How You Can Prevent Pain Medication From Causing More Pain

Opioid-Induced Hyperalgesia


Anytime I discuss medical issues I always clarify that I am in no way a medical physician.  Whether it is to a claimant, or an attorney, I can only interpret medical in my own opinion based on training and years of experience in this business. I do also clarify to people that I always try to stay up to date on new medical issues, since they can have a direct application on the handling of workers compensation insurance claims. 


There has been some talk of late about a new issue involving opiate medications, coined “Opioid-induced Hyperalgesia” or “OIH” for short.  Oftentimes a claims adjuster has a file where a claimant is taking a large amount of opiate medications for pain.  Every time the adjuster reviews the medical records, or talks to the claimant, the injured party seems to be in more pain than before, despite the presence or even increased dosage of strong narcotic medications.  How is this possible?  If Oxycodone is doing nothing for pain control, then what other steps could you take for pain control?


In the past, an adjuster worried about narcotic pain medication causing addiction issues, dependence issues, and increased medication tolerance issues. In addition to that, these medications are costly, and they seem to be prescribed on every claim no matter what the severity. But OIH has raised new concerns about longer-term chronic pain issues and what to do before these claims get out of control. 



The Cause of OIH:


The exact cause of why OIH occurs is currently under medical investigation.  The leading theory continues to be the excitation of nerves through chemical pathways by certain types of narcotics.  Research has shown that some narcotics may have a higher propensity to cause OIH than others.  These are mainly known as the “phenanthrene opioid” class of medications, which includes codeine, hydrocodone, oxycodone, and hydromorphone.  In patients where OIH could be the culprit, switching to a non-phenanthrene medication such as meperidine or tramadol often times leads to adequate pain relief, much to the surprise to those involved.


In simpler terms, OIH may be caused by the narcotic itself increasing the level of pain that the patient may be experiencing.  Almost out of the blue, this medication that is supposed to be used as a pain reliever is actually worsening the pain, thus requiring larger and larger doses of medication for adequate pain relief.  As these doses increase, so do the risks for the more well-known issues with pain medication which include central nervous system issues, depression, addiction, drug-seeking behavior, and the risk of overdose. Even more, the financial costs of these medications begin to dominate the claim more than anything else, including wage loss.



What to Watch For:


Some common characteristics of OIH include:


  • Worsening pain over time despite increased dosages of opiate narcotics used for pain control.


  • Pain that becomes more diffuse in and around the area of injury.


  • Sensitivity to touch around the injured area specifically.


  • Subjective setbacks in the progression to MMI without diagnostic objective findings.



The Future of OIH


Although this is a newer phenomenon, the study of OIH can change the way physicians diagnose and treat chronic pain cases.  To date, if a patient’s pain in not controlled by whatever medication they are taking, it is common to step the dosage up to the next level, and re-evaluate pain at the next doctor appointment.  Because increased doses are used, the patient also has increased tolerance for pain medication, and at that point the dose must increase again. But if OIH were to be present early on, but not addressed specifically, then who knows if that medication would have ever helped this person’s pain, no matter what the dose?


There is a large potential for work comp claimants to experience OIH symptoms since narcotic pain relief is often used early on, usually at the first visit to the clinic.  When reviewing your comp files, especially those longer-term files where a person has had chronic pain symptoms of an escalating nature without any exacerbation of the injury, those files should be sent for an OIH evaluation by a medical professional.





I believe it is a safe assumption that OIH could be responsible for a significant percentage of claims dollars spent within the workers compensation system.  Cost drivers that can occur if this is not diagnosed will be increased medication costs, medication side-effect management, and addiction treatment.  These three issues alone can be responsible for large amounts of money spent on the claim.  The ability to identify OIH very early on in the life of a claim can save massive amounts of claim money, and also benefit the claimant who would not have to deal with the strong side effects of the long-term use of these dangerous medications. The ability to identify and treat OIH correctly will lead to better claim outcomes, earlier returns to the workplace post-injury, and an overall decreased burden on the work comp system as a whole. 




Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%Contact:


Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. Contact






Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.


©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at:


Workers Compensation News From Around the Net

Input Needed in Providers Opioid Audit
The Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) acknowledges that prescription drug abuse and misuse, including opioids, is a serious issue in all health care delivery systems, including workers’ compensation.
The TDI-DWC seeks input and suggestions regarding the development of a new Plan-Based Audit for health care providers prescribing opioids. The Plan-Based Audit sets the scope, methodology, selection criteria, and program area responsibilities as laid out in the Medical Quality Review Procedure. A copy of the proposed Health Care Providers Pain Management Services (Opioid) Plan-Based Audit can be viewed at the TDI website here. [WCx] 
Broadspire Launches BOLD® Rx Network
Broadspire, a Crawford Company and TPA of workers compensation claims, liability claims and medical management services, has launched its BOLD Rx Network to help control the medical costs associated with WC claims. See here for more information.[WCx]
According to Broadspire, the BOLD Rx Network uses a multi-leveled strategy to achieve superior penetration rates and savings compared to the rest of the industry. “Rather than just partnering with one pharmacy benefit management (PBM) company, as is traditionally seen in the marketplace, Broadspire leverages multiple partners based on the value they bring to clients, creating a stronger pharmacy program,” they write.
Federal Court Rejects NLRB Authority to Force Posting of Employee Rights Notice
According to a well-written newsletter from McGuireWoods, a world-wide lawfirm with 900 lawyers, in Chamber of Commerce of the U.S., et al. v. NLRB (Dist. S.C., April 13, 2012), a South Carolina federal district court held that the National Labor Relations Board (NLRB or the Board) does not have statutory authority to force employers to post notices that the NLRB claims are designed to inform employees of their rights under the National Labor Relations Act.
McGuireWoods writes, “The Court’s decision directly conflicts with a recent decision from a separate federal court in the District of Columbia. These developments place all employers covered by the Act in a very difficult position.”
The regulations are to take effect April 30, 2012. “The conflicting court cases make it unclear whether employers will be required to post the NLRB notices on the current April 30, 2012 deadline. (Click here for more),” they write.
Columbus Dispatch Notices Lawsuits Against Doctors on Decline
Columbus Dispatch reporter Alan Johnson writes here that Ohio’s tort-reform law has reduced closed claims by 41 between 2005 and 2010. He discovered average payments for medical malpractice cases have declined 38 percent over that period.
Johnson writes, “The legal fight over curbing lawsuits and settlements in medical malpractice cases reached a tipping point in 2003 when the General Assembly passed and Gov. Bob Taft signed Senate Bill 281. The law capped non-economic damages, commonly known as ‘pain and suffering,’ at $500,000 per occurrence.”
Johnson reports that Tim Maglione, of the Ohio State Medical Association says doctors’ medical malpractice rates have dropped more than 26 percent. “It’s not only good news and a good trend, but it is proof that tort reform accomplished what it set out to do — slow the growth of what we thought were runaway lawsuits and to stabilize the market for physicians,” Maglione said. The numbers have also gone down, he said in the article, because doctors and hospitals are working harder to improve safety and cut down on mistakes. “The best error is the one that never happens.”
Progressive Medical Releases Annual Workers’ Compensation Medication Trends Report
According to Progressive Medical, Inc., WC medication spending declined in 2011. Their annual analysis, found here, reveals changes to medication expense patterns in workers’ compensation claims from 2010 to 2011 for Progressive Medical clients, as well as key factors that may influence future expenditures, such as chronic pain, product mix and government activity.
Key highlights from the 2012 Workers' Compensation Medication Trend Report include:
  1. Although medication AWP inflation was 5.8 percent in 2011, data shows a 1.3 percent reduction in total medication spend per claim.
  2. There was an overall 3.3 percent decrease in utilization per injured worker from 4.3 percent fewer prescriptions and a 1.1 percent decrease in average days of medication supply received.
  3. Across the industry, narcotics account for 35 percent-40 percent of workers' compensation medication spend while Progressive Medical showed a 3.9 percent decrease in total spending per claim in this drug category. Progressive Medical believes this is due to an emphasis on conducting interventions earlier in the lifecycle of a claim.
Note: If your company has any developments you'd like to share, please send them to us at:



Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:





Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.


©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at:

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Ways to Ensure Prescription Medication is Appropriate

The challenge:   A grey zone medication is any type of drug for which special attention is required to determine if it is appropriate for the injured worker based on compensability, relation to injury and medical history. Ensuring medications are appropriate has become increasingly complex due to an aging and unhealthy workforce. Workers who have more simultaneous ailments are leading to the use of medications that are unrelated to the actual injury.
The most common grey zone medication categories mirror the prescription trends within workers compensation as a whole; antibiotics, pain medications, hypnotics, anticonvulsants, antidepressants, ulcer medications, cardiovascular medications.
The solution: Implementing effective strategies to monitor grey zone medications helps ensure injured worker safety and reduces opportunities for instances of fraud, misuse and abuse.
  1. Develop customized medication plans
By working with a pharmacy benefit manager (PBM), payors can create medication plans that are based on specific criteria to ensure that medications are appropriate for the injured worker. Medication plans should be specific to body part and nature of injury, as well as the acute or chronic nature of the injury. PBMs should also offer electronic notification of approved and misaligned medications. This will reduce administrative burdens on claims professionals, allowing them to focus on jurisdictional issues related to the claim while the PBM can focus on medication concerns.
  1. Establish comprehensive utilization management programs
Utilization management programs are essential to limit cases of fraud, misuse and abuse and ultimately ensure injured worker safety. A quality program should include working with a clinical staff capable of performing in-depth, injured worker-specific drug utilization reviews. While PBMs offer utilization review programs, payors should also ensure their partner has a process in place that is managed by clinical pharmacists. The clinical utilization review program should use a combination of evidence-based medical guidelines, peer review journals and recommendations provided by government organizations.
·    Prospective utilization reviews– A prospective program allows all involved parties to plan for future outcomes with up-front information. Guiding future decisions through historical data and practices allows for the achievement of cost control and utilization control.


·   Concurrent utilization reviews– A concurrent program can prevent abuse involving the use of multiple pharmacies and physicians for different medications, or excessive early refill attempts. The PBM can trigger concurrent alerts to inform the dispensing pharmacist about possible reasons a medication should be questioned before filling. This process can ensure that prescriptions are not filled at the point-of-sale unless the medication is allowed or the PBM receives authorization from the payor.
Retrospective drug utilization reviews and clinical intervention programs– Conducting retrospective drug utilization reviews, physician monitoring and clinical intervention programs should be used to continually evaluate claims for grey zone medications and monitor inappropriate and/or excessive use. Staying on top of potential patterns can cut back on unnecessary spending and ensure injured worker safety.


·     Retrospective reviews– After a prescription is filled, the PBM’s clinical pharmacist team should audit the claim for indicators of misuse; multiple physicians, duplication of therapy, excessive duration and use.
 .  Clinical intervention programs– Seek a PBM that offers a wide range of clinical intervention programs to assist with evaluation needs. The range of programs should consist of registered pharmacists, nurses and other health professionals available for consultation on medication questions and peer reviews. The PBM’s clinical intervention team should provide recommendations for specific claims that require further evaluation.
  1. Physician monitoring
It is essential to have a process that monitors an injured worker with multiple physicians. A successful program should be based on established best practices and contain multiple components including:
    • Monitoring for appropriate medication utilization using evidence-based published therapeutic guidelines
    • Overseeing prescribing patterns at the physician level to establish appropriate/inappropriate use of brand name medications when an FDA approved generic equivalent exists
    • Participating in mandatory and voluntary state reporting programs that monitor for excessive prescribing patterns
    1. Pharmacist support
    The PBM must have a staff of clinical pharmacists available to provide customized support for medication-related decisions. The exchange of medication education between pharmacists and claims professionals is important for both general and injured worker-specific information.
    1. Nursing support
    A more holistic clinical picture of the claim should be obtained by the claims professional. Nurses on an experienced clinical services team are uniquely positioned to assist in explaining the details on medical service claims. Having access to experts in non-drug therapy can allow the claims professional to make more informed decisions.
    1. Claims professional education
    Effective seminars that train and provide guidance to claims professionals on the payor’s policies for managing grey zone medications should be provided. These sessions should be included within claims professional’s regular education and training,
    Summary: Managing medication utilization for injured parties has become increasingly complex for workers compensation payors. As new medications become available, the workforce continues to age and medical histories increase in complexity, navigating the grey zone medication maze will remain a challenge. By putting best practices into place to manage the appropriateness of medications, payors will ultimately ensure injured worker safety while reducing opportunities for fraud, misuse and abuse.
    For more detailed information on the definition and classification of grey zone medications and common grey zone drugs please visit Progressive Medical’s Grey Zone Resource Center.
    Author Tron Emptage, who holds a BS in Pharmacy, is Chief Clinical & Compliance Officer with Progressive Medical. Mr. Emptage has overseen Pharmacy Services, Clinical Services, National Account Management served as Vice President of Strategic Initiatives and Executive Vice President of Business. His 20-year plus experience in pharmaceutical and managed care defines him as a key player in moving the company forward in the arena of national pharmaceutical managed care. Contact him: or 800.777.3574 or visit Progressive Medical.
    About Progressive Medical
    Progressive Medical offers cost management services and programs to the workers compensation industry. By combining its clinical expertise with access to an expansive network of pharmacies, home health care services and medical equipment and supplies, the company enables its clients to manage costs while providing quality care to injured workers. Learn more at Progressive Medical or call 866.939.5365.
    Manage Your Workers Compensation Program:
    Reduce Your Costs 20-50%
    Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
    ©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact

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