WCRI Conference Focuses on Combating the Opioid Epidemic

By Deborah G. Kohl, Esq.

The last several years have seen the “opioid epidemic” become the hot topic in the workers’ compensation industry. It is a problem that everyone from elected officials, government agencies, insurance carriers, doctors and ultimately families have had to address. The WCRI conference held in Boston on March 2, 2017 focused its attention on this important issue with two interesting sessions discussing not only new approaches to combating the epidemic but also alternatives to the prescribing of opioid medications for chronic pain.

The first session included an overview by WCRI’s Dr. Vennela Thumula of interstate trends in the use of opioids. Interestingly this revealed that there has been a decrease in the frequency and amount of opioid usage per claim between 2010 and 2015. However, 70% of injured workers with pain medications continue to be prescribed opioids. Kentucky, New York and Tennessee engaged in reforms which have coincided with reduction in opioid usage while New York and Massachusetts have placed chronic opioid guidelines into effect for workers’ compensation cases. Other states have added opioids to their drug formularies. Despite the publicity regarding opioids and the efforts that states are engaging in to reduce their usage, opioids continue to be prescribed for injured workers oftentimes in conjunction with other sedating medications. However, the percentage of workers receiving both opioids and CNS depressants has decreased between 2010 and 2015. The amount of opioids prescribed per claim has seen significant reductions in most states. Louisiana followed by Pennsylvania and New York continue to reflect the highest amounts of prescribed opioids per claim.

The decreases shown by the study are a reflection of federal and state policies inducing the CDC Guideline for Prescribing Opioids for Chronic Pain, prescription drug monitoring programs instituted by states, state based treatment guidelines for opioids, drug formularies in states and limitation on prescribing and dispensing of opioids.

William Emrick from the Kentucky Labor Cabinet reported that his state has made significant inroads in reducing opioid dependency. Between 2011 and 2012 there were more opioid deaths than deaths from automobile accidents in Kentucky. Seeking to stem the tide, legislation was enacted to regulate the prescribing of controlled substances. This led to a reduction in the number of “pill mills”, basically putting them out of business in the state. The next step for Kentucky will center on treatment guidelines and formularies for workers’ compensation.

A different approach has been taken by Massachusetts. Senior Judge Omar Hernandez described a mediation process designed for settled claims with open medical rights where the parties will be able to engage a mediating judge to work together with the injured worker, counsel, the insurer and medical professionals to reduce opioid usage using alternative treatment methods. Instead of litigation which can take time and ultimately result in a legal rather than medical determination of a proper treatment program, this mediation process is designed to bring the parties together in a non-adversarial forum to discuss potential treatment modalities. The goal is to lessen dependency while at the same time allowing the injured worker to alternative pain treatment. Senior Judge Hernandez described his experience as a sitting judge deciding these difficult cases and the length of time that was required for litigation. His first -hand experience convinced him that speed was of the essence in order to both assist the injured worker in breaking the cycle of addiction in addition to allowing the insurer relief from the ever-increasing cost of opioid medication.

Both speakers acknowledged that the goal is to prevent addiction in the first place which ultimately will prevent the unintended consequences of the opioid epidemic. Mr. Emrick acknowledged that as the pill mills went out of business, the incidence of heroin deaths increased in Kentucky. Therefore, it is essential that any program have as its goal to prevent addiction in the first place.

The second session concentrated on treatment alternatives. Dr. Dean Hashimoto discussed the report of the National Academy of Sciences regarding the use of medical marijuana for chronic pain relief. Interestingly, states permitting medical marijuana dispensing experienced a 20% decrease in opioid addiction and an 18% decrease in opioid overdose deaths per a RAND report dated 2015. While the studies have demonstrated that medical marijuana can provide effective treatment for chronic pain, other problems arise around dosaging, routes of administration including standardization of prescription practices, potential side effects and most importantly the chief obstacle that it is still a Schedule I illegal drug pursuant to Federal law.

These issues were further addressed by Paul Sighinolfi, Exec. Dir of the Maine Workers’ Compensation Board and Paul Tauriello from the Colorado Div. of Workers’ Compensation. Both states have experience dealing with the questions surrounding the use and dispensing of medical marijuana. Case law in Maine has held that the prescription of medical marijuana is covered under the Act. Other states, including Massachusetts, have cases in the pipeline on this issue. In New Mexico, medical marijuana is part of the drug formulary. Clearly this is an issue that must be addressed.

The speakers discussed the key issues including:

“can you make an insurer pay for a drug that isn’t legal”

“how does a doctor prescribe marijuana”

“how is medical marijuana administered”

“what are the social impacts”

The attendees learned that doctors certify a prescription for cannabis, which is a medicine, and not marijuana, which is the plant. The injured worker then takes that certification to a licensed dispensary. The greatest concern at that point is dosaging. Unlike a drug dispensed by a pharmacy and produced by a drug company conforming to a chemical formula, marijuana is a plant with different chemical components. The methods for distilling the cannabis from the plant are largely dependent on the dispensary and can affect the quality of the product.

While marijuana is certainly another tool that can be used for pain management, it is clearly not a panacea and raises significant legal issues if Federal law continues to classify it as an illegal Schedule I drug.

The final speaker, Dr. Dawn Ehde described non-pharmacological alternatives to managing pain. In her work at the University of Washington, Dr. Ehde, a psychologist, is working on a pilot program incorporating exercise and behavioral alternatives. She emphasized that injured workers must self-manage their pain. Her program therefore emphasizes cognitive behavioral therapy and a collaborative care model including self-management skills training, physical activity, coaching and medication management. Her program is in the beginning stages and may serve as a model for alternatives to medical management of pain in the future.

All in all, the Conference provided insight into potential new avenues for opioid reduction programs and legislation as well as introducing the potential benefits and risks of medical marijuana and non-pharmacological alternatives for the treatment of pain in workers’ compensation claims.

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