Deadly Drug Combinations Escaping Notice

This potentially deadly drug mixture may not be on every payer’s radar screen because of the relatively low AWP for each drug. But when abuse is involved, payers need to seriously consider the additional costs of the consequences of abuse of this drug combination — detoxification and rehabilitation — as well as the real potential for loss of life.

The challenge for workers’ compensation payers is to identify and monitor risky drug combinations before they endanger the injured worker or are diverted to the street.  The risks inherent in opioid therapy have been well documented and significant efforts are being made by legislators, federal agencies, PBMs, payers and others to reduce opioid use in the workers’ compensation population. But opioid use alone is not the only concern.

What is escaping the notice of many payers is a popular but dangerous drug combination of short-acting opioids, muscle relaxants and anti-anxiety drugs. The combination is called the holy trinity by drug abusers because of the feeling of euphoria that it can produce — similar to that of heroin. There is a ready street market for these drugs, making them ripe for diversion. This led Healthesystems to dub the combination the unholy holy trinity.

C.S. Schade, MD, PhD, a past president of the Texas Pain Society, said he could “conceive of no legitimate medical reason” that the three medications would be prescribed together.¹ Though only a small number of claimants are prescribed this potentially deadly combination, payers should be aggressive in managing these outliers.

Identifying Problem Claims is the First Step

The challenge for PBMs and payers is to spot abusive drug behaviors before a claim spirals out of control. Opioid drug therapy is a major cost driver in workers’ compensation and is well known to pose high risks for abuse, drug diversion and accidental or intentional drug overdoses. Each component of the combination carries its own risk for abuse and addiction.

• The addictive properties of carisoprodol — perennially in the top 20 of prescribed medications in worker’s compensation population²— led the DEA to classify it as a controlled substance in 2011.³
• Benzodiazepines and opioids comprise eight of the top ten most abused medications in the US.⁴ 

It is becoming more well-known that drug overdoses seldom involve one agent. Opioid abusers learn to predict the effect of an opioid dose and can easily overdose when they seek to augment the euphoria with alcohol and/or other medications. When they augment it with carisoprodol and benzodiazepine, the risk for overdose is raised exponentially. 

• Of the 1.25 million medication-related emergency department visits in 2009, carisoprodol, alone or in combination, accounted for more than 30,000.  
• The far more commonly prescribed opioids accounted for more than 397,000 emergency visits. 
• Benzodiazepines, which have little to no clinical justification for long-term use, accounted for a remarkable 373,000 emergency trips.⁵
• Combining multiple central nervous system depressants such as Ambien®, Lunesta®, Valium, Xanax® and Halcion®, contributes to approximately 50 percent of opioid overdose deaths.⁶

Escaping Notice

Individually, opioids, carisoprodol and benzodiazepine have low average wholesale prices (AWP), costing pennies to about $1 per tablet. However, when abuse is involved, payers need to seriously consider the additional costs of the consequences of abuse of this drug combination — detoxification and rehabilitation — as well as the real potential for loss of life.

Common Components of the Holy Trinity

Taking the Next Steps

The Healthesystems clinical and technology teams worked together to create complex system logic and edits that identify claimants who have been prescribed all three types of drugs at some point in their treatment.  The information is shared with claims professionals along with clinical guidance on best practices for achieving an optimal outcome for the injured worker.

Healthesystems recommends that payers and PBMs clearly identify claimants who have been prescribed the opioid/ carisoprodol/ benzodiazepine combination so aggressive strategies can be implemented.  This could include clinical outreach to the prescriber(s), requests for justification of medical necessity, escalation for review to a clinical professional or a combination of efforts. 

Celebrity Deaths Involving Prescription Opioids in Combination

The use of opioids in combination with alcohol and other prescription drugs was a factor or direct cause of death for several high profile actors and athletes.

	Heath Ledger Actor, 28 Oxycodone, hydrocodone, diazepam, temazepam, alprazolam and doxylamine7
	Dana Plato Actress, 34 Carisoprodol and hydrocodone8
	Derek Boogaard Professional hockey player, 28 Alcohol and oxycodone11
	Edward Fatu “Umaga” Professional wrestler, 36 Hydrocodone, carisoprodol and diazepam10
	Erica Blasberg Professional Golfer, 25 Butalbital, temazepam, alprazolam, codeine, hydrocodone and tramadol9