Given the nature of workers’ compensation injuries, many claims contain one or several pain-reducing agents. Use of these agents puts the patient at higher risk for adverse effects, decreases the rate of successful recovery and creates safety concerns. While there is increased awareness of the dangers of opioid use, opioids are not the only medications that raise a red flag when evaluating safety and efficacy. The following factors are identified as red flags and should trigger a closer evaluation of a medication regimen:
Addictive properties of these pain-relievers are widely accepted by the medical community. CDC studies shows a linear correlation between the length of opioid therapy and the likelihood of chronic opioid use. Temporary disability payments are 3.5 times higher when opioids are prescribed. In addition to these risks, opioids have a number of adverse effects, which tend to increase the overall cost of therapy, such as opioid-induced constipation (OIC); erectile dysfunction in men; cardiovascular side effects, such a low blood pressure and slow heart rate; and respiratory depression. When one evaluates the medication regimen of an injured worker, it is paramount to identify risk factors and assess how the current therapy fits into the overall picture of the patient’s well-being.
Muscle relaxants block transmission of pain signals from the nerves to the brain, and can be just as addictive as opioids. Injured workers are often prescribed both muscle relaxants and opioids, which dramatically increases risks, raises concerns requiring intervention.
Benzodiazepines are generally used to alleviate anxiety and have a sedative effect. Many patients underestimate the degree of impairment caused by benzodiazepines. Benzodiazepines increase the risk of addiction, withdrawal, cognitive decline, motor vehicle crashes, and hip fracture. The risk of overdose is particularly great when combined with sedative drugs such as opioids. For these reasons, if used, benzodiazepines generally should not be prescribed continuously for more than one month and alternatives should be considered. As part of our services, ECS’ Pharm Ds review the injured worker’s medication regimen to suggest safe and equally effective alternatives.
A combination of several medications, obtained from different pharmacies, and prescribed by multiple doctors is another red flag. The cause for the high level of concern here is that the lack of communication between providers and the lack of transparency from the patient create the risk of duplicate therapies and increased side effects.
Custom made compounded topicals, as well as those ready for dispensing, such as LidoPro®, Terocin®, Lidothol®, and Dendracin®, tend to be an appealing option for some patients and providers. Providers tend to rationalize the use of these agents by the fact that topical administration is perceived to be safer than the oral route. However, the FDA has not approved these combinations of multiple ingredients into one topical product and thus the product may pose a severe risk to the patient, since it is unknown how the agents will behave in the body. Additionally, these custom designed products come with a very considerable price tag. In many cases, an over-the-counter alternative may be suggested and implemented as a safe and effective, cost-reducing, way to manage the symptoms.
ECS’ PharmDs perform pharmacy reviews to determine the right balance between appropriate therapies, patient risk factors, and positive outcomes; they also target their approach to ensure cost effectiveness and the appropriate duration of therapy. Identifying the red flags identified above and addressing them with the treating provider helps prevent detrimental consequences, improves therapy outcomes and reduces the overall cost of therapy.
For questions about medications or the ExamWorks Compliance Solutions Pharmacy programs, please contact Yelena (Lena) Berndt, PharmD, MSCC, at 678.256.5023 or firstname.lastname@example.org.
 Workers’ Compensation on Drugs: Ending the Inappropriate Use of Opioids. International Association of Industrial Accident Boards and Commissions, 2011.
2] Stewart SA. The effects of benzodiazepines on cognition. J Clin Psychiatry. 2005;66 (suppl 2):9–13.