Medication monitoring curbs prescription medication misuse

Study: Prescription claims data can help identify claimants at higher risk of fraud, waste and abuse

In 2011, more than 1.4 million emergency room visits were due to the misuse or abuse of pharmaceuticals, with about half involving opioid analgesics and benzodiazepines. Prescription medications, especially opioid analgesics, have increasingly been the cause—now accounting for at least 60% of overdose deaths (U.S. Department of Health and Human Services, 2013). And today, many (if not the majority) of workers’ compensation injuries involve the use of prescription medications, and a significant portion of these medications are for pain. While statistics suggest that white men between the ages of 45-49 years old are most likely to die from a drug overdose; in actuality, demographics alone cannot determine who is at risk for prescription medication misuse or abuse.

Guidelines by the American College of Occupational and Environmental Medicine (ACOEM) and Official Disability Guidelines (ODG) recommend that patients on chronic opioid therapy be monitored for prescription compliance through routine assessment, including urine drug testing. Confirming compliance with the medication therapy regimen is just as important as detecting those who may be misusing or abusing their medication. Recognizing this, payers are seeking tools that help proactively reduce misuse and abuse of prescription medications, especially opioid analgesics.

In March 2013, we began a comprehensive study to assess the proprietary criteria used to identify potentially high-risk injured workers who may benefit from the additional clinical oversight of a Drug Testing and Monitoring service. We examined a workers’ compensation payer’s population of injured workers with a date of injury greater than 90 days, looking at risk factors based on the injured worker’s workers’ compensation prescription profile over the previous 90 days and results of other clinical programs. Each risk factor was assigned a risk score and those injured workers with a total risk score equivalent to or exceeding a predetermined risk score threshold were identified as potentially high-risk injured workers who may benefit from the Helios Drug Testing and Monitoring service.

From March through December 2013, results of urine drug tests performed on these identified patients were analyzed for consistency with the injured worker’s current medication regimen as reported by the ordering prescriber at the time of specimen submission. Inconsistent tests were defined as those where the reported prescribed medications were not found in the urine, non-prescribed medications were detected, and/or an illicit substance was found.

The results of our study were somewhat surprising. While the use of multiple prescribers and multiple pharmacies are considered risk factors for misuse and abuse, our study revealed the opposite: a higher percentage of patients filling their prescriptions at multiple pharmacies and/or having prescriptions for opioids written by multiple prescribers had a urine drug test result consistent with their current medication regimen. We also found a higher percentage of patients who received a prescription for a cannabinol, stimulant, and/or those that were receiving therapy of a long-acting opioid pain reliever in the absence of any short-acting analgesic returned a test result that was inconsistent with their current medication regimen.

From this study, we therefore concluded that prescription claim information successfully identifies patients at a higher risk for fraud, waste, and abuse. Our Drug Testing and Monitoring service promotes appropriate use of opioid medications by facilitating urine drug testing at the prescriber level. By working with the drug testing laboratory and the prescriber, we ensure that on-going monitoring and an appropriate therapeutic plan is in place. We position the payer to make better decisions and effectively bend the curve from prescription medication misuse and abuse in the process. Having a tool to identify potential high-risk claims, facilitate testing, interpret results, and monitor progress can achieve better outcomes for both the injured worker and the payer.

To view a poster of this clinical study, click here.