Prescription Management

At the 2016 ACE Conference, Caryn Siebert with Knight Insurance Group presented a session discussing the challenges and solutions involved in prescription management.

In 2014, opioid overdoses killed over 28,000 patients. From 1999 – 2013, the number of opioid prescriptions quadrupled. Earlier this year, President Obama called for additional federal government funding to prevent opioid abuse.

Opioid treatment should be limited to 3-7 days during the acute phase of the injury. Beyond that things like ibuprofen or other over-the-counter drugs should be sufficient. Unfortunately, too often opioids are used as the first and only treatment for pain.

For any pain management program, the goal should be to increase the activity level. Pain control alone is not a reason to prescribe medications if there is no corresponding increase in the activity level.

Prescription Drug Monitoring Programs (PDMPs) are designed to allow physicians to monitor a patient’s prescription history to help limit abuse. However, most PDMPs are not mandatory and, because of that, they are not widely used. The PDMPs databases also do not cross state lines, making it easy to circumvent them for abuse.

For any pharmacy program, the physician should start with low dosages and progress the dosages slowly. If the total dosage exceeds a 50 morphine equivalent per day, then the program should be reassessed. Increasing the dosage typically only leads to dependence issues and rarely increases the functioning of the patient.

If prescriptions are coming from multiple sources, there is a high chance of abuse. There needs to be coordination between all physicians treating the patient. Urine drug testing can assist in ensuring that the patient is taking the appropriate amount of the medications.

The risk factors of opioid-associated harm include:

• Patients with sleep disorders or breathing problems.
• Depression.
• History of overdose.
• History of substance abuse.

Pharmacy Benefit Managers (PBM) can be effective in monitoring medications and watching for potential interaction problems and monitoring dosages,  but only if the patient is receiving all medications through the PBM. Too often the PBM only sees a portion of the total treatment.

Alternatives to opioids are an important consideration. Things like exercise programs can help restore range of motion and muscle conditioning. Over-the-counter medications can help reduce pain sufficiently to increase function. Finally, cognitive behavioral therapy can help the patient develop coping skills so that they can increase function without the opioid medications. It is important that claims payers be willing to authorize these alternative treatments instead of the medications.

It is important to remember that it is very challenging for a physician to try and segment issues caused by the work injury from other personal issues that may be impacting pain and perceptions. Physicians must consider the whole patient when developing a treatment pattern.