Chronic pain is one of the most common, costly, and challengingissues that workers' compensation payers face. The toll it can takeon the life of the injured individual is just as dramatic, andcostly, on a personal level.

According to the American Pain Institute, an estimated 75million Americans experience serious pain annually. Of these cases,50 million involve chronic pain (pain lasting six months or more),while the remaining 25 million experience acute pain (frominjuries, accidents, surgeries, and the like). Included in thesestatistics are the many Americans who experience pain associatedwith on-the-job injuries.1

Pain's impact on workers' compensation costs is clear. A reportin the April 2009 Journal of the International Association for theStudy of Pain stated that when a workers' compensation claiminvolves Schedule II opioids (such as Percocet and OxyContin) forthe treatment of pain, the added cost of a claim averages nearly$20,000.2 In terms of return to work, the report said that the oddsof chronic work loss are six times greater for claimants takingSchedule II opioids than for those not taking opioids. Injuredworkers taking long-term opioids of any kind are 11 to 14 timesmore likely to experience chronic work loss.2

PMSI's annual Drug Trends in Workers' Compensation studiesconsistently report that 70 percent of total pharmacy spend inworkers' compensation is related to medications used to treat pain.PMSI's 2009 report noted that the leading medication prescribed forpain (oxycodone formulations) accounted for 9.3 percent of totaldrug costs; narcotic pain medications as a group accounted for 34percent of medication spend in workers' compensation cases.3

Issues in Pain Management

In recent years, medical standards of care have shiftedregarding the use of opioids for the treatment of pain. Not longago, the medical community followed a very conservative approach toopioid prescribing. An unintended consequence was theunder-treatment of patients with legitimate pain. As a result, newclinical guidelines now emphasize the need to accurately assess andeffectively treat pain in all patients. This desire for moreeffective pain management along with aggressive marketing ofprescription opioids to physicians by drug manufacturers has led tomore liberal prescribing of these agents for the conventional, aswell as off-label treatment, of pain. As a result, the use ofprescription opioids has soared. Between 1997 and 2006 overallopioid use increased 127 percent while oxycodone use increased by899 percent.4

This trend is most evident in the United States. AlthoughAmericans constitute just 4.6 percent of the world's population,they consume 80 percent of the global opioid supply, and 99 percentof the global hydrocodone supply. From 1997-2006, U.S. sales ofhydrocodone increased 244 percent and oxycodone sales increased 732percent.4

As opioid prescribing increases so does the related potentialfor fraud and abuse. Research indicates that overall opioid abuseis up 85 percent, with oxycodone abuse up 166 percent over asix-year period.5

The issue of opioid abuse and diversion is troubling in workers'compensation due to its negative impact on claims costs and returnto work. The challenge for prescribers, patients and employersalike is to promote the appropriate use of opioids while preventingmisuse, with the goal being the achievement of an optimal level ofpain control that promotes return to work and improved quality oflife.

One barrier to the more appropriate use of opioids is the lackof communication between and among physicians and pharmacies. It isnot surprising that patients utilizing multiple prescribers and/ormultiple pharmacies may be at risk for medication-related problems.That risk is intensified when managing chronic pain with opioids.PMSI's clinical programs detect the presence of two opioidprescribers in almost seven percent of the injured workerpopulation suffering from chronic pain. A smaller number ofindividuals see three, four or even five prescribers for theiropioid medications. These patients are at risk for overdose anddrug interactions that can lead to significant morbidity andmortality.

This issue is likely a contributing factor to a recent FDAadvisory board recommendation to ban the use of prescriptionopioids combination products containing acetaminophen (such asVicodin and Lortab) due to increased reports of overdose, resultingin severe complications and death.6

The complexity of medication therapy represents anotherchallenge in managing pain. It was not long ago that a physicianwould prescribe one medication to treat pain. Common practice nowis to prescribe two or three. Injured workers' prescription useoften moves beyond opioids to include adjunctive or supportivetherapy for pain management. Rather than a pain medication alone,patients may take antidepressants or anticonvulsants for paincontrol. As with the use of multiple prescribers, patients oncomplex medication regimens are inherently at risk for drug therapycomplications. Caution must be exercised by the prescriber and thepharmacist to avoid drug interactions, duplication of the therapy,and cumulative side effects such as sedation that could impair thepatient's functional status and hamper the likelihood of return towork.

Finally, there is the issue of unsafe pain medication use, agrowing problem in managing chronic pain. Although off-labelprescribing of medications (for indications not approved by theFood and Drug Administration) is common place in medicine,overzealous marketing practices by drug manufacturers and lack ofprescriber knowledge regarding potential complications can lead toserious and sometimes fatal consequences for patients. For example,deaths associated with Fentora, a rapid-acting form of fentanylused primarily in an off-label fashion in workers' compensation,prompted a manufacturer warning letter to prescribers in 2007urging them to use Fentora only for approved indications.7 Thisdrug, already FDA-approved for cancer pain, was recently denied anexpanded indication for the treatment of chronic back pain due toFDA concerns regarding the potential for unsafe use.8

Getting Pain (and Costs) Under Control

What can a payer do to facilitate the effective treatment ofpain for high-risk injured workers while maintaining control overdrug costs? The most direct and effective strategy is toparticipate in a Pain Management Program (PMP) specificallydesigned to address the complex issues and challenges associatedwith pain in workers' compensation.

The purpose of a PMP is to facilitate the appropriate treatmentof pain via integrated interventions that involve all stakeholdersin the care continuum. PMPs provide various levels of services andinterventions with the goal of improving pain control, reducingrisk and controlling costs. To achieve these objectives, theydeploy a highly integrated effort designed to identifyinappropriate medication use and implement interventions that willavoid poor health outcomes for injured workers and unnecessarycosts for payers. The program must detect and resolve drug therapyproblems on an ongoing basis throughout the injury lifecycle.

A PMP requires a clinically solid, evidence-based foundation, anexperienced clinical team, and robust data management capabilitiesfor optimal results. A Pharmacy Benefit Management (PBM) companythat leverages its unique visibility of all the prescription claimsprocessed for the payer's claimants with the pharmaceuticalexpertise of the clinical pharmacist can provide intelligentoversight to mitigate high-risk medication issues and improvepatient care. Early detection and intervention on drug therapyissues that can lead to poor health outcomes is critical to thesuccess of the program, as is the involvement of all stakeholdersincluding the patient, prescriber, pharmacist and payer.

Integrated Pain Management Programs

Integration of services is the underlying principle of aneffective PMP, as unlinked, disparate interventions are unlikely todeliver the best results. Other important capabilities include:

Utilization Control: Benefits both acute and chronically injuredworkers by managing access to pain medications through theapplication of clinically based, workers' compensation-specificcriteria to proactively evaluate medication appropriateness andcost-effectiveness at point of service.

Targeted Intervention: Applies analytics to identify high-riskand high-cost medication issues that might go unnoticed at theindividual prescriber or pharmacy level. Once issues areidentified, interventions focus on resolving inappropriatemedication use, therapeutic duplication and potential abuse ordiversion.

Care Management: Focuses on improving medication-relatedoutcomes for chronically injured, high-risk patients by promotingthe most appropriate and cost-effective treatment regimens for thelong-term management of pain.

Education: Offers a solid foundation of educational materialsand experienced clinicians to educate patients, prescribers andclaims professionals on the appropriate use of opioids and adjuvanttherapy in the treatment of pain so that successful patientoutcomes and optimal cost savings can be realized.

The Bottom Line: Innovation

In order to respond effectively to the ever-changing landscapeof pain management in workers' compensation, successful programsmust embrace innovation. The challenges associated with painmanagement today are many: Escalating use of opioids, abuse anddiversion, multiple prescribers, complex medication regimens, andunsafe prescribing practices. Tomorrow will bring new challengesand concerns.

Payers seeking effective pain management solutions shouldpartner with a PBM that offers an innovative, integrated painmanagement program. This program should incorporate various levelsof interventions throughout the injury lifecycle, be administeredby a strong clinical team, and have the goal of improving paincontrol, reducing risk and controlling costs.

Maria Sciame, PharmD, CDE, RRT, is theexecutive director of clinical services for PMSI. She will be partof panel on the topic, “Is There A Doctor In The House? How CanWorkers' Compensation Carriers Put A Lid On Drug Costs?” onTuesday, Aug. 17, at the FWCI 65th Annual Workers' CompensationEducational Conference and 22nd Annual Safety and Health Conferencein Orlando. Conference information is available at www.fwciweb.org.

References:

1 American Pain Foundation

2 Pain (Journal of the International Association for the Studyof Pain), 142 (2009) 194-201, April 2009

3 2009 PMSI Annual Drug Trends Report

4 Manachikanti, Laxmaiah, and Singh, Angelie, “TherapeuticOpioids: A Ten-Year Perspective of the Complexities andComplications of Escalating Use, Abuse, and Nonmedical Use ofOpioids.” Pain Physician, March 2008.

5 Atluri et al., “ASIPP Controlled Substance Guidelines,” PainPhysician, Vol. 6, No. 3, 2003.

6 Joint Meeting of the Drug Safety and Risk Mangement AdvisoryCommittee, Non-prescription Drugs Advisory Committee, and theAnesthetic and Life Support Drugs Advisory Committee Meeting, June20-30, 2009.

7 Cephalon. Fentora Safety Information Letter to Prescribers.September 2007.

8 Cephalon Press Release. Cephalon Announces FDA AdvivsoryCommittee Recommendations Against Approval of an Expanded Label forFentora. May 6, 2008.