What if you had a crystal ball that could predict the future? In workers’ compensation, complex claims rarely become complex overnight; the challenge is recognizing the signs so we can intervene. As a workers’ compensation pharmacy benefit manager, our “crystal ball” is pharmacy activity, which serves as one measurable indicator of future claim complexity.
Because pharmacy utilization often begins immediately after injury, it is one of the earliest, most consistent data streams available to flag elevated risk – especially when it reinforces other indicators such as injury type, comorbidities, psychosocial concerns, and more. While no single prescription necessarily predicts a problematic claim, multiple pharmacy signals appearing together can provide a warning that the claim may be headed toward greater cost, duration, and clinical complexity. There are early risk signals hiding in medications and utilization, patient behavior, prescriber behavior, and channels used to obtain medications.
By understanding these signals, we can approach complex claims differently – moving from a reactive approach to a more proactive strategy that may prevent routine, manageable claims from becoming complex in the first place.
The medications prescribed early in a claim provide insight into potential safety concerns, treatment complexity, or prolonged recovery. The examples below represent some of the more common medication-related signals that may emerge in a workers’ compensation claim.
There is substantial evidence linking early opioid use, higher doses, longer days’ supply, and escalating Morphine Milligram Equivalent (MME) values to longer claim duration and disability. Injured workers who are prescribed high doses of opioids early in a claim remain substantially more likely to continue receiving high doses years later.1 And longer-term opioid prescriptions in claims are associated with temporary disabilities more than three times longer than claims without any opioid prescriptions.2
In a study of injured workers in Washington, exposure to high-risk opioid prescribing within 90 days of injury was significantly and substantially associated with long-term temporary and permanent disability.3 Another study that followed claims for 10 years from injury date found that opioid morphine equivalent doses of more than 5 milligrams per day for the first six months were associated with not being released to work at the end of the third year post-injury.4
Combining opioids with certain other drugs can increase overdose, sedation, cognitive impairment, and fall risk. Such dangerous combinations include opioids plus benzodiazepines, muscle relaxants, or gabapentin/pregabalin. In 2016, the U.S. Food and Drug Administration (FDA) added a boxed warning cautioning patients about the serious risks of taking opioids along with benzodiazepines or other central nervous system depressants.5 Additionally, in 2019 the FDA issued another warning cautioning that gabapentin and pregabalin could cause serious breathing difficulties in patients who use opioid pain medicines or other central nervous system depressants.6
The prescription of a specialty medication may not, by itself, indicate delayed recovery risk. However, it can signal financial and clinical complexity, particularly when the medication requires ongoing monitoring, specialty sourcing, adherence support, or coordination across providers and dispensing channels. Furthermore, long-term use of these drugs can pose safety concerns when inappropriately administered or ineffectively treating a patient’s condition.7
Drug-disease interactions are particularly relevant when comorbidities are known from medical records, diagnosis data, or inferred from the medication profile – and comorbid diseases are common among injured workers.8 Prescription of certain drugs when comorbid diseases are present – such as an NSAID prescribed to a patient with known renal disease – can indicate inappropriate therapy and lead to increased adverse event risk or delayed recovery.
Utilization patterns often provide a stronger risk signal than prescription of the medication alone. Duration, dose escalation, repeated fills, early refills, and concurrent therapies help reveal whether treatment is resolving as expected or moving toward a more complex trajectory.
The early introduction of high-risk medications, such as opioids, gabapentinoids, or sedatives/sleep medications, is a significant red flag, especially when combined with other utilization risk signals.
Another red flag is rapid drug class or dosage escalation, such as moving from NSAIDs to opioids in a short time frame or transition from a short-acting to a long-acting opioid. Research shows an association between increasing opioid doses and deaths for workers’ comp claimants even for low-severity diagnoses.9
The most egregious example of prolonged utilization is opioid use beyond acute recovery. A 2018 study found that workers’ comp claimants have a high proportion of persistent opioid use, with approximately 30% of claimants filling opioid prescriptions beyond 90 days from injury.10 Muscle relaxants are another culprit. While they can help with pain, they are not meant to be taken chronically, as overreliance can lead to dependence and withdrawal.11
Polypharmacy – taking many medications at once, sometimes five or more – often indicates increasing claim complexity, comorbidities, adverse effects, or fragmented care. Examples of inappropriate polypharmacy include multiple medications serving similar therapeutic purposes, new medications being added to treat side effects of existing medications, or medications added over time across multiple prescribers. Research on elderly patients shows that as the number of drugs taken increases, the risk of adverse drug reactions increases exponentially.12
Certain patient behavior/medication-use patterns may reflect barriers to recovery, adherence challenges, unresolved symptoms, safety concerns, or misuse risk. It’s important to note that these patterns should be interpreted in context rather than assumed to reflect patient intent.
Medication nonadherence may include delayed fills, prescription abandonment, or inconsistent use of therapy. It is associated with elevated mortality, increased healthcare utilization, and higher direct and indirect financial costs.13
A pattern of early refills for controlled substances may indicate escalating symptoms, inadequate pain control, misunderstanding of directions, access or coordination issues, or potential misuse. Early refills ranked among the top predictors of opioid use disorder in a large electronic health record machine-learning study.14
Gaps and restarts in therapy, such as stopping and starting opioids or extended lapses followed by renewed utilization, may lead to delayed treatment, longer recovery times, and increased overdose risk.
Certain prescribing patterns may suggest clinical quality concerns or treatment approaches that warrant additional review or care coordination.
A major red flag is a provider who prescribes outside treatment guidelines such as the American College of Occupational and Environmental Medicine (ACOEM) and Official Disability Guidelines (ODG), which are grounded in evidence-based medical literature. ODG users report a 34% reduction in claim duration, along with medical and indemnity cost savings.15
Another issue is prescribing off the formulary – a list of medications designed to ensure only safe and effective drugs are used. While some states mandate the use of formularies, others do not – leaving the choice to use a formulary to the prescriber. Depending on state regulations and payer policy, off-formulary medications may require additional review or prior authorization before approval.
Examples include high-dose opioids, compounds, and private-label topicals (PLTs). Compounded medications are not FDA approved for safety, effectiveness, or quality before marketing, and poorly compounded products may create contamination or potency risks. PLT products may also raise concern when they are high-cost formulations or packaged combinations with lower-cost over-the-counter (OTC) alternatives available. PLTs come with significant price markups over similar OTC products.16
Multiple prescribers for similar therapies may indicate fragmented care or incomplete medication reconciliation. This is especially concerning when controlled substances, sedating medications, or overlapping therapies are involved, because each prescriber may not have full visibility into the overall treatment plan. From a claims management perspective, activity involving multiple prescribers may warrant additional review to ensure treatment remains coordinated, clinically appropriate, and aligned with the plan of care.
The channels through which medications are prescribed and dispensed can influence visibility into treatment activity and negatively impact how the claim is managed from clinical and cost effectiveness perspectives.
Physician dispensing is when a provider dispenses medication to the patient directly from his or her office. Claims that involve physician dispensing have been associated with more lost time from work and higher claim cost compared to pharmacy dispensing.17 In a study of workers’ comp claim outcomes in Illinois, when opioids were dispensed by the physician, the number of days off work was 85% higher than pharmacy dispensations.18
When prescriptions are filled outside the pharmacy network, including via OON mail order, claims professionals cannot see real-time medication activity and pharmacists lose the holistic view of a patient’s treatment history. This can lead to patient safety risks such as inappropriate or duplicative treatments. OON pharmacies also operate outside the cost containment structure that is used for other types of medical services and often charge more as a result.
Using a consistent in-network pharmacy improves medication visibility, safety screening, and coordination. Conversely, when a patient obtains the same prescription from multiple pharmacies, they are at risk for adverse side effects and potential drug interactions. Research shows that patients receiving opioids from multiple prescribers or pharmacies have a higher likelihood of opioid-related overdose death compared with patients who receive opioids from one prescriber.19
Identifying the risks that drive claim complexity is a priority for today’s workers’ comp stakeholders. In Healthesystems’ 2026 survey, 52% of respondents cited complex claims as an industry challenge.20
As workers’ comp organizations continue to confront claim complexity, leading programs are increasingly focused on building the capabilities to identify, prioritize, and respond to risk earlier in the claim lifecycle. By looking beyond structured pharmacy and claims data, they can extract clinically meaningful information from unstructured documents, including medical records, physical therapy visit notes, home health documentation, diagnostic reports, and provider narratives.
These sources may reveal changes in pain, function, treatment response, adherence, care coordination, work status, and comorbidities that are not visible in transaction data alone. When combined with pharmacy activity, these insights provide a more complete view of the injured worker’s risk trajectory and can help claims professionals identify medication concerns, gaps in care, and opportunities for earlier intervention.
Some risks may be addressed prospectively through formulary or drug utilization review controls, while others may warrant targeted pharmacist review, prescriber outreach, patient engagement, nurse case management coordination, or additional medical record review. The goal is not to flag every variation in therapy, but to distinguish routine treatment from patterns that suggest escalating clinical, safety, or cost risk.
A 47-year-old warehouse worker sustains a lower back strain while lifting inventory. The injury is initially considered straightforward and is expected to resolve with conservative treatment.
The injured worker receives an anti-inflammatory medication and begins physical therapy (PT). A few days later, an opioid prescription is added to address ongoing pain complaints.
Several new pharmacy-related signals begin to emerge. Viewed independently, none of these events necessarily indicate a problematic claim:
Clinical insights: At this point, the claim may not require escalation solely because an opioid was prescribed. However, early refill activity, dose escalation, and the addition of a muscle relaxant may warrant a focused review of diagnosis, functional progress, prescriber follow-up, and return-to-work expectations.
Additional signals begin to accumulate. At this stage, the claim may still appear routine when viewed through any single lens. However, pharmacy activity is beginning to reveal a pattern of escalating utilization, increasing medication complexity, fragmented care, and potential adherence concerns:
Clinical insights: This is the point where pharmacy data should trigger coordination, not just claims review. The claims team and appropriate experts should confirm whether PT attendance barriers exist, determine whether the sleep medication reflects worsening pain or psychosocial distress, and assess whether prescribers are aligned on the medication plan.
As treatment continues:
What began as an uncomplicated injury now exhibits several pharmacy-related risk signals across multiple categories:
This example highlights how pharmacy activity can provide valuable insight into a claim long before final outcomes are known. While it is not a crystal ball in isolation and no single activity tells the entire story, prescribing patterns, utilization trends, treatment channels, and other pharmacy-related events can each offer important context about how treatment is evolving.
The value of these signals is not simply in detecting risk, it is in turning risk into action: aligning the medication plan with the diagnosis and recovery stage, supporting safer prescribing, engaging the injured worker when adherence issues or side effects emerge, and coordinating with claims, clinical, and return-to-work resources before the claim deteriorates.
Because pharmacy activity often begins immediately after injury and may continue throughout the course of treatment, it remains one of the earliest and most consistent sources of information available to stakeholders seeking to proactively manage claim complexity.
