Survey Says Regulators Must Be More Assertive Regarding Opioid Use

By John Stahl, Esq.

A November 12, 2013 webinar that peer review and drug management firm CID Management of Westlake Village, California sponsored summarized the results of a CID survey of front-line employees and executives in the workers’ compensation industry. That study asked the respondents questions regarding methods for addressing the heavy use of opioids in the workers’ compensation system.

This data from this effort represented the responses in the 272 out of 400 surveys that CID distributed.

The webinar was titled “Uncapping the Truth: CID Management’s First Annual Survey of Opioids in Workers’ Compensation.” Joe Paduda, who founded Health Strategy Associates, of Madison, Connecticut moderated the event.

Paduda initially discussed the well-known statistics and other facts regarding the alarming scope of the opioid problem in workers’ compensation. This portion of the presentation included reminding the participants that opioids were developed to treat the intense pain associated with various forms of cancer, and that the American College of Occupational and Environmental Medicine did not advocate using that form of medication for chronic non-malignant pain.

Identifying the Problem

The discussion of the survey results commenced with the findings regarding specific aspects of the opioid problem. The data regarding that topic reflected the areas that regulators and other workers’ compensation experts have previously targeted for reforms. These concerns include:

> Addiction/dependence;

> Cost;

> Abuse/fraud, and

> Excessive opioid prescription practices.

The fact that 76 percent of the survey respondents also expressed concern regarding long-term use of prescription opioids reflected the issues described above.

An associated concern regarding cost related to the need for medications to treat common side effects of opioid use; these included:

> Difficulty sleeping;

> Sexual dysfunction; and

> Constipation.

The discussion of the costs of opioids also noted that the nature of those drugs required taking larger dosages of them to achieve the same results that claimants obtained early in their use of those medications.

Paduda additionally addressed the results related to a question regarding which participant in the workers’ compensation system should assume responsibility for managing a claimant’s use of opioids for compensable harm. The findings regarding this issue were:

> 95.3 percent of respondents believed that a treating physician should oversee opioid use;

> 70.6 percent of respondents identified a workers’ compensation insurer as the entity that should oversee opioid use; and

> 70 percent concluded that a claimant should oversee his or her use of opioids.

The discussion of these findings noted that they reflected the ability of the identified classes of participants in the workers’ compensation system to take the action required to properly manage a claimant’s opioid use. One emphasized point included that training physicians required additional tools and training to better manage that use. Paduda added that claimants ideally would take the lead regarding that use but lacked the ability to do so.

The results regarding a question that asked survey respondents about the effectiveness of efforts by payers of workers’ compensation medical benefits to address the opioid problem revealed a notable difference between front-line employees and executives who responded to the survey. 47.6 percent of the front-line people stated that the payers were “very or somewhat effective” regarding that effort; this contrasted with 55.5 percent of the executives who responded to that question reaching the same conclusion.

These results were consistent with data from the survey that indicated that the front-line employees sometimes believed that people at the executive level lacked an accurate sense of how effectively participants in the workers’ compensation system were addressing the opioid problem.

Specific findings regarding the effectiveness of regulators’ efforts to manage opioid use were:

> 17.5 percent of front-line people thought that regulators were very or somewhat effective;

> 20 percent of executive-level people thought that regulators were very or somewhat effective;

> 65.5 percent of executive-level people thought that regulators were very or somewhat ineffective; and

> 64.7 percent of front-line people thought that regulators were very or somewhat ineffective.

Most Promising Solutions

The focus of the webinar then shifted to the methods that the survey respondents thought had the best potential for solving the opioid problem.

> 59.6 percent of respondents identified outreach to treating physicians as the best method;

> 58.7 percent of respondents chose peer review of a claimant’s long-term medical treatment as the best method;

> 51.5 percent of respondents considered a prescription drug formulary the best method;

> 50.8 of respondents determined that requiring prior authorization for prescriptions for opioids was the best method; and

> 48.5 percent of respondents selected urine drug testing (UDT) as the best method.

Paduda recommended regarding UDT that a claimant be tested before receiving a prescription for opioids; he noted that this helped determine both if the claimant was already taking opioids and if he or she was taking any other medication that might interact poorly with an opioid.

Paduda expressed an additional concern regarding the frequency of UDT. He stated that the fact that some treating physicians conducted that testing in their offices might result in testing more frequently than necessary.

A third observation regarding UDT related the issue of abuse/fraud associated with opioid use. Paduda pointed out that that testing also revealed whether a claimant was selling his or her Oxycontin or other prescription opioid on the street rather than taking it. Concern associated with this practice related to some claimants who sold their prescription opioids using a portion of the money to purchase heroin and keeping the surplus as a profit from the sale of the opioid.

A related theme that the webinar addressed was the underutilization of available resources. Paduda provided the example of a workers’ compensation insurer not using the services of a peer review firm that it hired; he added that front-line people were much more likely than executives to realize that those resources were going unused.

Paduda additionally recommended a comprehensive approach that incorporated the recommended methods described above. He further advocated limiting every initial prescription for an opioid to 7 days, noting that doing so was consistent with the recommended Evidence-Based Medicine approach to treating claimants.

Goals of Opioid Management Programs

After sharing statistics regarding the perceptions related to the opioid problem and issues related to approaches to reducing use of those medications, the webinar addressed specific objectives of methods that addressed challenges associated with opioids.

> 76.9 percent of respondents recommended that reforms address the risk of abuse/misuse associated with prescribing opioids;

> 75.2 percent of respondents opined that reforms should be directed at obtaining claimants the best health care;

> 74 percent of respondents advocated that reforms focus on reducing opioid use;

> 72.5 percent of respondents concluded that reforms should address the risk of addiction/dependency; and

> 71.5 percent of respondents suggested strictly limiting opioid use based on medical necessity.

The reported responses regarding the method for evaluating the effectiveness of a vendor’s effort to address the opioid problem included the following results:

> 72.2 percent of the respondents replied that they looked at whether an effort reduced the average duration of a claimant’s use of opioids;

> 63 percent of respondents stated that they examined whether a reform affected a treating physician’s prescription habits; and

> 47 percent of respondents looked at whether an effort reduced the number of initial prescriptions for opioids.

In addition to identifying which factors related to opioid use best reflected the effectiveness of efforts to reduce that use, roughly 50 percent of the respondents opined that determining the impact of opioid management programs required additional time.

Wrap Up

The value of the survey relates to it reflecting the views of the professionals who administer workers’ compensation claims. This feedback should be valuable to regulators, treating physicians, and other participants in the workers’ compensation system because it provides valuable data regarding what does  and does not work in practice.

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