Leverage Pharmacy Controls to Reduce Opioid Spending 13.4%

The workers’ compensation industry has been a leader in addressing the national opioid epidemic. Nevertheless, medical providers continue to prescribe these drugs for chronic pain, despite research and recommendations that caution against using them as a first line of treatment.


The good news is that payers can take steps to reduce the unnecessary use of opioids. In its latest Drug Trend Report, Express Scripts said its clients saw an average 13.4 percent decrease in spending for opioids — even though the drugs continue to be the most expensive and highly utilized class for work-related injuries.


Armed with more evidence of the dangers and with increased persistence, payers can further reduce the prescribing of opioids for injured workers.



The Problem


The Centers for Disease Control and Prevention ( CDC)  released a new study that shows the more days for which opioids are prescribed, the more likely a person would become a chronic opioid user. The risks for chronic opioid use increases with each additional day of prescription. The days most associated with chronic use of the drugs were the 3rd, 5th and 31st days of the prescriptions.


Starting a patient on a long-acting opioid showed the highest probability of continued opioid use at 1 and 3 years. Patients who were started on the drug tramadol were the second most likely to have continued opioid use.


Additional potential triggers for abusing the drugs were:


  • A second prescription or a refill. Authorizing a second opioid prescription was shown to double the risk for opioid use one year later.
  • A morphine equivalent cumulative dose of at least 700 milligrams.
  • An initial supply of 10 or 30 days.


Opioids cause changes to a person’s brain. They have a chemical structure similar to a natural substance in the body. The drugs go to the pleasure center of the brain and release dopamine, a neurotransmitter that can cause depressed breathing, blood pressure and alertness, as well as decreased pain and a euphoric effect. Eventually, the drugs can result in a compromised ability to regulate unsafe or risky behaviors.


Over time, the body can become tolerant and dependent on the drug, meaning the patient must take more of the drug to achieve the same pain relief results.  Some people then become addicted to the drugs.


Opioids can be life threatening, even for a first time user, due to depressed breathing. Other side effects associated with opioids include depression, constipation, confusion, insomnia, and sexual dysfunction.



What to Do


Adoption of strategies addressing morphine equivalent dose (MED) led to significant decreases for Express Scripts’ clients, the company said. “Payers who adopted the MED program had a 32.7% reduction in cumulative MED >100 and a 24.7% overall decrease in cumulative MED,” according to the Drug Trend Report.


The company also uses a proprietary “point-of-sale and concurrent drug utilization review (DUR) edits to identify dangerous drug combinations (such as benzodiazepines and/or skeletal muscle relaxants with opioids) or other therapy concerns (duplication, use of long-acting opioids as a first choice and more).” Benzodiazepines in combination with opioids “should be avoided whenever possible due to respiratory depression and greater risk for potentially fatal overdose.”


Additional best practices to control over use and abuse of opioids are the following:


  • Real-time monitoring of MED and payer notification prior to any opioid fill that exceeds predefined MED thresholds.
  • Patient education and prescriber outreach for certain prescribing patterns, dangerous combinations and MED thresholds.
  • Leveraging opioid prescriber and patient trends with sophisticated reporting and analytics to identify fraud, waste and abuse and other risky behavior.
  • Coordinating efforts among providers, governments and law enforcement.
  • Ensuring providers prescribe opioids for the shortest duration possible when used to treat acute pain. Three days or less is ideal, while more than 7 is rarely needed.
  • Inform providers and discourage them from unnecessarily prescribing tramadol for chronic pain.





Opioids have a place in the nation’s healthcare system. However, their use for chronic pain has clearly been exceeded in recent years.


Payers that stay abreast of the latest research findings and establish protocols based on the information can go a long way to help prevent an injured worker from developing chronic opioid abuse, and save significant dollars.




Michael Stack - AmaxxAuthor Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .


Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/


©2017 Amaxx LLC. All rights reserved under International Copyright Law.


Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

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