Pharmacy Management – Don’t Overlook the Impact of Age and Comorbidity

BY SILVIA SACALIS, PHARMD, VP OF CLINICAL SERVICES

The presence of comorbid conditions within a workers’ compensation claim can impact pharmacy management in ways that go beyond the obvious. Superior pharmacy management requires looking not only at drug therapies, but also considering the various characteristics of the patient who is receiving them.

Claims with a comorbidity have been steadily increasing over the last decade, contributing to increases in overall medical costs.¹ In general, comorbidities add to the complexity of a claim as more drug therapies are added to manage multiple conditions, in addition to the medications treating the work-sustained injury or illness. This leads to polypharmacy and a greater potential for drug-drug or drug-disease interactions. It can also mean the presence of multiple prescribers to manage different conditions, making it impossible for any one physician to manage a patient’s complete treatment plan.

But certain comorbidities bring some unique considerations to pharmacy management in the injured worker. The following are some examples of note:

RESPIRATORY DISORDERS

Examples of respiratory comorbidities include chronic obstructive pulmonary disease (COPD), asthma, sleep apnea, and other breathing disorders.

• Increased risk for opioid events: Respiratory depression is a significant and potentially fatal adverse event of opioids. Injured workers with a respiratory disorder face increased risk of respiratory depression. Certain opioids such as oxycodone are contraindicated in patients with specific respiratory conditions, and guidelines recommend that opioid therapy should be avoided in patients with sleep-disordered breathing, including sleep apnea.²
• Naloxone prescribing: Should a prescriber choose to prescribe an opioid therapy to a patient with a respiratory disorder, they may also prescribe the opioid overdose reversal agent naloxone as a precautionary measure.

PSYCHOSOCIAL DISORDERS

Psychosocial disorders such as depression and anxiety are prevalent within the injured worker population. These disorders can predispose an injured worker to chronic pain, impede recovery and return to work, and increase the potential for opioid misuse³; thus it is important to address and treat psychosocial comorbidities. But psychotropic drugs used to treat these disorders can introduce their own risks.

• Psychotropic drug misuse: Benzodiazepines, commonly prescribed in workers’ compensation to treat anxiety, are a frequently misused drug class. Antidepressant misuse, while not as common, does contribute to overdoses and emergency department visits, especially in women.⁴

ADVANCED AGE

The aging workforce continues to have an increasing impact on the management of workers’ compensation claims populations. While age itself isn’t necessarily a comorbidity, claimants with a comorbid condition are often older than other claimants and require some specific prescribing considerations.¹

• Increased polypharmacy risk: Older patients are more likely to be prescribed multiple prescriptions for long-term durations. A large portion of older adults also use over-the-counter medications and dietary supplements, which aren’t visible within a workers’ comp claim. These scenarios increase the risk that polypharmacy may occur – or even go unnoticed.
• Increased side effects: A number of drugs are contraindicated in the older population due to increased propensity for side effects. Other drugs may require special considerations or dosage adjustments to reduce potential side effects. For example, non-steroidal anti-inflammatory drugs (NSAIDs) prescribed to manage pain present an increased risk for stomach ulcers in patients age 60 or older. Thus concomitant prescribing of a gastro-protective medication may be appropriate.
• Drug metabolism changes: A medication dosing schedule for a patient who is 30 years old may not be appropriate for a patient who is 50 years old due to changes in drug metabolism that occur as a person ages.
• Cognitive decline: Older patients may experience cognitive decline, which could lead to forgetting to take medications (nonadherence), taking medications too often (misuse), or irregular refill trends.

HYPERTENSION

Hypertension (high blood pressure) is the most prevalent comorbidity among claims examined by the National Council on Compensation Insurance (NCCI).¹

• NSAID-related events: NSAIDs prescribed to manage pain in injured workers (e.g., naproxen, ibuprofen) can cause blood pressure to rise even higher, putting greater stress on the heart and kidneys.
• Antidepressants: Certain antidepressant medications commonly prescribed to treat psychosocial disorders in injured workers (e.g., fluoxetine, venlafaxine) can also raise blood pressure, increasing risk of a cardiovascular event.
• Erectile dysfunction medications: Tadalafil is among commonly prescribed medications in workers’ compensation, typically to treat opioid-induced erectile dysfunction. It too can contribute to high blood pressure.

SUBSTANCE ABUSE DISORDER

A history of substance abuse, including prescription medications, illicit drugs, or alcohol, is the number one red flag for potential opioid abuse. However, there are other considerations beyond opioids when determining appropriate pain management strategies for these patients.

• Other prescription drug misuse: A history of substance abuse can predispose an injured worker to prescription drug misuse. Commonly prescribed medication classes within workers’ compensation have increased potential for misuse, including benzodiazepines (e.g., diazepam, alprazolam) and sleep aids (e.g., zolpidem, eszopiclone).
• Acetaminophen toxicity: Because pain management options are limited in patients with a history of substance abuse, prescribers may turn to alternative medications such as acetaminophen. An important factor for consideration prior to prescribing acetaminophen in patients with a history of alcohol abuse is that they may have a compromised liver, putting them at increased risk for acetaminophen toxicity.
• Naloxone prescribing: If opioids are prescribed in patients with a history of substance abuse, the Centers for Disease Control and Prevention (CDC) recommend that the opioid overdose reversal agent naloxone be prescribed concomitantly.²

Silvia Sacalis, PharmD, provides clinical leadership as Vice President of Clinical Services at Healthesystems. Her experience and clinical expertise span the PBM, retail pharmacy and managed care environments. Leveraging her technology background, clinical skills and management expertise, she helps develop and operationalize strategic clinical initiatives to help workers’ compensation insurance payers maximize the impact of a pharmacy benefit management program. Throughout her career, she has held various leadership roles in which she provided oversight of the development of clinical services programs, and integration of analytics technology with clinical consultative support.