On a weekly if not daily basis, there are media reports about the growing impacts of addiction to opioids. The Centers for Disease Control and Prevention (CDC) reports that 78 people a day are dying from the effects of opioid overdose.1 Families are being systematically destroyed by the multiplicity of effects of this increasingly pervasive problem. In 2014, there were over 47,000 drug overdose deaths in the United States and over 28,000 of those deaths were caused by opioids (including heroin).2 The current overdose epidemic is unfortunately only one symptom of a greater problem in the U.S. Our nation consumes 80% of all opioids produced in the world, yet the American population makes up only 5% of the total world population.3 This strongly implies there is a societal, cultural profile in America that is unlike anywhere in the world, driving such demand and overuse.
As the national “epidemic” of opioid abuse continues to get increasing attention, it’s important to realize the effect it has on employers. Prescription opioid abuse alone cost employers more than $25 billion in 2007.4 Yet even if the injured worker never develops an opioid misuse disorder, long-term opioid use is still extremely problematic. The evidence tells us that the effectiveness of chronic opioid therapy to address pain is modest and effect on function is minimal.5 In addition, when injured workers are prescribed opioids long term, the length of the claim increases dramatically and even more so when other addictive medications like benzodiazepines (alprazolam, lorazepam) are prescribed.6 Perhaps the most troubling statistic of all, 60% of injured workers on opioids 90 days post-injury will still be on opioids at 5 years.7
Workers’ compensation stakeholders are increasing efforts to call more attention to the use of these potent pain relieving drugs by injured workers. In the highly complex and diverse field of workers’ compensation, entities from state governments to insurers and other workers’ compensation stakeholders are stepping up to address the issues and impacts of opioid use by injured workers in varying degrees through a myriad of methods.
Most work-related injuries involve the musculoskeletal system, with doctors increasingly prescribing short- and long-term opioids to address even minor to modest pain despite broad medical recommendations against long-term use. Because of the prevalence of back injuries in the workplace, opioids are increasingly becoming the treatment of choice for what often starts as a short-term treatment, but frequently becomes long-term with the likelihood of addiction occurring before treatment is completed.
Claims professionals should understand that there are many variations of opioids including fentanyl; morphine; codeine; hydrocodone (Vicodin, Lortab); methadone; oxycodone, (Percocet, OxyContin); hydromorphone (Dilaudid) – each with different levels of potency. For example, fentanyl is 50 to 100 times more potent than heroin. No wonder addiction is so often the end result.
Paul Peak, PharmD, Assistant Vice President of Clinical Pharmacy at Sedgwick, notes that opioids act on receptors in the brain; therefore, it’s expected that certain changes will occur over time as use continues. Each one of us would realize both opioid dependence (this means withdrawal symptoms occur when the drug is stopped) and opioid tolerance (this means more drug is needed to get the same effect as use continues) if we were to take opioids consistently for weeks or months. In many cases, patients who are prescribed opioids chronically will experience a worsening of pain that is actually caused by the opioids themselves.
Because opioids have these profound effects on our brains, engaging injured workers in their own recovery is a best claim practice and it is critical to achieving the best outcomes. This should begin early and a key part of it includes encouraging them to ask their doctors questions when they are being treated with drugs for pain. Some of these questions should include:
- 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.
- What are some of the potential adverse effects of opioids?
Opioids can affect breathing and should be used with great caution in patients with respiratory issues. They most often cause moderate to severe constipation. Even short-term use can decrease sleep quality and impair one’s ability while driving.
- Where can I safely dispose of remaining pills?
To protect others from potential misuse, any excess supply should not be saved for later use. Injured workers should be advised not to give them to friends or family, and to dispose of unused pills appropriately. States often provide disposal options/locations for opioids to reduce the chance of leftovers getting into the hands of unintended users. In addition, CDC guidelines now recommend patients are only given a 3-day or 7-day supply of opioids and some states are now putting laws in place following this recommendation.
- Am I at risk for abuse?
Risk Assessments are tools that providers can use that have been developed to help determine those people at greatest risk for abusing opioids if prescribed. Peak notes that opioids do have some benefit in the acute phase post-injury, say within four to six 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.
These are among the key questions for treating physicians that injured workers should ask. While engagement is a vital part of patient accountability, physician education is even more critical. Peak explains that more is expected of doctors because they are providing the care. Patients and physicians working together in a close, collaborative relationship is a key part of fighting opioid addiction.
Injured workers and family members should talk to the treating physician immediately if they see signs of addiction or dependence. There are some possible warning signs of addition such as craving the pain pills without pain or when pain is less severe, requesting early refills and/or stockpiling medication, taking more pills at one time or taking them more often than prescribed, or going to multiple prescribers for opioids or other controlled substances. Early detection can help stop the destructive cycle of addiction before it becomes too powerful to resist. Injured workers can also reach out to an addiction counseling organization.
A note of caution for all whose accountabilities touch this area of treatment – 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 injured workers using opioids, the relationship with their doctor will be the primary factor in determining how the treatment will end and the outcome that is achieved.
Strategies for the claims team
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 and which, if not managed closely, may lead to abuse and addiction.
Develop and define a strategy for identifying and then monitoring physician prescribing patterns and the specific use patterns in each affected case. Some of the tactics that should be considered include:
- Leveraging pharmacy utilization review services
- Directing patients to doctors who won’t over prescribe opioids; and those who use prescription drug monitoring programs and tools, which are available in most states
- Engaging nurse case managers early and regularly; their involvement and intervention can help deter addiction; nurses can advocate for other more clinically-appropriate options, and advocate for best practices including risk assessments, opioid contracts, pill counts and random drug screens
- Ensuring that injured workers are getting prescriptions through pharmacy benefit management networks
- Leveraging fraud and investigative resources that are often useful in uncovering underlying, unrelated patterns of behavior that would indicate a propensity for opioid abuse
- Considering the cost of opioids versus alternatives; while many alternate treatment modalities are on the front-end more expensive, certain drugs may be much more expensive in the long term, especially if they lead to addiction
- Addressing the opioid issue well before case settlement; as with most longer term open claims scenarios, those with opioid use will only produce worse outcomes and get more expensive over time without appropriate early interventions
Continued vigilance by claims professionals can enable and facilitate a better result at closure and avoid a lot of potential pain for the injured worker along the recovery path.
References
1 CDC. Drug overdose deaths in the United States hit record numbers in 2014.
2 CDC. Morbidity and Mortality Weekly Report. Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014. January 1, 2016. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm?s_cid=mm6450a3_w.
3 Johnson, Denise, Jergler, Don. Insurance Journal. Opioid Epidemic Plagues Workers’ Comp. 5/17/13. http://www.insurancejournal.com/news/national/2013/05/17/292528.htm.
4 Howard G. Birnbaum, PhD, Alan G. White, PhD, Matt Schiller, BA, Tracy Waldman, BA, Jody M. Cleveland, MS, Carl L. Roland, PharmD. Oxford Journals. http://painmedicine.oxfordjournals.org/content/12/4/657. DOI: http://dx.doi.org/10.1111/j.1526-4637.2011.01075.x657-667.First published online: 1 April 2011.
6 Lavin RA, Tao XG, Yuspeh L, Bernacki EJ. Impact of the combined use of benzodiazepines and opioids on workers' compensation claim cost. http://www.ncbi.nlm.nih.gov/pubmed/25046322.
7 Martin BC, Fan MY, Edlund MJ, Devries A, Braden JB, Sullivan MD. Long-term chronic opioid therapy discontinuation rates from the TROUP study. J Gen Intern Med 2011;26:1450-7.
Additional resources
- American Academy of Pain Medicine. Societal Costs of Prescription Opioid Abuse, Dependence, and Misuse in the United States. April 2011.
- https://www.wcrinet.org/STUDIES/protected/exec_summaries/use_narcotics2-es.html.
- We’re beating back opioids – Now what? Peter Rousmaniere in cooperation with CompPharma. June 2015. https://www.workcompcentral.com/pdf/Opioid_Report.pdf.
Chris Mandel SVP, Strategic Solutions, Sedgwick Director, Sedgwick Institute