The opioid epidemic, which gained attention in the 1990s, led to a significant focus on monitoring and managing opioid medication use. Even today, we continue to practice vigilance in opioid prescribing practices. However, this sustained emphasis on opioids may have unintentionally shifted attention from other classes of medications that can also lead to unfavorable circumstances, creating potential problems on a larger scale. In this article, we draw attention to one such medication—duloxetine, brand name Cymbalta—an SNRI antidepressant that has gained significance in the context of workers' compensation.
A recent assessment conducted by Broadspire using Pharmacy Benefit Manager (PBM) data has uncovered a noticeable trend in high dose[1] duloxetine prescriptions among injured workers. In this article, we delve into the findings of the survey, shed light on the potential risks posed by these prescriptions, and outline the proactive measures our team is taking to address this critical issue.
The opioid era and its implications
According to the Center for Disease Control and Prevention (CDC), the onset of the opioid epidemic in the 1990s[2] prompted a widespread focus on opioid medication utilization. This intensified scrutiny aimed to address the risks associated with opioid dependence, addiction, misuse and related adverse outcomes. Over the years, monitoring opioid use has remained a priority in healthcare settings and in the management of workers' compensation claims.
Unintended consequences and missed opportunities
While the focus on opioids has undoubtedly been necessary, it may have inadvertently overshadowed other classes of medications that could pose significant challenges and risks to injured workers. The limited attention given to these medications may lead to missed opportunities for early intervention and prevention of adverse outcomes. As healthcare professionals and insurance adjusters, it is imperative to broaden our perspective beyond opioids and remain vigilant about the potential dangers associated with other medications.
Unveiling the duloxetine dilemma
Duloxetine, a selective serotonin and norepinephrine reuptake inhibitor (SNRI), has garnered attention for its efficacy and frequent use in treating depression and various types of pain. This medication is commonly prescribed for the management of various conditions, including major depressive disorder, generalized anxiety disorder, diabetic peripheral neuropathy (nerve damage causing pain) and fibromyalgia (a widespread chronic muscle pain condition). While the recommended daily dosage of duloxetine[3] typically does not exceed 60 mg, our data survey revealed a shocking truth—approximately 20% of injured workers prescribed duloxetine are receiving doses that exceed the established limit.
Navigating uncharted territory
In the context of injured workers, managing pain and functional impairment is crucial for facilitating their recovery and return to work. Work-related injuries often result in acute and chronic pain, which can significantly impact an individual's ability to perform job-related tasks and engage in daily activities. Effective pain management strategies are therefore essential in optimizing functional outcomes and promoting successful rehabilitation.
Despite duloxetine's potential as an effective treatment for chronic pain, its specific efficacy and safety profile in the context of injured workers remain an area of interest. Our clinical interventions aim to support safe prescribing practices that align with published guidelines while ensuring optimal patient outcomes.
Balancing benefits and risks
The underlying mechanisms of neuropathic pain involve irregular signaling and processing of pain signals within the nervous system. Duloxetine, as an SNRI, exerts its therapeutic effects through the modulation of both serotonin and norepinephrine neurotransmission in the central nervous system, thereby influencing pain perception and mood regulation.
While clinical studies have explored the potential benefits of duloxetine at higher doses[4] (>60 mg per day) in patients with major depressive disorder, it is crucial to weigh these benefits against the associated risks. Research suggests that higher doses may provide additional relief for those who have not adequately responded to lower doses, but they also bring an increased risk of adverse events. Therefore, a prudent approach is necessary when considering the initiation of treatment with high-dose duloxetine.
Prioritizing patient safety
Approved by the U.S. Food and Drug Administration in 2004, duloxetine was first used to treat major depressive disorder (MDD) in adults. Common side effects with duloxetine at doses of 60 mg per day are nausea, dry mouth, dizziness, constipation, difficulty sleeping, excessive sweating, persistent weakness or fatigue, and high blood pressure. The use of high-dose duloxetine prescriptions poses a significant concern, potentially amplifying the risks of adverse effects[5] and drug interactions. Excessive doses and combinations of medications that affect serotonin (such as tramadol) can lead to a life-threatening condition known as Serotonin Syndrome, while combining duloxetine with benzodiazepines can make the effects of benzodiazepines even stronger.
A proactive response
By performing an evaluation of PBM data that manages medication utilization in workers' compensation cases, we gained valuable insights into the frequency and trends of duloxetine usage. To ensure patient safety and adherence to established guidelines, our team at Broadspire has embarked on a comprehensive safety project initiative to monitor and reduce the incidence of high-dose duloxetine prescriptions among injured workers.
Interventions that make a difference
To address the pressing issue of over-utilization, our team has developed and implemented targeted interventions. Clinical communication to healthcare providers emphasizes the importance of adhering to recommended dosages and monitoring patient safety. Additionally, we have established clinical alerts to serve as a tool to address overprescribing of high doses of duloxetine, polypharmacy and drug interactions. These interventions not only enhance awareness but also promote evidence-based prescribing practices and encourage appropriate utilization of duloxetine among injured workers.
Conclusion
As we continue to address the opioid epidemic and strive to enhance opioid safety in workers’ compensation, it is equally important to widen our gaze and acknowledge the potential risks associated with medications beyond opioids. Duloxetine, an SNRI antidepressant, serves as a compelling example. By maintaining a comprehensive approach that encompasses various medication classes, including duloxetine, we can better safeguard injured workers’, minimize risks and optimize their outcomes.
Our proactive approach of monitoring and targeted clinical interventions works to impact the percentage of injured workers receiving medication doses exceeding recommended limits. By prioritizing patient safety, promoting evidence-based prescribing and fostering awareness among healthcare providers, we are making strides toward mitigating the risks associated with high-dose duloxetine utilization.
It is our collective responsibility to stay vigilant, address emerging trends and take preventative measures that contribute to the well-being of injured workers. By actively engaging in efforts to optimize medication safety, we play a crucial role in facilitating their recovery, supporting their return to work and ultimately improving their overall quality of life.
