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Experts Offer Guidance on Opioid Management Strategies

June 10, 2013 (5 min read)
By John Stahl, Esq.
The double-edged sword regarding using opioids to relieve pain associated with compensable harm is that the workers’ compensation claimants benefit from the effects of feeling little or no pain and health-care practitioners value the profitable and quick-fix aspects of this treatment, but that practice has very serious negatives. The fact that the high costs to the health-care industry generally and workers’ compensation specifically do not adequately enter into the equation has facilitated this opioid epidemic.
A May 2013 draft report entitled “Reducing Inappropriate Opioid Use in Treatment of Injured Workers: A Policy Guide” from the International Association of Accident Boards and Commissions (IAIABC) is one recent effort to combat the opioid problem. It recommended that every worker’s compensation system “evaluate each of the elements of this policy guide and … use them to craft a policy response that can be successfully implemented within their system.”
Additional guidance was offered in a June 6, 2013, webinar presented by “Risk & Insurance” magazine. That program, entitled “Preventing Opioid Abuse: Using Peer Interactions to Increase Successful Workers' Comp Outcomes”, featured
Dr. Mike McQuilken of Costa Mesa, CA,  the Senior Vice-President of Sales for Integrated Prescription Services,  and Dr. Jacob Lazarovic of Atlanta, GA, the Chief Medical Officer of Broadspire.
The webinar noted that “the complexity of managing acute and chronic pain is extremely challenging for patients and physicians. No one wants to restrict proper medical use of these potentially dangerous drugs, but efforts increasingly must be made to ensure responsible prescribing and use. ”
Unrecognized Scope of Problem
The IAIABC draft report cites widely publicized statistics to illustrate the scope of the opioid epidemic. The report goes on to describe the problem as “a serious failing of the workers’ compensation system.” Understanding the concerns that extend beyond the well-known high monetary costs of long-term opioid use and the addiction and death associated with that practice helps acquire the perspective that effectively reducing the problem requires.
The report quotes workers’ compensation expert Peter Rousmaniere, who states that “these opioid-related deaths are the lost, invisible cases. OSHA recording does not pick them up and insurers are not required to report them to state agencies. Had there been a more accurate and timely reporting of these deaths, it is likely that the workers’ comp system would have responded earlier and more forcefully to the risks inherent in opioid prescribing.”
The report refers as well to research regarding the impact of opioid use on return-to-work statistics that the California Workers’ Compensation Institute released in 2012.  The reported conclusions included that “workers who got high doses of opioid painkillers to treat injuries like back strain stayed out of work three times longer than those with similar injuries who took lower doses.”
Overview of Suggestions
The report suggests a myriad of policies, which include:
  • Active cooperation between workers’ compensation agencies and other state entities;
  • Evidence-based treatment guidelines that reflect risks associated with opioid use;
  • Recognition that “pain is real and [that] clinicians recognize it must be treated in a way that is responsive to the patient’s needs.”
  • Manageable prior approval standards;
  • Separate guidelines regarding acute and chronic pain;
  • Adequate enforcement procedures
The consistent theme regarding the items listed above and the other elements of the recommended policies is a combination of common sense and the lessons from prior research regarding opioid advice. This boils down to exercising appropriate care in prescribing opioids, properly monitoring patients who take those drugs, and helping ensure that a profit motive does not influence treatment plans.
Trends Regarding Opioid-Related Crackdowns
McQuilken observed that opioid-related enforcement efforts have extended beyond cracking down on doctors who improperly prescribe those drugs to closing pharmacies that over-dispense medications such as oxycontin and oxyocodone. He emphasized that officials have moved beyond revoking the licenses of pharmacists who engage in improper practices to closing the entire pharmacy.
A concern regarding the enhanced enforcement included hindering an ability to fill a proper opioid prescription. McQuilken did not address whether the new enforcement directed at pharmacies has impacted the practice of physicians dispensing opioids from their offices.
Drug Formularies
Lazarovic contributed the perspective of a claims and medical services management expert to the discussion of best practices regarding opioids. He identified developing a formulary that includes appropriate drugs as the crucial first step for ensuring that a claimant receives an appropriate, if any, amount of opioids. This recommendation included urging that evidence-based medicine guide the drug selection process.
The provided criteria for evaluating candidates for inclusion in the formula include:
  • Availability of generic substitutes
  • “Indications and contra-indications”
  • A “sensible weaning schedule”
Professional Review Procedures
Lazarovic additionally discussed the merits of a physician review of a claimant’s drug regime. The bases for such a review include:
  • Pharmacists’ reports;
  • The claimant’s drug history, including dosages;
  • Available medical records; and
  • Consulting the claimant’s treating physician.
(Although Lazarovic did not specifically mention it, an effective state prescription drug-monitoring program includes these components.)
Lazarovic  further discussed peer-review procedures. Recommended requirements regarding that tool include involving medical-care providers from the following disciplines:
  • Anesthesiology
  • Psychiatry
  • Internal medicine
  • Occupational medicine
The assumed benefit regarding this holistic approach includes helping ensure that every aspect of the required medical care is properly evaluated.
Similar to physician reviews, Lazarovic suggested that a peer review examine a claimant’s entire medical file and drug regime. He stated that 97-percent of properly conducted peer reviews conclude that a claimant’s “medical regime is not optimal.”
General Conclusions
Properly understanding the true nature of the opioid problem requires completely comprehending every aspect of it. Utilizing that knowledge to improve the problem requires a “village” approach that involves every expert with something to contribute.
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