Case Study: A Question of Appropriateness
A 23 year old male lathe operator sustained a dislocated shoulder while at work in May 2010. Five months later, in October 2010, the Healthesystems clinical database flagged his drug regimen as potentially inappropriate. At the time of this alert, the patient had been prescribed two skeletal muscle relaxants (cyclobenzaprine, carisoprodol), Celebrex®, and hydrocodone/acetaminophen. Issues related to the medications selected and their prolonged use relative to the perceived nature of the injury triggered a recommendation for two Healthesystems clinical program services, a Therapeutic Alert Letter and an Independent Pharmacotherapy Evaluation.
Healthesystems issued a Therapeutic Alert Letter to the prescriber which questioned the appropriateness of Celebrex use in late October 2010. The rationale being most patients in need of an NSAID analgesic can take an older, non-selective NSAID such as ibuprofen or naproxen. A small subset of these patients may require a medication added to prevent stomach ulcers, and an even smaller subset of patients may actually be appropriate candidates to be prescribed Celebrex. Therefore, use of Celebrex in this young patient before attempting to use any other NSAID raised the question of appropriateness.
In addition to concomitant use of two skeletal muscle relaxants, another significant concern was the presence of carisoprodol in the regimen. Carisoprodol (brand name Soma™) is commonly used in the workers’ compensation population, however, it is also a frequently abused agent, possibly due to its pronounced sedating effects, which makes it extremely concerning.
Further, chronic use of opioids should be predicated upon objective functional goals, with the ultimate goal being functional restoration and return to work. The claimant’s injury of record appeared to be relatively minor (dislocated shoulder) requiring a short recovery time for a 23 year old person. Therefore, not only was the need for opioids in question, but the duration of therapy appeared to be disproportionate to the injury. Opioid “exit strategies” should be incorporated into all such regimens.
As a result of these concerns, a detailed examination of the patient’s recent medication use was conducted by Healthesystems clinicians. The following observations and recommendations for improved therapy were provided to the physician in an Independent Pharmacotherapy Evaluation (IPE): discontinue the use of carisoprodol; wean the opioid dose; incorporate alternatives to Celebrex.
Over the course of four months, the patient was weaned from the use of hydrocodone and carisoprodol. Five months after the outreach to the physician, all medications were discontinued and the claim was closed.
Physician-level outreach, through the use of an evidence-based IPE, can be an important impetus in changing prescribing practices, and can also provide necessary educational information for use in future cases. As this case demonstrates, clinical intervention early in the course of the injury can play an essential role in altering the claim’s cost trajectory. Payers utilizing specialized clinical services within their pharmacy benefit management program benefit from the clinical professional’s expertise and their ability to quickly identify and intervene in these potentially costly and clinically inappropriate cases.