Opioids: a Stumbling Block to Good Claim Outcomes

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.