A Healthesystems publication

Winter 2016

How to Treat a Lady: Drug Therapy Risks for Women in Workers’ Comp

FAST FOCUS: Trends show that women may face increased drug therapy risks with certain medications that are often prescribed within workers’ comp. While these trends may be associated with biology, they can also be traced to social behaviors such as gender-biased clinical research and prescribing differences between women and men. Awareness of these risks and their causes is critical to understanding the specific needs and considerations of injured worker populations.

When we think of injured workers, we often think of men in casts and crutches who were hurt in labor-intensive jobs related to construction, machinery or heavy lifting. This imagery, while very much a real part of workers’ comp, can dominate the minds of many and overshadow the significant portion of women in the injured worker population.

Women make up almost half of the workforce,1 and approximately 40% of nonfatal occupational injuries involve women.2 Women face many of the same risks for workplace injury as men, but when it comes to drug therapy, there exist certain gender-specific trends.

DRUG CLASSES WITH GENDER-SPECIFIC TRENDS

OPIOIDS

RELEVANCE TO WORKERS’ COMP

Commonly used in workers’ comp to manage pain from work-related injuries, opioids come with many inherent risks, as well as some gender-specific concerns.

EXAMPLES

RISKS

All patients, male and female alike, face significant risks when it comes to opioids, but gender-specific trends demonstrate that women may be more susceptible.

Women are more likely to be prescribed prescription pain medications such as opioids – often at higher doses and for longer durations – than men.3 Women are more likely to experience chronic pain,3 and they are more likely to use opioid analgesics than men.4

Every three minutes, a woman visits the emergency department due to prescription pain medications such as opioids, and deaths from prescription pain medications have increased more than 400% for women since 1999, compared to 265% among men.3 Women most susceptible to prescription pain medication misuse or abuse are between the ages of 25-54, an age that greatly represents the working population.3

To compound the problem, opioids are frequently prescribed along with benzodiazepines, despite serious, even lifethreatening risks of doing so.

BENZODIAZEPINES

RELEVANCE TO WORKERS’ COMP

Benzodiazepines are often prescribed in workers’ comp for anxiety, muscle spasms, insomnia, and other concerns. Injured workers taking prescription opioids may experience side effects such as insomnia and anxiety, which can lead to the prescribing of benzodiazepines.

EXAMPLES

RISKS

The Centers for Disease Control and Prevention (CDC) warns against combining benzodiazepines and prescription pain medications,3 but benzodiazepines are almost always prescribed in combination with opioids in workers’ comp, despite significant risks.5 The rate of overdose deaths involving benzodiazepines (not specific to gender) has quadrupled since 1996.6 Benzodiazepines are involved in 31% of opioid overdose deaths,7 and overdoses that involve benzodiazepines are 75% likely to involve opioids.8

While the combination of opioids and benzodiazepines is a concern for any patient regardless of gender, the use of benzodiazepines is twice as prevalent in women than men.9 Benzodiazepines also send more women than men to emergency departments,3 and therefore trends involving benzodiazepines are incredibly relevant when considering potential drug therapy risks for this given patient population.

ANTIDEPRESSANTS

RELEVANCE TO WORKERS’ COMP

Injured workers who experience reduced function can develop depression, which can hinder their ability to recover and require the prescription of antidepressants.

EXAMPLES

RISKS

Women are twice as likely to be diagnosed with depression than men,10 they receive more antidepressants than men,11 and they are more than twice as likely to take antidepressants prescribed to them than men.12

The CDC advises caution when combining antidepressants with prescription pain medications such as opioids.3 Women are more likely to visit an emergency department due to antidepressant use than men, and more women than men die from overdoses of antidepressants.3

WHY MIGHT WOMEN FACE INCREASED DRUG THERAPY RISKS?

Behavioral Differences

Women are more likely than men to seek the care of a physician,13 making them less likely to neglect or ignore an injury or illness, and more likely to be prescribed drug therapy. In general, women are significantly more likely to use a prescription drug to manage health concerns than men,14 and women are more likely to engage in doctor shopping – the obtaining of prescriptions from multiple prescribers – than men.3

Biological Differences

One thing we must remember is that women and men have several biological differences, ranging from hormonal differences to dimensional differences in organs. Women may react differently to certain drug therapies, and they may exhibit different symptoms than men.

For example, research has shown that women experience more intense opioid cravings than men,15 and they become dependent on prescription pain medications more quickly than men.3 Women are also nearly twice as likely to experience adverse drug reactions overall.16 However, it is possible these risks stem from gender bias in medical research due to the fact that the female experience is not studied in enough depth.

Social Differences

Women are underrepresented in clinical trials, and there is no law or official policy that requires the inclusion of women in industry sponsored clinical trials.16

A lack of research, inclusion, and awareness leads to gaps in medical care. Interventions and testing may be tailored to the needs of men, leaving women with care that does not adequately meet their specific needs. For example, while clinical trials for depression treatments do include women, the trials may not examine outcomes by gender, and women and men may differ in response to depression treatment.17 Not taking such differences into consideration could lead to suboptimal care.

Furthermore, trends indicate that physicians exhibit different prescribing patterns when it comes to women and men. As noted earlier, physicians are more likely to prescribe women prescription pain medications such as opioids, as well as drugs such as benzodiazepines and antidepressants.

If women are not receiving care that is appropriate for their specific needs, their condition could worsen or complicate, or they may experience new or exacerbated adverse events. Ultimately, this results in poor injured worker outcomes. From a payer perspective, this prolongs the life of the claim and leads to higher medical costs.

WHAT CAN BE DONE?

Injured female workers benefit greatly when drug therapy adheres to evidence-based guidelines – particularly when it comes to potentially dangerous and addictive medications such as opioids and benzodiazepines. Mood-altering drugs such as antidepressants and antianxiety medications also warrant a closer look into the patient profile to determine if psychosocial concerns could be interfering with recovery, as depression and anxiety are often associated with opioid misuse.18

But superior claims management requires looking beyond drug therapies and towards the patient receiving them. Characteristics such as gender should be considered when managing a patient as those characteristics may have related trends and impacts. Patient characteristics are part of a holistic picture of health that can highlight intervention opportunities.

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SOURCES

1 -Women’s Bureau, U.S. Department of Labor. American women: Looking Back, Moving Ahead: The 50th Anniversary of the President’s Commission On the Status of Women Report. March 2015. https://www.dol.gov/wb/PCSW-03-30-2015.pdf
2 -Bureau of Labor Statistics. Nonfatal occupational injuries and illnesses requiring days away from work, 2013 [news release]. December 2014. http://www.bls.gov/news.release/archives/osh2_12162014.pdf
3 -Centers for Disease Control and Prevention. Vital Signs: Prescription Painkiller Overdoses. July 2013. http://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.html
4 -National Center for Health Statistics. Prescription Opioid Analgesic Use Among Adults: United States, 1999–2012 [NCHS Data Brief]. February 2015. https://www.cdc.gov/nchs/data/databriefs/db189.pdf
5 -Lavin RA, et al. Impact of the combined use of benzodiazepines and opioids on workers’ compensation claim cost. Journal of Occupational & Environmental Medicine. September 2014. doi: 10.1097/JOM.0000000000000203
6 -Bachhuber MA, et al. Increasing Benzodiazepine Prescriptions and Overdose Mortality in the United States, 1996-2013. American Journal of Public Health. April 2016. 106:686–688. doi:10.2105/AJPH.2016.303061
7 -CDC. Vital Signs: Variation Among States in Prescribing of Opioid Pain Relievers and Benzodiazepines — United States, 2012. July 2014. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6326a2.htm
8 -Jones CM, McAninch JK. Emergency department visits and overdose deaths from combined use of opioids and benzodiazepines. American Journal of Preventive Medicine. October 2015. 49(4):493-501. doi: 10.1016/j.amepre.2015.03.040. Epub 2015 Jul 3.
9 -Olfson M, King M, Schoenbaum M. Benzodiazepine use in the United States. JAMA Psychiatry. 2015;72(2):136-142. doi:10.1001/jamapsychiatry.2014.1763 December 17, 2014.
10 -Depression in women: understanding the gender gap. Mayo Clinic Web site. http://www.mayoclinic.org/diseases-conditions/depression/in-depth/depression/art-20047725. Published January 2016. Accessed May 6, 2016.
11 -Zhong W, Kremers HM, Yawn BP, et al. Time trends of antidepressant drug prescriptions in men versus women in a geographically defined US population. Archives of Women’s Mental Health. 2014;17(6):485-492. doi:10.1007/s00737-014-0450-7.
12 -Pratt LA, Brody DJ, Gu Q. Antidepressant use in persons aged 12 and over: United States, 2005–2008. NCHS data brief, no 76. National Center for Health Statistics. October 2011.
13 -Centers for Disease Control and Prevention. Variation in Physician Office Visits By Patient Characteristics and State, 2012. September 2015. http://www.cdc.gov/nchs/products/databriefs/db212.htm
14 -Gender Differences in Health Care, Status, and Use: Spotlight on Men’s Health. The Henry J. Kaiser Family Foundation Web site. http://kff.org/womens-health-policy/fact-sheet/gender-differences-in-health-care-status-and-use-spotlight-on-mens-health/. Published May 31, 2013. Accessed May 20, 2016.
15 -Back SE, Payne RL, Wahlquist AH, et al. Comparative profiles of men and women with opioid dependence: results from a national multisite effectiveness trial. Am J Drug Abuse. 2011;37(5):313-23. doi: 10.3109/00952990.2011.596982
16 -FDA Office of Women’s Health. Dialogues on Diversifying Clinical Trials: Successful Strategies for Engaging Women and Minorities in Clinical Trials. September 2011. http://www.fda.gov/downloads/ScienceResearch/SpecialTopics/WomensHealthResearch/UCM334959.pdf
17 -Weinberger AH, McKee SA, Mazure CM. Inclusion of women and gender-specific analyses in randomized clinical trials of treatments for depression. J Women’s Health. 2010. doi:10.1089/jwh.2009.1784.
18 -Artera J et al. Evaluation of how depression and anxiety mediate the relationship between pain catastrophizing and prescription opioid misuse in a chronic pain population. Pain Medicine. August 2015. doi: 10.1111/pme.12886.
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