Early refills may be a sign of undertreated pain or possible development of abuse/addiction to the medication.

Building Safeguards Into Prescribing Practices

As a risk manager, safety consultant, or claims professional, you can help injured workers better understand their condition.

Pain is one of the most common reasons people consult a physician, yet it frequently is inadequately treated, leading to enormous social cost in the form of lost productivity, needless suffering, and excessive healthcare expenditures.
-- American Pain Society

Chronic pain is a common occurrence in the United States, afflicting approximately 100 million adults per year at an estimated cost of $560 to $635 billion, according to the Institute of Medicine. Treatment measures vary widely, but almost all consist of some medication management method, typically opioid utilization. The use of these potent and potentially addictive agents in pain treatment has dramatically increased the associated risks of misuse, abuse, and addiction. According to the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA), the number of emergency room visits linked to abuse of prescription opioids went from 144,644 in 2004 to 305,885 in 2008, a 111 percent increase. In an effort to curb abuse and misuse, prescribers are now discouraged from prescribing opioids.

With such great potential for harm and misuse, it can be easy to forget that opioids do have a legitimate clinical application. They remain the most efficacious medications for controlling severe pain. In fact, studies have proven that effective pain control with opioids provides a means for returning to normal life activities, including work and recreation. The key is appropriate, monitored use, with the ultimate goal being pain control for patients while effectively addressing patients’ daily living needs, including physical, psychological, social and return-to-work factors.

It is important to incorporate safeguards into prescribing practices, along with understanding the signs of aberrant behaviors. This can help to minimize the potential for abuse and keep the workplace safe from hazards while still providing maximum pain relief. Equally important, patients must take a proactive and involved approach to their recovery. As a risk manager, safety consultant, or claims professional, you can help injured workers better understand their condition. Educate yourself so you are better equipped to share this information with your team.

  • Initial visit. At the prescriber's office, an initial medical history, prescription history, and physical examination will be obtained. Generally, the following information is documented into the medical record: the diagnosis, nature and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, and history of substance abuse. The injured party should be ready to tell the physician about all prescription or non-prescription drugs, vitamins, or supplements being taken. It may be helpful to take the actual pill bottles to the appointment.
  • Treatment plan. The treatment plan states the goals for recovery and outlines the objective measurements that will be used to determine treatment success, such as pain relief and improved physical and function status. It also should indicate whether further diagnostic evaluations or other treatments are planned. After treatment begins, the drug therapy can be tailored to meet the needs of each injured worker. Other treatment options or a rehabilitation program may be necessary, depending on the cause of the pain and the extent to which the pain is associated with physical and psychosocial impairment.
  • Know the risks and the benefits. Understand the risks and benefits of using opioids as part of the treatment plan. The more the injured party knows about the medications being taken, the better equipped he or she is to understand the impacts, any potential side effects, and risks. Suggest that the patient take notes to help himself remember prescriber instructions, as well as to track the effects (good and bad) from the medication.
  • One prescriber and one pharmacy is best practice. Effective pain management is best achieved by using one prescriber and one pharmacy for all medications. This significantly decreases the potential for therapy duplications and drug-to-drug interactions. It also helps determine whether the treatment plan is appropriate. For example, early refills may indicate that a higher dose or frequency is needed than prescribed. This may be a sign of undertreated pain or possible development of abuse/addiction to the medication.
  • Talk with the prescriber and pharmacist. Encourage injured parties to communicate with their prescriber and pharmacists. This may be done through follow-up visits or when refilling the prescription. Share information about how the recovery is going -- any new information about the cause of the pain, side effects, and your overall condition. During these visits, the prescriber will determine whether continuation or modification of opioids for pain management therapy is appropriate. Adequate response to treatment may be indicated by decreased pain, increased level of function, or improved quality of life. However, inadequate progress will require reassessment of the current treatment plan and consideration for the use of other therapeutic modalities will be determined.
  • Random urine drug monitoring. When done for the right purpose, this can be a very useful tool used to help monitor patients’ treatment plans and manage their chronic pain while helping them achieve better outcomes. Information from these tests help prescribers determine whether the medication is being taken correctly and whether the treatment plan is progressing as planned. It also can prevent harmful drug-to-drug interactions and identify ways to refine treatment plans, if necessary. It is important to keep in mind that urine drug monitoring is not an indication there is suspicious behavior occurring, but rather is standard protocol. When administered randomly as part of the organization's standard protocol, no injured party is ever singled out or accidentally skipped over.

Be Proactive
The vast majority of injured workers take their pain medications as directed. It is important to remember that opioids can be effective therapy for pain control when used appropriately.

Being proactive, educating yourself, and sharing this information with your workforce is the best way to prevent opioid abuse and misuse. Nevertheless, if situations of misuse and abuse do occur, your pharmacy benefit manager can be a helpful resource as part of your overall risk management process.

This article originally appeared in the February 2013 issue of Occupational Health & Safety.

About the Author

Noor Amara, RPh, PharmD ([email protected]), is a clinical pharmacist for Progressive Medical Inc. of Westerville, Ohio. She helps to provide clinical services to adjusters and claimants so they can manage treatment outcomes more effectively. She also is on the Progressive Clinical Oversight Committee, which helps to determine medication plans/drug strategies and new clinical interventions for its clients. She completed her pre-pharmacy curriculum at Sinclair Community College and received her doctor degree in pharmacy from the University of Cincinnati in 2009. She has also been an active member of American Society of Health System Pharmacists since 2005.

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