Five medication management trends to watch in workers’ comp

Opioid prescriptions continue their downward trend.

“Our most recent data shows that we’ve made progress, with the figure now standing at 31.2%. This means that currently, less than one in three claimants are using opioids,” Emptage said.

More and more prescribers are opting for topical dermatological agents to address pain. Given their more limited absorption in the body compared to oral medications, they have fewer side effects, making them more attractive from a safety perspective.

“Unfortunately, topical medications may not always be as effective in managing pain compared to oral medications that are absorbed throughout the body, like anti-inflammatories, skeletal muscle relaxants, and anticonvulsants. There is a trade-off between fewer side effects and potentially reduced efficacy in pain management,” said Robert Hall, MD, Corporate Medical Director, Optum.

Topicals can be quite expensive, Hall said, but he foresees this trend of increased utilization of topicals continuing until there is increased regulatory pressure to control costs through fee schedules or other measures.

Claims are increasingly complicated by the presence of comorbidities. Obesity in particular is becoming more prevalent in the U.S. population. Obesity and related conditions like heart disease and diabetes can hinder recovery after an injury and necessitate the prescription of additional medications to manage those conditions, driving up pharmacy spend.

Weight loss medications, for example, may be needed in certain scenarios.

“If an injured worker with preexisting obesity requires a knee replacement, the surgeon may refuse to perform the surgery until the patient loses weight. Another scenario is when a severe injury results in a drastic decrease in mobility and calorie expenditure, leading to weight gain. Spinal cord injuries, severe head injuries, or amputations can cause sudden changes in mobility and energy expenditure, making it harder for the individual to maintain a healthy weight. These are legitimate cases where weight loss medications could be prescribed in workers’ compensation claims,” Hall said.

However, high-cost medications for comorbid conditions can sometimes be shifted to workers’ comp claims when they should really be covered by group health insurance. Hall said it will be crucial to determine whether a prescription for a comorbid condition is directly related to a work injury, and ensure such medications are paid for appropriately.

The prescription of high-cost migraine medications is becoming more common in recent years, though they may not always be warranted.

“There are a few reasons for the increase in migraine prescriptions within workers’ compensation claims,” Hall said. “Firstly, migraine is likely being over diagnosed among healthcare providers.”

Migraines occurring purely as a result of a work-related injury are not very common. Neck injuries causing radiating pain to the head or exacerbation of pre-existing headaches due to increased anxiety, pain, or depression after an injury may be inappropriately labeled as migraines in the workers’ compensation context.

“Secondly, the current class of CGRP [inhibitor] medicines for migraines is incredibly effective, more so than any previous treatments. This effectiveness has led to increased prescribing for those who may have a genetic predisposition to migraines, which can spill over into workers’ compensation claims,” Hall said.

The combination of overdiagnosis, highly effective medications, and misattribution of headache causes has led to the increase in migraine prescriptions within workers’ compensation claims.

Initially, legislation addressing treatment of PTSD within workers’ comp applied primarily to first responders, who may experience traumatic instances daily. In recent years, legislation has expanded to apply to workers in a variety of industries — teachers exposed to school violence, for example, correctional officers, and 911 dispatchers. Some states have even considered global PTSD coverage for all state employees.

The workers’ comp industry has become much more aware of the connection between behavioral and physical health, and recognizes the need to treat an injured worker as a whole person, addressing mental and emotional factors beyond just the physical injury in order to aid recovery. But when it comes to PTSD and the medications used to treat it, “the data still hasn’t caught up to the policy,” said Kevin Tribout, VP, Public Policy and Regulatory Affairs, Optum.

“Recent legislation expansion includes all the mental health care that will take place, along with the different utilization of medications to treat PTSD. These medications are often lifetime treatments, and policymakers are racing ahead while we try to catch up and understand the potential impact on the marketplace, which could be much bigger than anticipated,” he said.

Beyond treatment for PTSD, there is a growing need for better medication management as it relates to behavioral health in general. Several challenges have contributed to the difficulty in appropriately managing prescriptions for mental and behavioral health conditions.

“First, there is a significant shortage of mental health professionals, particularly in rural areas. This shortage makes it difficult for individuals to access the care they need, including medication management,” Hall said.

“Second, there is often a lack of coordination between primary care providers and mental health specialists. This can lead to fragmented care and suboptimal medication management. Finally, there is a need for more education and awareness about behavioral health conditions and the appropriate use of medications.”

However, efforts are underway to address these challenges. These include initiatives to increase the number of mental health professionals in underserved areas. There are also programs aimed at improving care coordination and increasing education and awareness about behavioral health conditions and treatments.

“With continued efforts to address these issues, we can improve the access to and quality of behavioral health care, including medication management, for individuals in workers’ comp,” Hall said.

Optum will continue to monitor these trends as they unfold in the coming years and work with key players to ensure policies align with data and emerging treatment modalities in the workers’ comp space.

“These topics are the main focus areas we’re watching and working on for the 2025 timeframe,” Tribout said. “We’ll continue to monitor these key issues and work with our trade associations for policy development.”

Optum is also carefully monitoring the potential impact of the recent tariffs on international suppliers on the cost and availability of treatments. Our organization already has protocols in place to address potential medication shortages that may occur in the market or in our home delivery pharmacy. We provide the injured person with options: they can be put on a 30-day medication waiting list; they can ask their doctor to prescribe an alternative medication; or they can have their prescription transferred to a local pharmacy that has the medication in stock.

And as Drew Holcomb, Director, Ancillary Network, Optum added, “Another chief concern from the healthcare community has been the potential impact on DME and supplies. Currently, there has been no exemption announced for these products and with the present manufacturing landscape spread globally, cost increases seem inevitable. Unfortunately, for a healthcare organization that purchases DME or supplies, it is very difficult to project the potential increase in cost, since it is at the supplier’s discretion of how to adjust their pricing based on their increased tariff expenses when importing goods.”

There are numerous healthcare suppliers and organizations lobbying the administration to consider a carve out for MedTech, DME, and supplies due to the potential consumer impact as well as accessibility concerns for patients in need.

Optum is watching and evaluating the situation closely, As Eric Harrison, Director, Financial Analysis stated, “We understand that this issue is of utmost importance to our clients and will continue to communicate any relevant information as we become aware of it. At this point, while there is a great deal of speculation and concern about what could happen if the tariffs were imposed on pharmaceuticals, so far there have only been threats. The only real action taken to date by the current administration has been the initiation of probes and investigations.”

By keeping the lines of communication open with clients and suppliers regarding any events or updates that could affect shared business interests, Optum will continue to support patient and provider satisfaction through timely access to clinically appropriate treatments and payer goals through cost-effective claims management.