primarily developed--though not necessarily used--for nonanalgesic purposes. They include anti-depressants, anti-convulsants and anti-arrhythmics.

Barry's doctor just never gave up trying. First, he must have prescribed several pain drugs designed to provide immediate relief. More than one drug was likely needed because a single one would not address all of Barry's 24-hour pain experience.

Second, the doctor began to prescribe more extended-release pain medications on top of immediate-relief drugs. This happens in about half of the cases Andrews' firm reviews, most often with a finding of total disability. He surmises that Actiq--delivered by lollipop--may have entered into the case in this stage, to provide on-the-spot relief from pain spikes. This is used for the most severe conditions. Andrews doubts its necessity in Barry's case.

The treating doctor was most likely asking the patient to complete pain self-assessment tests, but probably failed to probe to find if the patient was highly functional in parts of daily life--driving, shopping, recreation.

Then there began cycles of new drugs to compensate for secondary effects of existing ones. The treating doctor never appeared to have erred triggering specific adverse interactions. But combinations and dosages led to trying, for example, to cope simultaneously with insomnia at night and drowsiness at day.

Barry was carefully relieved of much of his drug cargo after the case was removed from the treating physician. What does Barry's case suggest to you how when and how pharmacy expertise should be brought into the claims team?

PETER ROUSMANIERE, a Vermont-based consultant and writer, is the workers' comp columnist for Risk & Insurance®.

March 1, 2006

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