On a weekly, if not daily, basis, there are media reports of the growing
impact of addiction to narcotics, opioids in particular. As reported at the
Tennessee Pain, Opioids, Problems, and Solutions Forum held on April 5, 2016,
in Nashville, 89 people a day are dying from the effects of opioid use,
primarily from overdose.
Families are being systematically destroyed by the multiplicity of effects
of the increasingly pervasive problem of opioid addiction. According to an
article from the Insurance Journal, data from the Centers for Disease
Control and Prevention (CDC) shows the death toll is actually close to 40,000
overdose drug deaths each year in the United States, and the number continues
to rise. More than half of overdose deaths involve prescription drugs, and
opioid-related deaths now exceed those involving heroin and cocaine
combined.1
With 5,000 people a week being injured and disabled for at least 1 week,
chronic pain becomes a reality for many.2 While
reliable data showing the proportion of injured workers that may be addicted to
opioids is hard to find, it is estimated around 60 percent of all those
prescribed. Regardless, we do know that 1.75 deaths per 1,000 patients occur
among those taking a medium to high dose of opioids.3
Prescription opioid abuse alone costs employers more than $25 billion in
2007. With opioid prescriptions up 400 percent since 1999, it is safe to
extrapolate this $25 billion to be at least $50 billion or more
now.4 Other studies show people with addictions are
far more likely to be sick or absent from work or to use workers compensation
benefits. A 2014 study by Helios reflects a slowing of use and a 3.9 percent
reduction in opioid prescriptions with a 2.9 percent reduced utilization, yet
the number of users and prescriptions remain startling high when compared to
all other drug use.5
Even more disconcerting is the fact that 80 percent of all opioid
consumption occurs in the United States, where only 5 percent of the world
population resides. This strongly implies there is a societal and cultural
profile in America that is unlike anywhere in the world, driving such demand
and overuse. Also, while not regularly a characteristic of workers compensation
claims, illegal drug use is a factor in opioid abuse. This is not hard to
understand when you consider that a kilo of crack has a street value of
$30,000, whereas a kilo of opioids can have a value of $1 million to $4
million.6
Growing Concern
The national "epidemic" of opioid abuse is getting increasing
attention across the nation. Workers compensation stakeholders are stepping up
efforts to call more attention to the use of these potent pain-relieving
narcotics by injured workers. In the highly complex and diverse field of
workers comp, entities from state governments to insurers to an array of other
stakeholders are stepping up to address the issues and impacts of opioid usage
by injured workers in varying degrees through a myriad of methods.
Many work-related back injuries occur, with doctors increasingly prescribing
opioids for both short-term and long-term treatment, even for sometimes minor
to modest pain. This is despite broad medical recommendations against long-term
use. Because of the prevalence of back injuries among workplace injuries,
opioids are increasingly the treatment of choice for what often starts as a
short-term treatment but turns into longer-term treatment, with the increasing
likelihood of addiction occurring before treatment is completed.7
Avoiding Addiction
It is very difficult, if not impossible, to predict the potential addictive
effect a drug will have on those to whom they are prescribed, as the brain and
body chemistry of each patient are different, as is each person's tolerance
for its effects. Engaging injured workers in their own recovery is a best
claims practice and is critical to the best outcomes. This engagement should
imply an obligation for injured workers to ask questions of their doctors when
being treated with drugs for pain. Some of these questions should include the
following.
- Is this prescription for pain medicine an opioid? (Doctors should educate
patients on what an opioid is and how to use it safely to relieve pain.)
- At what level of pain should I take this prescription?
(Opioids are for moderate to severe pain only. Lesser pain
should be treated with safer, less powerful drugs.)
- Do I have to take every pill in the prescription given? (Injured workers
(IWs) should only take opioids when pain levels are moderate to severe.
Leftover pills should be discarded so no other individual can obtain, use, or
redistribute them.)
- Where can I safely dispose of remaining pills? (States often provide
disposal options/locations for opioids to reduce the chance that leftovers
will get into the hands of unintended users.)
- What can I do to avoid addiction? (Opioids should only be used when an
injured worker has moderate to severe pain and as directed by the treating
physician. IWs should not take more pills than their physician directed.
Excess supply should not be saved for later use to protect others from
potential misuse. IWs should be advised not to give them to friends or family
and to dispose of unused pills appropriately. Opioids might be good for use
in the acute phase, say within 4 to 6 weeks after injury. However, when
improvement doesn't occur in this time frame, continuing use of opioids
is not appropriate, as addiction becomes increasingly assured.)
- What are the possible warning signs of dependence or addiction? Some red
flags of addiction include the following.
-
- Desire or cravings to use the pain pills without actual pain
symptoms
- Asking for refills even though pain has subsided
- Using more pills than specified or taking them more often
- Going to a different doctor for pain medication when the IW has been
refused by the current physician
- Using or considering use of illegal drugs, such as heroin, as a
substitute for pain pills
- What can I do if I believe that I might have developed a dependence on a
drug? (IWs should talk to their doctors immediately if they or a family
member show signs of addiction or dependence. Early detection can help stop
the destructive cycle of addiction before it becomes too powerful to resist.
IWs can also reach out to an addiction counseling organization.)
These and possibly other questions for treating physicians should be part of
the IW's accountability for his or her own care. This concept of patient
accountability is a critical aspect of fighting opioid addiction. It is part
and parcel to a close, collaborative relationship with treating/prescribing
physicians.
Varieties of Opioids
Claims professionals should understand that there are many variations of
opioids—including fentanyl, morphine, codeine, hydrocodone (Vicodin, Lortab),
methadone, oxycodone (Percocet, OxyContin), hydromorphone (Dilaudid), and
meperidine (Demerol)—each with different levels of potency. These opioids can
be 10–12 times as powerful as morphine and 100 times as powerful as heroin. No
wonder addiction is so often the end result.
While there is a place for opioid medications in pain management, the
growing abuse of these drugs has reached epidemic proportions in many states.
This growing epidemic has led to a wide variety of responses from an even wider
variety of stakeholders. Among these responses, a growing number of states have
developed their own set of tactics to fight back. One of the better, more
comprehensive examples of this comes from the Pennsylvania Medical Society,
which created a public advocacy program called "Opioids for Pain: Be Smart. Be Safe. Be Sure."
The program goals are as follows.
- Reduce opioid abuse and overdoses
- Educate patients about the safe use of opioids and the warning signs of
addiction
- Help physicians prescribe opioid drugs with more precision and less
potential for abuse
The key elements of the Opioids for Pain program are as follows.
- Be smart. This moniker emphasizes that patients should know the risks of
opioid use when they receive a prescription. It acknowledges that while no
one plans on becoming an addict, many do become addicts by ignoring physician
instructions on dosage limits and frequency.
- Be safe. This element emphasizes that patients should be instructed on
how to use opioids for moderate to severe pain and warned not to save extras
or give them to friends or relatives. Physicians must be encouraged to write
smaller prescriptions with fewer refills.
- Be sure. This element emphasizes that patients should be told of the
early signs of addiction or abuse and how to protect themselves from
addiction, including how to avoid it and where to turn if they feel they may
have developed a problem.
Empowering those most at risk through education is a key to addressing the
addiction crisis. The good news is that increasing awareness of this health
epidemic is starting to show results. And while the United States opioid
addiction rate is a multiple of that of other countries, total prescriptions
written for opioids have decreased in many states and across the nation for the
last 2 years. The reasons for this trend shift are still being studied, but
meanwhile, there are component parts of interdiction and addiction mitigation
that claims professionals should be aware of in their role of shepherding
injured workers through the workers compensation process. Overall, that means
understanding the roles key stakeholders have in mitigating this problem.
Beginning with treating physicians, there are specific things they should do
to help fight opioid abuse. The following are things to look for from proactive
physicians.
- Do they know and follow prescribing guidelines where they exist? For
example, through a collaborative effort between the Pennsylvania Medical
Society, Pennsylvania Department of Health, and Pennsylvania Department of
Drug and Alcohol Programs, continuing medical education on opioid prescribing
guidelines are available for use by physicians of all types. Some states,
like Pennsylvania, have a prescription drug monitoring system database. All
physicians can and should regularly use the state prescription drug
monitoring system when considering whether to prescribe a controlled
substance. Similar tools exist in many states.
- Learn to identify red flags that a patient may need help with substance
abuse. It is physicians who have the biggest opportunity and leverage for
getting patients the right help when they suspect addiction is likely.
- Physicians are often under pressure to satisfy a patient's perception
of his or her pain. Sometimes, this requires prescribing an opioid. But
caring also means sometimes saying no and recommending an alternative course
of treatment, no matter how difficult that may be. Is the treating physician
acting diligently to manage the addiction risk and not just capitulating to
patient demands for drug relief of pain?
- Is the treating physician closely monitoring the patient's real need
for pain relief from opioids? Is he or she letting patients know when they no
longer need a prescribed medication and that it is okay to stop taking
them?
According to an article from the Insurance Journal, Trey Gillespie
of Property Casualty Insurers Association of America (PCI) said the
following.
"All states have a problem with the overutilization of prescription
drugs including narcotics. The Workers' Compensation Research Institute has
looked at the data from 21 states and found longer-term use of opioids was most
prevalent in New York and Louisiana. Other states with significant long-term
opioid usage were Texas, Pennsylvania, South Carolina, California, and North
Carolina."8
The study also found that in New York and Pennsylvania, the percentages of
injured workers that become longer-term users of opioids are among the highest
in the nation.9
In the world of workers comp, the studies and efforts to curb usages are
also being driven by the bottom line, since the medical benefits portion of a
workers comp claim may be open for a number of years and may be open for the
lifetime of the injured worker.
According to Mr. Gillespie, "As the years progress, prescription
medication becomes a bigger portion of the medical expense. This is especially
true if the worker has become dependent or addicted to opioid medication to
control pain. Consequently, payers are working hard to reduce the incidence of
workers who become dependent or addicted to pain medication and look for better
treatment alternatives to opioid pain medication to manage
pain."10
The following are some of the mitigative tactics that are emerging in many
states.
- Improving utilization of statewide databases that track opioid
prescriptions and ferret out and punish overprescribing doctors
- Dealing with the growing number of pain management clinics
- Imposing stricter controls in management provider networks
Claims professionals should also be aware that opioids are generally
prescribed for the following three reasons in workers comp claims.
- Catastrophic injury with chronic pain
- Injury involving surgical treatment that necessitates immediate pain
control
- General pain control
General medical guidelines specify a 2-week timeframe after surgery or
substantial injury for opioid use. Unfortunately, use often hurdles this
threshold and becomes a longer term "solution" for continuing pain.
Over time, the ability to even perceive improvement in pain levels becomes
impaired for some by the narcotic itself.
Conclusion
So where does all this leave claims professionals who want to see injured
workers recover successfully and appropriately from their workplace injuries?
Here are a few final things to consider in the overall strategy of managing
claims involving opioid prescriptions, which, if not managed closely, may lead
to abuse and addiction.
Develop and define a strategy for identifying addiction and then monitor
physician prescribing patterns and the specific use patterns in each affected
case. Some of the tactics that should be considered as a part of this strategy
include the following.
- Leverage pharmacy utilization review.
- Direct care by getting patients to doctors who won't over-prescribe
opioids.
- Engage nurse case management early and regularly to deter chances of
addiction.
- Leverage prescription drug card programs.
- Use physicians that use state prescription drug monitoring programs and
tools available to doctors in most states (mandatory in only three).
- Leverage fraud and investigative resources that are often useful in
uncovering underlying, unrelated patterns of behavior that would indicate a
propensity for opioid abuse.
- Consider the cost of opioids versus alternatives. While many alternate
treatment modalities are, on the front-end, more expensive, they may be less
expensive in the long term, especially if they avoid long-term
addiction.
- Address the opioid issue well before case settlement. As with most longer
term open claims scenarios, claims with opioid use will only produce worse
outcomes and get more expensive over time, without appropriate early
interventions.
Finally, a note of caution for all whose accountabilities touch this area of
treatment. You must understand that terminating prescription opioids "cold
turkey" can be dangerous and even fatal. Throughout the life of the claim
and at the end of the day, for opioid-using injured workers, the relationship
between the patient and the doctor will be the primary determinant of how the
treatment will end and the outcome achieved. Continued vigilance by claims
professionals can enable and facilitate a better result at closure and avoid a
lot of potential pain for the injured workers along the recovery path.
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