At the 2017 Business Insurance/CLM Workers’ Compensation Conference a panel discussed the controversial issue of polypharmacy from the perspectives of the medical community and the claims/legal community. The panel was:
- Greg McKenna – Vice President, Gallagher Bassett
- Bill Pipkin – Attorney, Austin Lewis Pipkin and Maddox LLC
- Dave Randolph – Medical Director, Midwest Occupational Health Management
Polypharmacy means taking a LOT of medications. In workers’ compensation, injured workers taking too many medications can be a significant cost driver on claim. Too often multiple medications are prescribed to treat symptoms rather than trying to get to to the root cause of the problem and treat the diagnosis. The medications treating the side effects of a condition can cause their own side effects leading to even more medications. This can build on itself until the injured worker is taking so many medications that the side effects from these are actually more debilitating than the underlying injury.
Pain is subjective, but there are very objective measures of this. A person who says their pain is a 10 on a scale of 1-10 should not have normal pulse, blood pressure, etc. There are many “syndromes” such as complex regional pain, fibromyalgia, reflex sympathetic dystrophy that are based on subjective pain complaints which that can lead to a significant amount of medical treatment with little to no objective findings.
There are many factors that increase the risk of poor outcome when it comes to use of pharmacy on claims.
- Historical inaccuracy including incomplete information.
- Incomplete exam, workup or documentation by physician.
- Treatment of symptoms vs the underlining disease or injury.
- Lack of objective findings.
- Inaccurate or misinterpreted urine drug testing screens.
- Pill counts often not done to ensure patient compliance.
- Diminished physician involvement. Too often exam is done by PA, or NP.
- History of substance abuse/misuse.
There is much discussion right now about pharmogenetic testing which is supposed to help medical providers find the correct medication for the patient. The presenter felt there was limited value in that test as there is so much variation between patents it is impossible to accurately make any predictions in this area.
Everything a physician does should be safe and effective. High doses of narcotics and polypharmacy have been shown to be hazardous to patients and rarely lead to meaningful functional restoration. The science does not support treatment of non-malignant pain with high doses of opioids or polypharmacy.
- Continued or increased pain which is out of proportion with physical findings.
- Drug seeking behaviors.
- Increasing drug doses without corresponding improvement in functionality.
- History of ineffective intervention techniques which do not improve the condition.
- Extreme dosages of pain medications well beyond the expected recovery period.
- Insufficient objective findings to support subjective physical complaints.
The workers’ compensation industry has gotten much better in recognizing these issues. The next step we need to take is to push back and take action to prevent harm to the injured workers. Get an independent medical exam to review the situation. Be willing to approve drug detox programs and alternatives to opioids for pain management. If you are convinced a physician is engaging in truly abusive prescribing patterns do not hesitate to report that physician to the appropriate state medical board.