According to the ACPA (American Chronic Pain Association) Resource Guide to Chronic Pain Management, “persistent or chronic pain is prevalent in older adults.”
“Nearly one third of all prescribed medications are for patients over the age of 65 years. More than thirty percent of hospital admissions among the elderly may be linked to an adverse drug related event or toxic effect from opioids and sedatives. Unfortunately, many adverse drug effects in older adults are overlooked as age-related changes (general weakness, dizziness, and upset stomach) when in fact the patient is experiencing a medication-related problem. In addition, some older individuals may be more sensitive to medications, more likely to experience side effects, and more likely to be using multiple drugs with the associated risk of interactions between the drugs.”
Workers’ Comp Implications
For those who manage workers’ compensation claims, these statistics should highlight the importance of a consistently executed decision making paradigm when authorizing prescription medications for older patients.
Before approving a new pain medication for an elderly injured worker, confirm that the initial dose is being prescribed at the lowest possible strength and frequency.
When increases are requested, approve only those changes to strength and frequency that are adjusted slowly to optimize pain relief.
When possible, confirm that the patient is monitoring and managing his / her own side effects.
When dealing with less dangerous treatment options for injuries in the elderly population, potential treatment options include:
Use of multiple drugs together – Careful use of multiple drugs is potentially advantageous as the combination of smaller doses of more than one medication may minimize the dose-limiting adverse effects of using a particular single drug.
Alternatives to pharmacologic treatment – As an alternative to prescription drugs, physical rehabilitation and other interventional therapies, including targeted injections and acupuncture, can be helpful to minimize side-effects and maximize physical function with pain relief
Triggers For Potential Concern
Pain management in the elderly is a unique challenge. Beyond the normal concerns of addiction and overuse, those who authorize treatment in a workers’ compensation claim for an older worker must also compare the potential dangers associated with the side effects of the medication against its promised value. Triggers that may warrant intervention for an older injured worker include:
Opioid treatment that continues for more than 90 days post injury / surgery
An increase in the strength or frequency of an opioid prescribed more than 90 days post injury / surgery
A request to change from an orthopedic or other specialist to a pain management specialist more than 90 days post injury/surgery
A decrease in opioid drug use followed by a request for a new treating physician
The appearance of a long acting opioid medication following continued use and/or an increase in dosage of a short acting opioid more than 60 months post injury
Identify, Intervene and Remain Involved
By peeling back the onion one layer at a time, questions can be raised, physicians can be challenged and evidence based treatment guidelines can be used to confront the status quo. The first step is to ask your workers’ comp PBM to identify claims that meet your triggers. Once identified, intervene with the treating physician either directly, or through a formal peer review. Once intervention is complete, remain involved until changes are complete.
When preparing for settlement, it’s critical to work with an MSA partner who will serve as gatekeeper to identify the same triggers and intercept problem claims before the MSA is prepared. Working hand in hand, positive outcomes can be achieved for the elderly. The process is simple. Consistent execution is the key.
For more information on medical and pharmacological issues related to pain management in the elderly population, I encourage you to review the publications made available by the American Geriatrics Society (http://www.americangeritrics.org). For questions related to pain management issues related to Medicare Set Asides, email us at firstname.lastname@example.org.