The opioid epidemic in workers’ comp
DEC 19, 2017 | BY MARK PEW
Repercussions from opioid use in the United States continues at an epidemic level.
The CDC has documented there were 64,070 drug overdose deaths in 2016 and approximately 63% (around 40,000 total or 109 per day) of those deaths were related to opioids. Unfortunately, the trend is toward more powerful versions of opioids, transitioning from opioids that were legally prescribed, to heroin and now to illicit fentanyl and carfentanil.
Workers’ compensation has been dealing with the prescription opioid epidemic since over-prescribing started in the mid 1990s. However, anxiety over opioid use increased dramatically in 2006 when the Centers for Medicare and Medicaid Services (CMS) put forth that Work Comp Medicare Set Aside (WCMSA) calculations should include pharmacy cost projections over the life expectancy of Medicare-eligible injured workers.
A huge financial burden has resulted from increasing monthly expenditures for opioid drugs that were often creating more harm than good, paying for functional restoration and detoxification programs, the inability to settle and close claims, and even death benefits when an overdose occurred. The impact on the workers has been significant as well. Many have suffered cascading side effects from the drugs and their interactions. They also endured reduced levels of function, an inability to return to work and a diminished quality of life.
The good news is that work comp has made progress in this battle, to the point that the use of opioids has actually declined over the past few years. According to two pharmacy benefit manager (PBM) drug trend reports, opioid utilization decreased from 2014 to 2015 by 3.2% (Coventry First Script) and 4.9% (Express Scripts). So while there has been some positive progress, the problem is by no means fixed.
Here are five suggestions on how to maintain and even enhance progress:
1. Consistently and proactively evaluate medication safety
Every prescribed drug should be validated. The benefits must outweigh the risks with minimal side effects and interactions and maximum efficacy. Education is key, for prescribers and patients, but sometimes an objective third-party review is needed. Although some of that can be automated in PBM formularies and step therapy logic, often this requires a hands-on evaluation of patient response. Not all painkillers are clinically inappropriate as there are legitimate reasons for their use (during the acute and sub-acute phase and even at times for chronic pain).
Deciding when a prescription drug should be used is complicated and individualized. Rather than personal opinion, the evaluation should be made according to evidence-based medicine that defines the expected standard of care in managing a patient’s condition. This can be done by nurse triage, peer review, case management, and independent medical examinations among other options. Everyone must remain vigilant at every stage of treatment.
2. Use a biomedical, psychosocial and spiritual treatment model
It can be easy to forget that injured workers are people, too. The biomedical model focuses more on physical treatments like surgery or therapy to resolve medical conditions, but can lose sight that the patient consists of body, mind and soul. The whole-person approach deals with psychosocial conditions that can either be helpful or detrimental to the healing process.
Addressing issues regarding upbringing and social environment may not be directly compensable to work comp. However, these factors can negatively impact resiliency and coping mechanisms. Without these skills, use of potentially addictive pills becomes a sub-optimal choice.
Paying market rate to high-quality practitioners for behavioral psychological treatment like cognitive behavioral therapy (CBT), motivational interviewing (MI), and acceptance and commitment therapy (ACT) can have a positive impact. Also important are assessment tools that should be used before writing the first prescription and certainly before “automatic” refills. Forgetting, or ignoring, the role of the psychosocial and spiritual components in the injured worker’s recovery can dramatically reduce the likelihood of successful outcomes.
3. Encourage non-medication pain management techniques
Paying for treatments like CBT, mindfulness, biofeedback, and acupuncture would have been laughable in workers’ comp five years ago, as would reimbursing for gym memberships, nutritionists, yoga, tai chi and activity trackers. In many areas, hard caps on the number of physical therapy and chiropractic treatments were considered the gold standard in pain management. And the use of medical marijuana for pain was just a pipe dream. However, as the opioid epidemic has unfolded (with corresponding overuse of benzodiazepines, muscle relaxants, anticonvulsants and antidepressants), acceptance has increased for non-pharma/behavioral options.
Many of these treatments are backed by at least anecdotal stories of success, if not science. The term “mindfulness” is used to define a variety of methods for relaxation, so measuring success scientifically, which requires uniformity and control, can be difficult. But most behavioral psychologists use mindfulness techniques with success on a daily basis.
The goal is not to create a checklist but a toolbox. Every individual is unique, not just in terms of physical condition, but also the psychosocial and spiritual elements. There is no single treatment plan that works for everyone. Instead, it’s important to provide access to as many tools as possible. This enables the right combination to be found for each person to manage pain effectively. Payers need to continue to become more comfortable in evaluating, approving and paying for this multimodal approach.
4. Taper inappropriate polypharmacy regimens
There are, unfortunately, no treatment guidelines in workers’ comp or elsewhere that provide guidance to tapering inappropriate polypharmacy regimens. Seemingly, nobody takes opioids alone as they often take anti-anxiety, sleep aid, anti-constipation and other drugs to address compounding side effects. Each drug that is added for a new symptom has its own side effects and potential interactions with existing medications, which makes the prioritization of the drug to start tapering first incredibly important and challenging.
Here are some measures that are often considered in these types of cases:
- Use of medication-assisted treatment (MAT), such as buprenorphine, naltrexone or methadone, can help facilitate tapering and reduce recidivism.
- A non-MAT approach with methodical titration by drug or classification is a viable option not discussed enough.
- An inpatient stay or outpatient setting needs to be determined.
- Selection and use of non-pharma coping skills must be added – as drugs decrease, coping skills must increase.
As outlined previously, the process is complex, dynamic and individualized. It can also be costly and time-consuming. But if the goal is to achieve maximum medical improvement, inappropriate polypharmacy regimens need to be replaced with better attitudes and actions toward the engaged management of pain.
5. Monitor federal and state interventions
The fact that a Massachusetts prescriber can only write a seven-day supply of opioids for first-time adult prescriptions (not the status quo 30-day supply) has a direct impact on workers’ comp — as do these other factors:
- Mandated use of California’s CURES prescription drug monitoring program.
- CDC Guideline for Prescribing Opioids for Chronic Pain, which is used by an increasing number of states for the expected standard of care.
- The Joint Commission’s new standards for the nearly 21,000 certified health care organizations in pain assessment and management that are effective on Jan. 1, 2018.
None of these federal, state and community initiatives that address the opioid epidemic explicitly mention workers’ comp, but they also do not explicitly exclude work comp. Although work comp has introduced its own tactics (treatment guidelines, drug formularies and the New York weaning hearing process), the practice of pain management will be impacted as much by outside forces. As the efforts continue to grow, it is important for payers to understand the issue from multiple angles and how these various changes impact the status quo.
The workers’ comp industry, along with other payers and society, owe it to the individuals caught up in the opioid epidemic to find more appropriate management options for pain, whether up-front during the acute phase or once it has, unfortunately, transitioned into a chronic state.
Workers’ comp is responsible for the consequences of decisions made from the moment a workplace injury occurs. The industry has its own role to play in helping to #CleanUpTheMess. In this case, “mess” means the opioid epidemic, and the source of that “mess” has been the overreliance on prescription painkillers. Now it’s time to clean up that “mess” by not creating the same issues for future injured workers and to help those already caught in the “mess” to regain their lives and livelihoods.