A Healthesystems publication

Fall 2013

Red Flags in Opioid Therapy

Analyzing each claim from multiple perspectives can reveal risky situations if data are readily available and you know what to look for. and Environmental Medicine and the Official Disability Guidelines.

The large number of workers’ compensation claimants receiving prescriptions for opioid therapy requires payers to dig deeper into the data to uncover inappropriate behaviors – whether it is risky prescribing practices, questionable claimant behavior or activities that are indicative of fraud, drug abuse or medication misuse. Often the signs that a claim is veering off course escape notice because the details may seem insignificant and unrelated.

However, looking at a claim from multiple perspectives often reveals associations among activities that can add up to suspicious behaviors. Even claims with a relatively low drug spend may deserve a closer look.  

FDA Changes Labeling Requirements for Long Acting Opioids
In October the FDA announced class-wide safety labeling changes and new postmarket study requirements for all extended-release and long-acting (ER/LA) opioid analgesics intended to treat pain. This is the latest effort by the FDA to combat misuse, abuse, addiction, overdose and death from these potent drugs

There are a number of red flags that can alert claims professionals to take early action so they can prevent problems.
A close review of claims involving opioids may be in order if any of these circumstances are present.


Medication Combinations Patterns of Prescribing Pharmacy Transactions & Dispensing Trends
  • Prescriptions for short-acting opioids, carisoprodol and benzodiazepine — a combination dubbed the holy trinity by abusers because of the feeling of euphoria often associated with taking them together.
  • Prescriptions for short-acting opioids and carisoprodol - a combination dubbed the Las Vegas cocktail by abusers for their combined effects which can mimic heroin. 
  • New prescriptions are written for opioids or high-cost compounded products after an extended period involving no prescription therapy, despite no indication that the injury was re-activated.
  • Concurrent use of more than one type of long-acting opioid.
  • Only opioid therapy is prescribed. 
  • Prescriptions for brand names that indicate dispense as written per the prescriber (DAW1) or dispense as written per the injured worker (DAW2), particularly when opioids, sedatives and muscle relaxants are specified. 
  • Opioids continue to be prescribed even when objective improvements are not documented over an extended period of time.
  • Prescriptions for 15 or more medications concurrently. 
  • High dollar spends for individual prescriptions or overall prescription therapy.
  • A consistent pattern of early refills for opioids within the allowable five to seven day window. This could indicate stockpiling and lead to risks for abuse, diversion and misuse. After six months, the pattern can yield an additional month supply. 
  • A pattern of refilling prescriptions on time for opioids, carisoprodol and  benzodiazepine, and refilling prescriptions late or not at all for Cymbalta® or gabapentin. This could signal use of the medication for something other than pain relief.
  • Prescriptions for opioids from multiple physicians from different practices, which can indicate an unauthorized dose escalation or doctor shopping. 
  • A frequent change in pharmacies for opioids fills when the pharmacies are not part of a chain or network. 
  • Moderate to high opioid risk doses. 

Monitoring Tools

Most PBMs make a variety of tools available to assist payers in identifying and managing claims with potential for high risk. They may take the form of subject-specific reports, papers, calculators and the like.  Healthesystems offers a risk management dashboard that provides an innovative way to view and manage high-risk claims in real time.  

Recommended Actions

To the extent that claims professionals have the proper reports and tools available to identify red flags in claims involving opioid therapy, they can appropriately enlist help from other stakeholders and take early action to avert problems.  

Depending on the payer, this can include:



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