The prevalence of comorbidities associated with work-related injuries is increasing, as can be seen through national trends, as well as through individual, claimant-level chart reviews. The early identification and treatment of comorbidities is essential to successfully managing the care of an injured worker, but the issue of work-relatedness should also be acknowledged and appropriately addressed for compensability purposes.

2. Body part and nature of injury

Injuries that result in Workers' Compensation claims can take multiple directions with respect to outcomes.

It is not just the catastrophic diagnoses, such as amputation, spinal cord injury and traumatic brain injury that can lead to higher costs and more medically complex claims. A study from the Ohio Bureau of Workers' Compensation in 2010 found that common injuries, such as those to the lumbar spine, the shoulder, and cervical spine represent some of the highest costs per claim by body. Being aware that certain injuries, based on the body part involved, are associated with higher costs allows for an earlier recognition and a more proactive, hands-on approach to those high-cost claims.

3. Plan of care

Establishing a patient-centered plan of care (or treatment plan) with specific, measurable and attainable goals is vital in treating any illness and is a requirement for the workplace injury.

This allows the treating provider and the injured worker to work together in developing a realistic and mutually agreed upon treatment plan. Patient education on the natural history of the injury, that is, how the injury typically heals over time, provides the foundation for more practical expectations.

Furthermore, the plan of care should be well-documented by all active providers, e.g., physical therapists, chiropractors, home health nurse, etc., and should be updated on a regular basis to reflect the most recent changes in the injured worker's medical status. If treatment plans are not being regularly documented or updated, they should be requested from the active providers.

4. Prescriber demographics

Demographics of the prescriber may have an influence on the types of medications prescribed, their dosages, and the timing of the prescription.

As an example, a study in the February 2009 issue of the American Journal of Industrial Medicine analyzed the differences in the prescribing of opioid analgesics for acute, work-related low-back pain by geographic region. The study found significant variation between states, with 5.7% of the injured workers in Massachusetts receiving early opioid prescriptions versus 52.9% in South Carolina.

Similarly, a study in the 2012 issue of the Journal of Pain found that the counties having the highest prescribing rates for opioid analgesics were disproportionately located in Appalachia and in southern and western states. Therefore, being aware of the geographic variation in prescribing patterns allows for an earlier identification of potentially high-risk claims based on opioids being prescribed in a higher-risk region of the city, county or state.

5. Medication patterns

The timing and types of medications being prescribed may provide insight into the path of a claim, especially when prescribing is outside of best-practice standards or even the standard of care.

For instance, the prescribing of multiple long-acting opioid analgesics is not appropriate and their presence significantly increases the risk of adverse events. The same can be said for claims that involve multiple sedating medications that, when combined, can contribute to lethal outcomes. The concomitant prescribing of opioids, benzodiazepines, muscle relaxants and sedatives is an example of a medication pattern that, once identified, should be intervened upon to decrease the risk of overdose.

6. Multiple prescribers and pharmacies

The use of multiple prescribers and/or pharmacies clouds the visibility into the injured worker's medication therapy regimen and can result in serious safety concerns, such as increasing the risk of dangerous drug interactions and therapeutic duplication.

Therefore, it is important to look for signs indicative of controlled substances being prescribed by multiple prescribers, such as frequent emergency room or urgent care visits, or medications being dispensed by multiple pharmacies. A study in the June 2012 issue of Medical Care found that of patients in West Virginia who were receiving prescriptions from four or more pharmacies, based on the state's prescription drug monitoring program, 55% were also receiving prescriptions for controlled substances from four or more physicians.

7. Medication monitoring

Medication-monitoring programs and tools help confirm that injured workers are adhering to their medication treatment plan and can identify cases of possible misuse, abuse, diversion and fraud.

Methods for medication monitoring include pill and/or patch counts and urine drug testing with the frequency of each being based upon the individual worker's level of risk.

National Workers' Compensation treatment guidelines, such as the American College of Occupational and Environmental Medicine and the Official Disability Guidelines, firmly support and recommend that regular medication monitoring is performed when opioid analgesics are being prescribed.

The use of prescription drug monitoring programs, which track prescriptions for controlled substances, is also essential.

Finally, medication agreements that outline the risks and benefits of the medications being prescribed, the expectations necessary to maximize their safe use and consequences for non-adherence to the agreement should be contained in the medical record.

8. Nonpharmacologic treatment

The medical management of injuries should include more than just medications as nonpharmacologic treatments can be extremely beneficial, not only in pain relief but also in injury healing and in the prevention of further injury.

Examples of nonpharmacologic treatment options include physical medicine, heat and cold therapy, electrotherapy and cognitive behavioral therapy. If nonpharmacologic treatment has not been attempted in the past, it may be considered as there might be enough resultant improvement in pain and function to decrease at least some of the injured worker's medications.

However, if pain medication usage remains the same or increases, the actual effectiveness and clinical appropriateness of the nonpharmacologic intervention may be lacking and further therapy should be reevaluated.

9. Interdisciplinary care

Interdisciplinary treatment programs consist of multiple provider specialties, such as physical therapy and chronic pain psychology, with the common objectives of decreasing pain, restoring function and improving quality of life.

Working toward common goals and collaborating on the creation of the most practical and effective treatment plan, specialists focus on their own area of expertise yet incorporate and build upon the skills and functional gains the injured worker has obtained from other providers within the team.

This also serves as a valuable tool in assessing how medications are contributing to or hindering recovery. For instance, the physical therapist on the team can provide useful feedback to the treating physician about the effects any new medications are having on the patient from a functional standpoint, that is, if the patient is now more fatigued or somnolent as a result of recently added medications.

For injured workers who have not shown any significant improvements in pain or function with medications alone, an interdisciplinary pain management program may be considered.

10. Effective and open communication

Communication between the injured worker and all professionals involved must be well-coordinated and consistent. Care decisions and clinical updates should be provided in a timely fashion to all healthcare professionals, the claim manager and the injured worker. Any barriers to return-to-work, whether perceived or actual, should be communicated to the employer to help level-set expectations and reinforce the process of developing a meaningful and realistic return-to-work program.

Finding the way to better outcomes

Identifying areas of risk and opportunity within a claim provides a heightened level of awareness of just how “on-track” the claim is for successful resolution.

Having a detailed road map of the most important factors to consider in the treatment of chronic pain can help guide injured workers, clinicians, claims managers and employers to better outcomes more efficiently and with less obstacles and complications along the way.

Robert Hall, M.D., is the corporate medical director at Memphis, Tenn.-based Helios, where he advises on evidence-based clinical therapy and rehabilitation. He is also a practicing physician and serves as an adjunct assistant professor of Physical Medicine & Rehabilitation at The Ohio State University Wexner Medical Center.