Workers’ Compensation: Dangerous Prescribing Practices and At-Risk Patients

1. Workers’ Compensation:
Dangerous Prescribing Practices
and At-Risk Patients
Presenters:
• Teresa Bartlett, MD, Senior Vice President of Medical Quality,
Sedgwick
• Paul Peak, PharmD, Director, Clinical Pharmacy, Sedgwick
• Stephen Fisher, MD, PhD, Director of Health Services, Medical
Advisor to the CEO, Chesapeake Employers Insurance
Third-Party Payer Track
Moderator: Christopher M. Jones, PharmD, MPH, Director, Division
of Science Policy, Office of the Assistant Secretary for Planning and
Evaluation, U.S. Department of Health and Human Services, and
Member, Rx and Heroin Summit National Advisory Board

2. Disclosures
Teresa Bartlett, MD; Stephen Fisher, MD, PhD;
Paul Peak, PharmD; and Christopher M. Jones,
PharmD, MPH, have disclosed no relevant, real,
or apparent personal or professional financial
relationships with proprietary entities that
produce healthcare goods and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

4. Learning Objectives
1. Identify dangerous prescribing practices
observed in management of workers’
compensation insurance claims.
2. Describe strategies that have proven successful
in resolving dangerous prescribing practices.
3. Outline approaches to identify and manage
high-risk claims within the workers’
compensation population.
4. Provide accurate and appropriate counsel as
part of the treatment team.

6. Teresa Bartlett, MD
SVP, Medical Quality
Sedgwick
Teresa Bartlett, MD, has disclosed no relevant, real
or apparent personal or professional financial
relationships with proprietary entities that produce
health care goods and services.
Paul Peak, PharmD
Director Clinical Pharmacy
Sedgwick
Paul Peak, PharmD, has disclosed no relevant, real or
apparent personal or professional financial
relationships with proprietary entities that produce
health care goods and services.
Presenters & disclosures

7. • Identify dangerous prescribing practices observed in
management of worker’s compensation insurance claims
• Describe strategies that have proven successful in
resolving dangerous prescribing practices
• Outline approaches to identify and manage high-risk
claims within the workers’ compensation population
• Provide accurate and appropriate counsel as part of the
treatment team.
Learning objectives

8. In group health, typically 3% of drug spend is on prescription opioids – in
workers’ compensation, the drug spend on opioids is between 25% and
40%. It is 29% for the Sedgwick book of business.
Addition of opioids to a WC claim means a 53 week increase in the
duration of the claim (on average).
In the WC population, 60% of patients taking opioids for at least three
months are still on opioids 5 years later.1
Studies show that overall the effectiveness of chronic opioid therapy on
addressing pain is modest and effect on function is minimal.2,3
Opioid use in workers’ compensation
1.Martin BC, Fan MY, Edlund MJ, Devries A, Braden JB, Sullivan MD. Long-term chronic opioid therapy discontinuation rates
from the TROUP study. J Gen Intern Med 2011; 26:1450-7.
2.Furlan AD, Yazdi F, Tsertsvadze A, et al. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety
of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med
2012;2012:953139.
1.Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. The Cochrane
database of systematic reviews 2010:Cd006605.

9. The Sedgwick approach

10. Best practices
• Avoid compounds
• Avoid dangerous combinations of medications
• Use over the counter topical medications when needed

11. • 66 year old female
• Industrial injury occurred when she was 23 years of
age – has not worked since 1979
• Hurt back during a fall at work
• Diagnosis: Failed back with bilateral legs and psych
issues also accepted
• Pre-interventional status:
Medications - [MED: 555mg] oxycodone ER (OxyContin®),
oxycodone IR, sertraline
• Years since a taper attempt
• Current status:
Medications – [MED:60mg] oxycodone/APAP
Jane’s story

12. Glenn’s StoryGlenn’s story
• 52 year old male
• Industrial injury occurred when he was 35 y/o –
Patient is still at work
• Suffered head contusion which also caused cervical
and low back strain
• Pre-interventional status:
Medications – [MED: 840mg] oxycodone ER (OxyContin®),
hydrocodone/APAP, zolpidem, methylphenidate
• Physician did not want to taper
• Current status:
Medications – [MED: 60mg] hydrocodone/APAP

13. Carla’s story
• 55 year old female
• Industrial injury occurred when she was 42 y/o and
involves a right foot injury and right shoulder
• Intentional overdose with hospitalization in 2007
• UDS unprescribed medications
• Caregiver for grandchild
• Physician only sees the patient every 6 months and the
husband picks up her prescriptions
• Pre-interventional status (recently started on this claim):
Medications – [MED: 630mg] oxymorphone ER, hydromorphone,
ziprasidone, duloxetine

14. Attempt to bring about change
Discuss the health and safety of the injured workers
To represent our clients
To call attention to aberrant prescribing patterns
To enhance communication with their office staff
To let them know how carefully we are watching
Sometimes it takes a personal visit

15. Our team includes over 50 nurses, 11 pharmacists, and 5 physicians
2015
Reduced the average number of medications per claim by 31%
Decreased the Morphine equivalent dosage by 49%
38% of urine drug screen results are not consistent with prescribed
medications
The next evolution: Pain coaching
Pharmacy program results

16. Workers’ Compensation:
Dangerous Prescribing Practices
and At-Risk Patients
Stephen Fisher, M.D., Ph.D.
Director of Health Services
Medical Advisor to the CEO
Chesapeake Employers’ Insurance

17. Disclosure
• Stephen Fisher, MD., Ph.D., has disclosed no relevant, real or
apparent personal or professional financial relationships with
proprietary entities that produce health care goods and services.

18. Learning Objectives
• Identify dangerous prescribing practices observed in management of
workers’ compensation claims
• Describe strategies that have proven successful in resolving
dangerous prescribing practices
• Outline approaches to identify and manage high-risk claims within
the workers’ compensation population
• Provide accurate and appropriate counsel as part of the treatment
team.

19. Chesapeake Employers’ Overview
• Insures primarily small to medium employers- approx.
21,000 policy holders
• Large percentage of policyholders in construction and the
trades
• Insures 70% of all Maryland municipalities and counties
• Third party administrator for the State of Maryland

20. 2015 RX COUNT BY THERAPEUTIC CLASS
Therapeutic Chapter Description Rx Count Rank
Rx
Count
Ing
Cost
Rank
NARCOTICS 1 8,114 1
COMBINATION NARCOTIC /ANALGESICS 2 5,269 4
ANTICONVULSANTS 3 4,492 2
MUSCLE RELAXANTS & ANTISPASMODIC AGENTS 4 4,051 3
NSAIDS 5 3,951 8
MISCELLANEOUS ANALGESICS 6 2,208 7
MISCELLANEOUS ANTIDEPRESSANTS 7 1,916 5
ANXIOLYTICS 8 1,328 17
HYPNOTIC AGENTS 9 1,141 12
SELECTIVE SEROTONIN REUPTAKE INHIBITORS 10 850 21
(Chesapeake Employers’ Insurance 2015)

21. Top 20 Oxycodone Scripts by Count & Quantity
RANKED BY QUANTITY
# RXs Quantity
OXYCODONE HCL 10 MG TABLET 510 50,179
OXYCODONE-ACETAMINOPHEN 10-325 366 39,457
OXYCODONE HCL 15 MG TABLET 355 39,116
OXYCODONE HCL 10 MG TABLET 352 35,730
OXYCODONE HCL 5 MG TABLET 404 28,345
OXYCODONE HCL 15 MG TABLET 216 24,485
OXYCONTIN20 MG TABLET 341 23,364
OXYCODONE HCL 5 MG TABLET 282 21,737
OXYCODONE-ACETAMINOPHEN 10-325 205 20,774
OXYCODONE-ACETAMINOPHEN 5-325 325 20,041
OXYCODONE-ACETAMINOPHEN 10-325 187 19,778
OXYCODONE-ACETAMINOPHEN 5-325 260 15,896
OXYCODONE-ACETAMINOPHEN 10-325 167 15,751
OXYCONTIN40 MG TABLET 206 15,399
OXYCONTIN10 MG TABLET 248 14,320
OXYCODONE HCL 30 MG TABLET 85 13,854
OXYCODONE HCL 5 MG TABLET 196 13,565
OXYCONTIN30 MG TABLET 182 12,932
OXYCODONE HCL 15 MG TABLET 96 12,528
OXYCODONE-ACETAMINOPHEN 5-325 248 12,184
(Chesapeake Employers’ Insurance 2015)
RANKED BY RX COUNT
# RXs Quantity
OXYCODONE HCL 10 MG TABLET 510 50,179
OXYCODONE HCL 5 MG TABLET 404 28,345
OXYCODONE-ACETAMINOPHEN 10-325 366 39,457
OXYCODONE HCL 15 MG TABLET 355 39,116
OXYCODONE HCL 10 MG TABLET 352 35,730
OXYCONTIN20 MG TABLET 341 23,364
OXYCODONE-ACETAMINOPHEN 5-325 325 20,041
OXYCODONE HCL 5 MG TABLET 282 21,737
OXYCODONE-ACETAMINOPHEN 5-325 260 15,896
OXYCONTIN10 MG TABLET 248 14,320
OXYCODONE-ACETAMINOPHEN 5-325 248 12,184
OXYCODONE HCL 15 MG TABLET 216 24,485
OXYCODONE-ACETAMINOPHEN 5-325 210 10,419
OXYCONTIN40 MG TABLET 206 15,399
OXYCODONE-ACETAMINOPHEN 10-325 205 20,774
OXYCODONE HCL 5 MG TABLET 196 13,565
OXYCODONE-ACETAMINOPHEN 10-325 187 19,778
OXYCONTIN30 MG TABLET 182 12,932
OXYCODONE-ACETAMINOPHEN 10-325 167 15,751
OXYCONTIN15 MG TABLET 153 9,547
TOTAL 5,413 443,019

22. Highly Prescribed Drugs/Doses
drug name dose # scripts quantity avg pills/ script
Oxycodone 10 mg 1,787 181,119 101
Oxycodone 5 mg 1,925 122,187 63
Oxycontin 1,130 75,512 67
(Chesapeake Employers’ Insurance 2015)

23. How is Prescription Drug Use Different in WC
• 75% of Injured Workers are Prescribed Opioids but Rarely Receive
Associated Services (UDS, PT, Psychological Eval and Support (Thumula and
Wang, Interstate Variations in Use of Narcotics, 2nd Ed) (Longer Term Use of Opioids, 2nd Ed, May 2014)
• 1.75 deaths per 1000 patients/yr if on opiates vs. 1/1000 for high risk
occupations- fishing, logging (Property Casualty360.com, July , 2015)

24. Low Back Injuries
Higher amounts of narcotics in treating acute work-related low back
pain cause injured workers to be:
• Away from work longer (up to 69 days longer)
• Have higher medical costs
• Be 3X more likely to have surgery
• Have a 6X greater chance of using narcotics beyond
the recommended time (WorkComp Central 7/20/09)
• Receiving more than a one week supply of opiates following an injury
doubles the risk of disability one year later (Franklin, G.M., Stover, B.D.,
Turner, J.A., Fulton-Kehoe, D., & Wickizer, T.M. (2008). Disability Risk
Identification Study Cohort. Early opioid prescription and subsequent
disability among workers with back injuries: the Disability Risk
Identification Study Cohort. Spine, 199- 204.)

25. Chesapeake Employers-Prescribers by Specialty
Rank by
Cost Specialty % of Rxs % of Cost
# of Rxs with
MED > 90
1 Physical Medicine & Rehabilitation 10.9% 14.4% 662
2 Internal Medicine 12.9% 13.9% 195
3 Physician Assistant 12.6% 11.5% 687
4 Nurse Practitioner 9.8% 10.2% 595
5 Family Medicine 8.4% 8.0% 220
6 Specialist 6.1% 5.9% 198
7 Psychiatry & Neurology 5.7% 5.8% 73
8 Pain Medicine 3.6% 5.8% 274
9 Anesthesiology 4.5% 4.9% 271
10 Orthopaedic Surgery 6.5% 3.2% 220
11 Registered Nurse 1.1% 2.2% 96
12 General Practice 1.5% 1.4% 291
13 Clinical Nurse Specialist 0.2% 0.8% 23
14 Neurological Surgery 1.4% 0.8% 55
15 Emergency Medicine 1.2% 0.6% 30
16 Surgery 0.7% 0.6% 24
(Chesapeake Employers’ Insurance 2015)

26. Chesapeake Employers’ Program Initiatives
• Pharmacy Benefit Manager (PBM) partnership on Fraud, Waste and
Abuse
• Pain Management team
• Pharmacy Nurse
• Behavioral Health Assessments
• Functional Restoration Programs
• Identifying groups prescribing and or dispensing inappropriately
• Education of injured workers of the dangers of long term opioids
• Soft tissue algorithm to prevent medical and drug over utilization
• Internal educational programming for adjustors, nurses, attorneys

27. Clinical Programs
• Soft Tissue Algorithm training for adjustors and health services staff- early
intervention tool
• Pain Management Program:
• Pain Management Nurse
• IME tracking
• Peer to Peer programs
• Behavioral Health- Cognitive Therapy
• Functional restoration
• Legal representation
• Pharmacy Benefit Manager
• Adjuster participation
• Coordination of inpatient/ outpatient detox programs
• Monitoring by urine drug screens

28. Pharmacy
• Rules based formulary for establishing pre-authorization at point of
sale
• Limits number of opioid fills to (3) before requiring pre-authorization
• Pharmacy PBM portal:
―Houses all prescription data in one program
―Irregular prescribing pattern or drug regimen
―Point of sale messaging (example: Drug not covered. Please contact
prescriber for an alternative medication.)
―Sets MED limit (90-120)- by individual drug and accumulative
• Fraud, Waste, and Abuse Program
• Opioid educational letter to prescriber and injured worker

29. Pharmacy Benefit Manager (PBM) Reporting
• Comprehensive reporting:
- Top prescribers by drug name, rx count and quantity
- MED- individual and accumulative
- Escalating MEDs
- Narcotic Alert Report (date of 1st script and most recent fill, number of days,
and count of scripts)
- RX Alert Report- 16 rules based criteria
- High risk drug combinations
- Ad hoc reports

30. Nurse Case Management
• Utilize pharmacy portal for management of drug use
• Nurse Case Management Intervention Program for NCM assignment-
trigger of MED >90 in addition to other high risk drug combinations
(Houston Cocktail)
• Field case management- high risk, non-compliance, non-cooperative
providers, managing weaning regimen
• Consultations with in-house Medical Advisors
• Works closely with adjusters
• All case managers are accountable for drug assessments and
continuous monitoring

31. Mental Health Issues In WC
• Depression present in 7-16% of workers in the U.S. (Paradigm Outcomes Symposium,
Oct. 2015) “We Can’t Remain Complacent About Mental Health. Step Out
of Your Comfort Zone.” (Renee-Louise Franche)
• Depression has been diagnosed in 18% of WC patients within one
year of suffering a minor injury (Healthcare Solutions. Drug Trends
2013. Available at: http://hsdrugtrends.com/. Accessed November
12, 2013.)
• 33% of Chronic pain patients also have depression and 45% of those
with one mental health diagnosis have at least one additional,often
anxiety. (Wideman TH, Scott W, Martel MO, Sullivan MJL. Recovery from depressive symptoms over the course of physical
therapy: a prospectivecohort study of individuals with work-related orthopaedic injuries and symptoms of depression.J Ortho
Sports PT. 2012;42(11): 957-968)

32. Behavioral Health
Cognitive Behavioral Therapy
― Delayed recovery and Return to Work
―Psychosocial dysfunction- fear avoidance, catastrophic thinking, depression
and anxiety
―Unsupported opioid use- pain and function unchanged or increases
―Escalating MED
―Use of Physical Medicine Diagnosis
• 96150 – Health and Behavioral Assessment
• 96125 – Health and Behavioral Intervention
• 98968 – Telephonic Case Consultant

33. Behavioral Health Outcomes
• 98% of treating providers agreed to make referral
• 87% represented by an attorney
• 100% RTW referrals did return to work
• 71% non-compliance have documented pre-existing psych dx
• 33% full and final settlement
• Workers’ Compensation Commission support of cognitive behavioral
therapy
(Chesapeake Employers’ Insurance 2015)

34. Legal
• Maryland Workers’ Compensation Commission
• Highly litigious state
• According to WCRI, 50% of injured workers in Maryland obtained an
attorney (Claims Journal, May 17, 2012)
• Resolution of prescription drug related issues frequently at the
Workers’ Comp Commission
• Legal Round Tables – in-house attorneys are well versed on pain
management and opioid abuse
• Commission rulings in this area are often times favorable for provider
weaning or outpatient/ inpatient detoxification.

35. Percentage of Narcotics to Total Scripts
• 2011 (39.1%)
• 2012 (38.4%)
• 2013 (36.6%)
• 2014 (35.8%)
• 2015 (34.5%)
(Chesapeake Employers’ Insurance)
32
33
34
35
36
37
38
39
40
2011 2012 2013 2014 2015
% Narcotic to Scripts

36. Morphine Equivalent Dose (MED) Tracking

37. Number of Injured Workers Using Opioids
(Percent of Claims Receiving PBM Benefits)
34.0%
34.5%
35.0%
35.5%
36.0%
36.5%
37.0%
37.5%
38.0%
38.5%
Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015
% Injured Workers Using Opioids
(Express Scripts)

38. # Workers Receiving Opioids 1/2015-1/2016
0
50
100
150
200
250
300
350
400
450
500
# injured workers
January 2015
# injured workers
July 2015
# injured workers
October 2015
# injured workers
January 2016
≤ 50
51-90
91-119
≥ 120
(Express Scripts)

39. Number of Opioid Prescriptions Monthly
1000
1050
1100
1150
1200
1250
1300
1350
1400
1450
1500
# Opioid Prescriptions
(Express Scripts)

40. # of Prescriptions <90 MED Monthly
700
750
800
850
900
950
1000
1050
1100
# Rx <90 MED
# Rx <90 MED
(Express Scripts)

41. # Scripts >300 MED
0
10
20
30
40
50
60
70
80
# Rx >300 MED
# Rx >300 MED
Linear (# Rx >300 MED)
(Express Scripts)

42. MED Category Trend
0
500
1000
1500
2000
2500
3000
Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015
Number of Prescriptions MED
<90
Number of Prescriptions MED
90-120
(Express Scripts)

43. External Affairs
• Multi-disciplinary back injury study
• Scope of Pain CME sponsorship
• DHMH engagement
• Heroin and opiate abuse task force participation
• Funding of PDMP
• Speaking opportunities

44. Workers’ Compensation:
Dangerous Prescribing Practices
and At-Risk Patients
Presenters:
• Teresa Bartlett, MD, Senior Vice President of Medical Quality,
Sedgwick
• Paul Peak, PharmD, Director, Clinical Pharmacy, Sedgwick
• Stephen Fisher, MD, PhD, Director of Health Services, Medical
Advisor to the CEO, Chesapeake Employers Insurance
Third-Party Payer Track
Moderator: Christopher M. Jones, PharmD, MPH, Director, Division
of Science Policy, Office of the Assistant Secretary for Planning and
Evaluation, U.S. Department of Health and Human Services, and
Member, Rx and Heroin Summit National Advisory Board