Editor's note: Tron Emptage ischief clinical officer, Progressive Medical/PMSI, soon to be knownas Helios

Anne loved the hustle and bustle of her job. However, one day in2004, she hurt her lower back, left knee and right ankle atwork.

From that point on, things were very different. Over the nextseveral years, she sustained further injuries from falls, underwentlumbar surgery and had two unsuccessful spinal cord stimulatortrials. At one point, she was on very high doses of narcoticmedications and even went through inpatient detoxification. Today,at 57, Anne lives with chronic pain.

Most patients enter the workers' compensation system due tophysical injury, which often requires treatment for pain. As aresult, a significant proportion of workers' compensation pharmacyspend relates to the treatment of pain. Moreover, the medicationtherapy regimen commonly includes opioid analgesics.

These medications can be used successfully for short-term painrelief, however, their long-term use has been associated withseveral potentially serious side effects, as well as aberrantdrug-related behaviors, addiction and diversion. A recent Centersfor Disease Control and Prevention (CDC) report illustrates thispoint: 46 people die every day from an overdose of prescriptionpainkillers in the United States, and, in 2012, 259 millionprescriptions for painkillers were written—enough for everyAmerican adult to have a bottle of pills.

A report in the 2009 Journal of the InternationalAssociation for the Study of Pain further stated that when aworkers' compensation claim involved opioid analgesics, the claimcosts averaged nearly $20,000 more than claims without opioidanalgesics. Moreover, the odds of chronic work loss were six timesgreater when opioid analgesics were used.

However, claims do not have to become high-cost, high-risksituations. Resources are available to payers and injured workersthat can effectively keep, or if needed redirect, a claim on a paththat leads to a positive outcome. The key is to assemble thevarious products, services, expertise, tools and resources in sucha way that better decisions are made earlier on and throughout theclaim.

Pre-dispense controls

Before Anne even entered the workers' comp system, her employer,along with its claim administrator and pharmacy benefit manager(PBM), established programs, processes and procedures to helpensure that any employee, should they become injured, would receivethe right medications at the right time. At the foundation of theseefforts are pre-dispense controls.

Pre-dispense controls help claims professionals review andmanage medication utilization throughout the life of a claim.Useful in both acute and chronic injuries, these controls monitortriggers such as high-risk medication therapy, use of non-formularymedications (i.e. compounded medications) and therapy duplication.Some of the pre-dispense controls include medication plans andformularies, drug utilization review, and step therapy.

• Medication plans and formularies, often considered “the firstline of defense,” define approved medications for workplaceinjuries based on medical evidence and approved medical guidelines.Their use promotes appropriate medication utilization by requiringauthorization for medications that may not be injuryrelated.
• Drug utilization review (DUR)is a process used to alert thepharmacist of potential clinical and eligibility issues related toan injured worker. A payer's approach to medication plans andformularies, jurisdictional guidelines, and other business rulesinfluences DUR, as do advances in medicine, legislative policy andchanges in medical guidelines.
• Step therapy draws from clinical guidelines to identify optionsfor dispensing lower cost, yet therapeutically equivalentfirst-line medications to injured workers. For example, if Annepresents a prescription for a brand name medication when afirst-line and/or generic medication is therapeutically equivalentand has not been tried, the pharmacist may contact the prescriberand recommend a switch to an alternative medication.

Use of these, and other pre-dispense controls help preventunnecessary medication spend and promote optimal medication therapystarting with the first fill.

Claim escalation

As Anne's injury and chronic pain persists, new medications andtreatments are tried. This can escalate cost and introduce newrisks to the claim. Signs of a potential clinical concern includethe presence of multiple prescribers and/or dispensers of opioidanalgesic medications, use of high-cost brand name medications andprescription therapy exceeding recommended clinical guidelines, toname a few. Once identified, intervention of one type or anothermay be appropriate.

For example, medication monitoring through urine drug testingcan deliver accurate information on whether the injured worker isfollowing the prescribed therapy. Testing can identify aberrantmedication use (i.e., not taking prescribed medications) andnon-prescribed substance use, whether illicit or prescriptionmedication.

A maturing or escalating claim might also benefit frompsychological intervention. Depression is a recognized co-morbidcondition, commonly encountered in chronic pain claims. Feelingdepressed can exacerbate the pain experience, preclude completionof daily activities and delay (if not impede) recovery. Theeducational and emotional support provided by a psychologist canmake a positive difference in a claim, equipping the patient withcoping skills to reframe catastrophic thinking into positivethoughts and to offer relaxation techniques that reduce feelings offear.

Staying on a path toward better outcomes

The use of pre-dispense controls establishes a foundation forkeeping a claim on the right path from the very first fill. It setsthe stage for open communication, collaboration and coordinatedprocesses that emphasize timely, cost-effective treatment of theinjured worker to achieve better outcomes. As a claim matures,using all available tools and resources to improve the quality ofcare and overall efficacy of treatment, particularly medicationtherapy, can help assure claims follow the right path towardsmaximum medical improvement, and ultimately, settlement and/orreturn to work. The key is proactive coordination of resources,collaboration and open communication among all involved throughoutthe life of a pharmacy claim.