Opioids and Occupational Injuries

With each day, there seems to be a new statistic or a news story that demonstrates the growing crisis that is driven by the proliferation of opioids. We seem to have reached the crisis stage long ago. Knowledge has increased in terms of the risks and concerns of taking these medications. Overall, there seem to be positive trends in the direction of dispensing of medications. A recent article in Business Insurance discussed a New Jersey case where a judge determined, based on a treating physician’s recommendation, that a continued use of opioids as a long-term strategy was not a viable option. However, we continue to see issues of clear abuse, overprescribing and addiction on workers compensation claims. What is becoming increasingly clear is that the important thing is to manage the opioid issue before it begins. And if it does begin, proactively managing the issue with effective tools will mitigate the potential impacts on the injured worker.

The problem persists. Opioid analgesic-related overdose deaths now outnumber overdose deaths involving all illicit drugs, such as heroin and cocaine, combined. While that seems shocking, what is more shocking is that the number of drug overdose death rates has increased five-fold since 1980, with prescription medications – specifically opioid analgesics – becoming increasingly involved. While the issue impacts both occupational and non-occupational medicine, the issue is quite acute in the occupational space. In the workers’ compensation industry, approximately 60% of claimants take opioid analgesics as part of their treatment regimen. That percentage would not be so bad if it were not accompanied by the fact that workers’ compensation claims with opioid prescriptions cost on average $20,000 more than those claims without opioid analgesics.

So, what do we do to combat the issue? The first thing we need to examine is what do we do if they are prescribed? It will happen. These are legal medications. They will be prescribed until more jurisdictions try to stop them altogether. At the start of a regime, it is critical to make sure there is an effective treatment plan. The goal is to decrease suffering and increase function for the patient. This can be done without these medications, so developing a strategy with the physician and the injured worker is what will drive success. The goal is to see an improvement in pain associated symptoms so that sleep disturbance, depression and anxiety can be avoided. Establish these goals early in the process. In addition, revisit the treatment plan often to incorporate patient advances and progress. It is important to individualize the objectives specific to the patient.

One of the key success factors in successful management of claims with opioids is patient engagement. In worker’s compensation, often the patient has no prior relationship to their treating physician. As a result, there are no trust levels or a true understanding of the patient’s prior medical history or experience. While the physician is supposed to provide an overview of the possible side effects or risks of a medication, in today’s rushed environment, this may not always happen. In addition, because of a patient’s lack of familiarity with the physician, they may feel uncomfortable with asking questions. There are alternatives to solve this. One idea is direct patient education. Creating tools that are easy to understand and follow will make sure the injured worker is aware of potential issues and provide them with a forum to discuss them with physician or medical case manager.

Often the injured worker does not understand the potential risks of opioid therapy. There are a number of potential side effects of taking opioids such as the likelihood of tolerance and physical dependence. There is limited clinical evidence as to the benefits of extended use of opioid therapy. We do know that there is a risk of drug interaction and over sedation. We have seen numerous news stories of parents passing out with children still in their cars. Some of these cases of interaction and over sedation can also result in death. The risks of impaired motor skills while driving or even doing household chores can have tragic results. And what is now being seen are the long-term physical impacts of extended opioid use. This is why it is important to follow up at frequent intervals of treatment to ensure risks are addressed and questions are answered.

What are some of the other tools available to help manage the opioid issue? Because this is really a medical issue, many adjusters are just not skilled or equipped to manage the intense complexities of managing claims where there is a high level of opioids. Appropriate clinical oversight and management is important to ensure a successful outcome for the injured worker. Integrated medical case management can help to do this. Specific workflows should be developed to allow for joint strategy and task management between adjuster and medical case manager. Early involvement of medical case management is essential to improved outcomes. Waiting until the case is at crisis stage does not save money. It only makes a case more complex and more expensive overall.

Peer Review and Peer to Peer Education and Guidance is another effective tool to manage and mitigate the long-term use and impacts of opioids. We know that claims with physician dispensed medications have higher costs and durations. The Peer interactions make treating physicians accountable to their peers. Peer monitoring and oversight will change physician prescribing behavior. This can also be done with a Prescription Drug Monitoring Program (PDMP.) A PDMP is an effective way to integrate patient and provider into the recovery program. It can create enhanced levels of accountability.

One of the most important takeaways from this article should be the understanding of the term Morphine Equivalent Dosage or MED. It is essential for monitoring and management of injured workers on opioids. An MED is the relative potency of opioid medications. Morphine is the “standard†for comparison. So – 1 mg of morphine = 1 MED. When we look at MED, we are determining the 24-hour cumulative dose calculated: milligrams/day. The MED scale allows for a comparison of the opioid medication dose. There are evidence-based guidelines for the MED. Official Disability Guidelines (ODG) set the number at 100 milligrams per day MED limits. There are also state specific, AECOM and CDC recommended MED limits. It is important to understand what this is and how to monitor it. An organization should also have specific protocols in place for claims that exceed thresholds. When there are claims that have exceeded these thresholds, it is important to take immediate action.

From a Claim Program Management, an essential element is the adjuster training. There should be initial clinical overview training to educate not just on the terminology, but also on the specific actions. Do adjusters know when to reach out for clinical resources? And more importantly, do they have a clear sense of knowing what you do not know and do not try to make medical judgements where they do not fully understand the ramifications? Sometimes a pharmacy script is approved just so the injured worker does not get mad or does not get an attorney. What can be the long-term effects of those decisions?

Are there specific vendor assignment protocols in place? This helps to put action into motion that is consistent. From a quality perspective, it is important to make sure that if there are clinical guidelines put in place, they are followed consistently. Have clinical referral criteria established in advance. And automate referral process to expedite assignment and to make sure that it happens.

Also, look to changing the way that claims are reviewed. Are you still managing claims looking at the same indicators from 20 years ago? Are you still conducting the same old claim reviews? Medical now accounts for more than 60% of total spending. If you are not using the right resources in a claim review, you may be missing some of these critical long term medical issues. Be sure to engage with your medical director or program pharmacist to serve as a consultant during these discussions.

Finally, what is the technology and reporting strategy? Are you capturing the right data? Effective program oversight and accountability should be in place to identify and review flagged claims. This can help to manage the issue prospectively. The alerts and triggers should be automatic. If it is a manual process it may lead to a lack of compliance and consistency. This is especially true if they are not integrated in your claim systems.

For now, this issue is here to stay. Opioids continue to receive attention at the state and national level. This increased focus will better target a comprehensive solution to the crisis at a macro level. As we continue to look at claims at a micro level, having a comprehensive plan will continue to help to mitigate and manage the costs and medical concerns. Insurance and the workers compensation system may not have caused the problem, but it is our responsibility to continue to address it and manage it to ensure that injured workers receive medical care that will not put them in a condition that is worse before they were injured. It is simply the right thing to do.