New Approaches to Managing Medications
Understanding a patient’s inherited genetic characteristics and their responses to opioid and psychotropic drugs
As a physician and a medical director for an insurance company specializing in the workers compensation arena, I believe it is increasingly evident that the management of the injured worker and the goal to return to work are being hampered by the incorrect use, and potential overuse, of opioids and pyschotropic drugs in the treatment of injuries. It is not my intent to preach to the choir, but rather to suggest a potential partial solution to this growing problem.
First, let’s go back a number of years to when treating infections was a guessing game because antibiotics were still new on the market and little was known about which antibiotics worked best. Suddenly, the bright idea of doing culture and sensitivity tests was hatched, and these became key components of the practitioner’s black bag. The result was astonishing. We could now determine what medication would be best for the treatment of a particular infection and—behold!—the cure rate increased significantly.
Let’s carry that thought across the threshold and apply the principle to opioid and psychotropic prescription delivery. The enzyme method of detection is commonplace testing. The literature today has shown that genetics could possibly explain responses to and variability in the effectiveness of drugs. If you accept this premise, then it is reasonable to use the genetic tools to enable better and more appropriate responses to specific medications such as opioids and pyschotropics.
Ongoing research demonstrates that there is a defined relationship between patients’ inherited genetic characteristics and their responses to pharmaceutical drugs. Three basic categories exist: the rapid metabolizer; the normal metabolizer; and the poor or slow metabolizer. Each of these groups predictably demonstrates the pharmacogenomics of its specific activity of absorption resulting in the outcomes of the rate of metabolic activity. Simply put, the rapid metabolizer results in a lack of efficacy with insufficient dosing, while the poor metabolizer results in overdosing and the potential for excessive dosing.
Compwest Insurance took the bull by the horns by developing a program three years ago to actually apply this theory. Once the injured worker candidate was identified, and after the worker consented, an enzyme evaluation was conducted to determine the metabolic rate of the opioids and psychotropic drugs prescribed by the provider. The information was only addressed by the provider to the injured worker. The doctor-patient relationship was maintained and the management of the findings recorded only by that relationship, thereby adhering to the Genetic Information Nondiscrimination Act of 2008 (GINA). If a change in the medication, either by dose or drug, is necessary, it can be accomplished quickly and directly. Physician cooperation is imperative, as is the cooperation and understanding of the goals by the injured worker.
In the initial development of the program, several issues and concerns needed to be addressed and solutions created before the program’s initiation:
Deciding when to initiate testing. It was impractical to test every injured worker. It was decided that the most appropriate time for testing was within the first 30 days of the first prescription prior to any potential refill of the drugs.
Addressing confidentiality concerns. It was critical to address injured workers’ concerns and make certain that the testing remained confidential and in accordance with any laws or regulations, like GINA. This issue was addressed by making the program strictly voluntary on the part of the injured worker. Strict adherence to confidentiality between the provider and the worker was maintained, with no direct contact with the payer.
Measuring Success. Determining how and when to capture the information identifying whether the program was effective in reducing the unnecessary continued exposure to potential improper prescription management was crucial. The cooperation of industry pharmacy companies is essential because of their ability to recognize prescription-filling habits and notify the payers of findings. It has been my experience that the large pharmacy organizations track dispensing criteria and can be supportive in obtaining the necessary information to help guide your criteria.
Educating providers and injured workers on why the program is essential. Concerns surrounded billing issues for reimbursement of the testing time and the additional time to discuss issues with injured workers. There are billing codes to accommodate their concerns. Questions about the interpretation of the reports can be addressed by simplifying the reports and graphs received from the labs. Simple brochures are available to help injured workers fully understand the procedure as well as the value of the testing performed.
Following are three case studies picked at random for review on the application of enzyme testing. The reports were reviewed by the treating provider, and we were able to look at the results by retrospective drug utilization review of medication scheduled on our weekly reviews. All reports were confidential and within the HIPAA and GINA regulations/guidelines.
Case One: The individual is currently on pain medication, including Tramadol and Effexor. The testing indicated that the current dosage of the Tramadol had reached a point of toxicity to the patient. The report sent to the provider indicated that the medication either needs to be reduced in dose or changed. Alternative medication was suggested.
In the case of the Effexor, which is used for depression and anxiety as treatment for pain management, evidence showed that the patient was a hypometabolizer and continued use would be toxic. A change in the class of drug was recommended.
The reports furnished indicated red (needs change), yellow (needs review), and green (ok) functions; Tramadol and Effexor were in the red group.
Case Two: This injured worker was taking multiple pain medications, including hydrocodone, oxycodone, and two nonsteroidal anti-inflammatory drugs (NSAID), ibuprofen and naproxen. The testing demonstrated the toxic impact of the “cocktail,” and the recommendation was made, to the provider and to the injured worker, that a reduction was required. The recommendation was to eliminate one of the NSAID drugs, and to eliminate one of the opioids and substitute a less-dangerous drug from the list of compatible medications forwarded to the provider in the report.
The reports in this case indicated red notices for the “cocktail” combination with recommendation of suggested change.
Case Three: The injured worker was taking multiple medications for pain and depression, but the report reviewed by the provider and the patient indicated that the dosing and medication was within accepted guidelines and did not demonstrate a need for change at this time.
Drug management at best is difficult. Any reasonable solution to the current problem that enables more appropriate prescribing of medications and improved return to work outcomes is a must.