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According to the National Council on Compensation Insurance Inc., four of the top ten prescriptions in 2005 and 2006 were narcotics. At Progressive Medical Inc., the Columbus, Ohio, Pharmacy Benefit Manager (PBM) for workers' compensation, the use of narcotic analgesics represents 37 percent of drug spending by clients, which include insurance carriers, third-party administrators and self-insured employers. That 37 percent is contrasted by the three percent use of narcotic analgesics in the group health world.

In addition, insurance carrier Liberty Mutual recently released data outlining how the growing use of powerful narcotics in treating work-related lower back pain results in longer recovery times and higher treatment costs for injured workers--one clearly negative result from this trend. The Liberty Mutual report, released via a Webinar, also noted that several of the powerful narcotics, such as Actiq and Fentora, originally developed to treat terminal cancer have become widely prescribed for low back pain.

Two Liberty Mutual studies have documented the negative impacts and geographic variability of treating work-related low back pain with narcotics.

According to those studies, medical providers prescribe narcotics well beyond accepted medical guidelines, rather than reserve narcotic use for only the most severe cases. Also, study data illustrate the clear association between early narcotic prescribing and negative medical outcomes for disabled workers--strongly suggesting that more intensive use of narcotics may delay recovery.

Also, higher amounts of narcotics in treating acute work-related low back pain cause injured workers to:

--Be away from work longer (up to 69 days longer).

--Have higher medical costs.

--Be three-times more likely to have surgery.

--Have six times the chance of using narcotics beyond the recommended time limited course.

Finally, the NCCI points out that as claims age, the narcotics' share of total drug costs increases due to a shift toward more expensive narcotics. And, in most jurisdictions, workers' compensation is responsible to continue to pay benefits to an injured employee who has become addicted to narcotic prescriptions as a result of their on-the-job injury. This could include any rehabilitation treatment necessary to break the addiction.

These negative trends in narcotics use to treat pain are no surprise to the folks at Progressive Medical, which offers its services in all 50 states.

"When you have a workplace injury, particularly in an economy with many job losses, there is unfortunately a financial incentive for some claimants to indicate a high level of pain," says Jason Winters, RPh, MBA, Clinical Services Manager, at Progressive Medical. Winters notes that while downsizing and layoffs come and go, indemnity payments associated with a workplace injury typically continue for the life of the ailment. One side effect of overstating a painful condition is the escalation of drug doses, particularly narcotics.

"Pain is very hard to objectively measure. Unlike diabetes or high blood pressure, there is no test or machine to verify the true extent of the discomfort," he says.

According to Tron Emptage, RPh, MA, Vice President, Strategic Initiatives, at Progressive

Medical, another critical issue when it comes to narcotics for workers' compensation injuries is the lack of education of the prescribers around adequate pain management.

"There are different types of pain, and due to that lack of education, instead of physicians using a wide level of treatments, they gravitate to narcotics," Emptage explains.

Of course, there also is the black market for narcotic painkillers such as Oxycontin, Vicodin and Percocet--which rank 1-2-3 among the leading drugs prescribed in Progressive Medical's 2007-2008 client analysis.

"These products have high street value," Emptage says. "So there is also the temptation for some injured workers to sell rather than use these dangerous drugs."

Then, there are the "downstream" costs associated with the overuse of pain medications. For example, the U.S. government estimates that $60 billion a year is wasted due to reduced output on the job with workers using these types of drugs, a situation called presenteeism.

"Pain management can cost tens of thousands of dollars in a single claim," Emptage says. "Workers' compensation payors are on the hook for it, not to mention the troublesome side effects from narcotics for the patient, everything from addiction to a reduction in testosterone levels."

Progressive Medical is working with its clients to find ways to turn these trends around. One particularly effective strategy is medical therapy management, which works with the providers by providing effective pain management education.

According to Progressive's Winters, another strategy is to educate providers on the use of alternatives to long-acting narcotic analgesics. He explains that inappropriate overuse of long-acting narcotic medications is often the result of a less-than-accurate diagnosis of the type of pain the patient is experiencing.

"Pain often contains a neuropathic (nerve) component, in addition to the tissue-damage component," he says. "Appropriate treatment for the neuropathic component of pain revolves less around narcotic analgesics, and more on classifications of drugs which are generally less prone to abuse/addiction, such as anti-convulsants or select anti-depressants. These alternative medications also often come at a reduced price for the carrier."

Another part of the Progressive effort is provider education around the use of urine drug tests as a way for healthcare providers to determine if patients taking prescribed opioids for chronic pain are using their medications as directed. Because of the high risk of drug diversion (selling on the black market), urine drug tests (UDTs) can be helpful in cases of suspected noncompliance, abuse and other types of misuse.

Because of the high risk for noncompliance and drug abuse inherent with the use of controlled substance medications commonly prescribed for patients being treated for chronic pain conditions, Progressive Medical recommends using periodic urine drugs tests to assess patient adherence.

"UDTs are commonly included in narcotic pain contracts to discourage medication misuse," Winters says. "While there is some debate about whether or not UDTs are sensitive enough to measure high or low drug levels, they are very effective in identifying when other illicit and controlled substances are being used, or when prescribed drugs are not being taken by patients."

By becoming aware of that type of behavior, Winters adds, providers have the ability to make therapeutic changes, hopefully improving patient outcomes, and better managing the patient's condition.

Progressive Medical has several programs directed at monitoring/reporting chronic opioid users that fall within each part of the company's Drug Utilization Review program.

Emptage explains that the medication strategy assigned to the claim determines if a narcotic would normally apply to that type of injury. When a particular strategy allows for a narcotic, the program has limits on the units used per day. Additionally, the acute medication strategies do not routinely allow for the introduction of the longer-acting narcotics, such as Oxycontin, Opana ER and Kadian.

Concurrently, at the point-of-sale, the dispensing pharmacist receives guidance from Progressive Medical on potential indicators of abuse through clinical messaging. This messaging alerts the pharmacist to behavior that may indicate fraud/abuse, such as using multiple pharmacies and doctors for different narcotics, or excessive early refill attempts.

Retrospectively, one month after each prescription is dispensed, Progressive Medical's clinical pharmacist team audits high dollar claims for indicators of inappropriate narcotic use. Among the factors audited are:

--Sole use of narcotics as treatment

--Use of multiple physicians

--Use of multiple long-acting narcotics

--Use of multiple short-acting narcotics

In addition, Progressive Medical currently is broadening the program to include additional auditing features including:

--Auditing prescribers for questionable prescribing patterns

--Searching for high narcotic dosing via the use of morphine equivalence

"Our clinical team works hard to balance clinical outcomes with money saving opportunities for our clients," Winters concludes.

For more information about how Progressive Medical can help your organization with its workers' compensation pharmaceutical benefit management, visit www.progressive-medical.com.

(The above piece is part of our continuing Insights series designed to highlight key products and services to our readers. This paid-for Insights was written and edited by Risk & Insurance® on behalf of our marketing partner. Additional Insights can be found on our Web site at www.riskandinsurance.com/.)

September 17, 2009

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