An Overlooked Risk?
The 2012 National Survey on Drug Use and Health, conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), found the rate of binge drinking among people ages 65 and older was 8.2 percent, the rate of heavy drinking was 2 percent, and the rate of current illicit drug use among adults ages 50 to 64 has increased during the past decade.
“According to SAMHSA experts the baby boomer generation contains a higher percentage of illicit drugs users than any other age group because boomers were the first generation to participate in widespread use of a variety of recreational drugs, the first generation to have prescription medications readily available to them, and the last generation to grow up with a strong stigma against seeking substance abuse treatment,” said Kevin Glennon, vice president, clinical education and quality assurance, One Call Care Management.
Baby boomers’ formative years played out during a period of broad experimentation with and acceptance of illicit drugs. Now they’re entering a phase of life where any children they have are likely grown and independent and retirement is on the horizon, which could translate to fewer responsibilities both at home and at work. That freedom may make it easier for boomers to pick up old habits, only this time with prescription medications.
The national drug use survey estimates that the number of adults age 50 and older who will need alcohol or drug treatment will increase from 2.8 million in 2002-2006, to 5.7 million by 2020. Currently, 4 million older adults need substance use treatment, including 0.4 million for illicit drugs, 3.2 million for alcohol, and 0.4 million needing treatment for both.
“Today, many boomers are turning to prescription opioids as their drug of choice. Baby boomers do not view this as an issue requiring intervention, and as such are extremely guarded when treatment options are discussed,” Glennon said.
Employers and workers’ comp payers should not overlook these factors if they have an older worker on prescribed painkillers for a work-related injury or illness.
“After a certain period of time the patient will begin to develop a resistance to [the opioid] and it stops controlling the pain effectively,” said Bill Spiers, vice president of risk control services, Lockton. “Because the healing time is slower, just by nature of the effects of aging on the body — they regenerate tissues slower — it extends that period of time. So what ends up happening is the person — and this happens typically with soft tissue injuries — will experience slower pain improvement, and so the medical professional will look for solutions.”
Pharmacy benefit management is one go-to way to keep an eye out for red flags and monitor physician prescribing patterns, but employers can take a more proactive approach by setting up a workplace support system.
One factor that can contribute to an older worker’s propensity to abuse a substance is the psychological component. Some boomers certainly look forward to retirement with excitement, but others fear losing a sense of purpose or relevance. That disconnectedness lends itself to loneliness and depression, both of which can contribute to the development of an addiction.
“Today, many boomers are turning to prescription opioids as their drug of choice. Baby boomers do not view this as an issue requiring intervention, and as such are extremely guarded when treatment options are discussed,” — Kevin Glennon, vice president, clinical education and quality assurance, One Call Care Management
“There are two reasons why injured workers have problems with their claim; when they get injured, they’re either angry or afraid. And those cause workers to shut down and not want to get treatment or cooperate,” Spiers said. Lockton trains ‘injury counselors’ to work one-on-one with patients, providing the type of support that the workers might be lacking from their own social network.
“The injury counselor tries to develop a friendship so they stay in touch. Not everyone has strong family or social ties around them, so they need someone that follows up with them and stays on top of them,” Spiers said. “Things like depression can exacerbate that claim, one technique that employers use to keep that person motivated to work though their pain is to keep them engaged in the workplace, which they do through close communication.”
Employers can also make extra efforts to keep injured workers — especially those nearing retirement age — engaged in activities both in and outside of the workplace through wellness initiatives. Encouraging exercise can help an injured worker grown stronger both physically and mentally, Spiers said.
Providing a support network and establishing a channel of communication may in fact be the best that employers can do, since a red flag isn’t raised on every case where a medication is abused.
“Addiction or abuse, regardless of the drug of choice is often very hard to detect,” Glennon said. “There are functional alcoholics that work and function with no signs of intoxication, the same holds true with prescription drug use or abuse.”
Vaping: Smoking Gun
SCENARIO: It’s 2040, and there were not quite as many attendees of the 25-year high school reunion party as expected. Gossip begins to circulate just as it did around the cafeteria and corridors a couple of decades earlier.
“Is John coming tonight?” one man asked an ex-classmate.
“No, didn’t you hear? He’s in the middle of chemo treatments right now,” she responded solemnly. “Esophageal cancer.”
“Hey Kelly!” another alumnus shouted. “I don’t think I’ve seen you since Nationals senior year. How are you? Still running?”
Kelly was a standout miler on her high school and university track teams, known for her strong finishing kick.
“No,” she responded, exhaling a cloud of raspberry-flavored vapor as she lowered her still-glowing e-cigarette.
“I haven’t been able to run much lately, not without an inhaler, anyway. Developed asthma a few years ago.”
In 2015, when this group was graduating, “vaping” was the latest and greatest trend. It delivered the soothing effects of nicotine without the carcinogens of tobacco smoke, tasted much better, and there were no age restriction laws.
The litigants claim their health issues stem directly from the dubious concoction of chemicals in the e-liquid his company imported from China and sold in their branded vape pens.
E-cigarette advocates predicted that vaping would dramatically decrease the rates of lung cancer and other smoking-related diseases. But 25 years later, the effects of the e-liquid’s various chemicals and concentrated nicotine are clear. Rates of lung cancer, which had been decreasing steadily in the U.S., are rising again, along with heart disease and other types of cancer.
That same night, the CEO of a national e-cigarette distributor is staring at a subpoena. His company is being sued by the families of a few hundred of his most loyal customers who have developed respiratory and heart problems.
In fact, a recent longitudinal study of “vapers” by the Centers for Disease Control and Prevention found strong positive correlations between high use of e-cigarettes and incidence of heart disease and cancers of the respiratory system.
The litigants claim their health issues stem directly from the dubious concoction of chemicals in the e-liquid his company imported from China and sold in their branded vape pens.
Tests of several batches of the liquid by the FDA revealed inconsistent concentrations of nicotine, propylene glycol, and other flavor additives and preservatives. The levels of nicotine found in the vapor were also inconsistent with the label.
The class-action litigants were seeking punitive damages totaling $20 billion, half of which would be used to create a medical treatment fund. The number is staggering, but not out of line with some of the lawsuits that emerged against “Big Tobacco” companies in the late 1990s, the highest of which sought damages of $23.6 billion. Other smaller distributors had already been knocked out by smaller settlements, still in the millions.
The CEO had already talked to his broker. The contractual protection they had in place pinned product liability to the manufacturer, based in Shanghai, but did not address risks of long-term health effects. That liability was all theirs.
ANALYSIS: In 2015, the retail vaping industry is forecast to reach $3.5 billion, more than twice the $1.7 billion estimated for 2013, according a Wells Fargo Securities report on tobacco trends in the U.S.
E-cigarettes, which deliver a nicotine hit without tobacco combustion — and the carcinogens that come with it — attract customers from the traditional cigarette market looking for a healthier or safer alternative to their smoking habit, and from the youth market, drawn to the sleek styling and fun flavors of vaporizers, as well as the claim that they are far less dangerous than combustible cigs.
According to the CDC’s National Youth Tobacco Survey, “the number of never-smoking youth who used e-cigarettes increased from 79,000 in 2011 to more than 263,000 in 2013.”
According to “Monitoring the Future,” a study from the University of Michigan analyzing drug and tobacco trends among teens, there were twice as many e-cig users than smokers of combustible cigarettes among eighth, 10th and 12th graders. Sixty-two percent of eighth graders surveyed said that cigarettes are very harmful to health, while only 15 percent reported feeling that way about e-cigarettes.
And there is basis for these beliefs. Studies of e-vapors show that the amounts of toxic chemicals they contain are negligible, compared to traditional cigarettes, and their concentrations are nearly equal to those already present in the air we breathe. Many public health advocates laud e-cigs as a long-term tool to reduce smoking rates and the respiratory illnesses that come with it.
“There’s no question that e-cigarettes are much safer,” said Michael Siegel, a professor at Boston University’s School of Public Health.
“The risks are minimal, compared to tobacco smoking.”
But the danger in any new product lies in the unknown. Vapors produced from e-liquids may not be as harmful as smoke, but the composition of those liquids varies widely.
“A lot of these devices are made in countries that struggle with quality issues in the manufacturing process,” said Mark Wood, president and CEO of LifeScienceRisk, a subsidiary of RSG Underwriting Managers.
“When using foreign contract manufacturers, you don’t always know who exactly is making the product.”
Inconsistent manufacturing leads to variability in nicotine levels. Byproducts of the manufacturing process, flavoring and other preservatives also potentially introduce other carcinogens into the mix. But the final composition is largely unknown.
Adverse health effects of those unknown chemical mixtures could range from allergic reactions to cancer.
The heating element of e-cigarettes also poses a threat. If it gets too hot, it can “trigger a thermal breakdown” of the materials used to make the e-cig, creating carbonyls like formaldehyde and acetaldehyde. These compounds are delivered in nano-sized particles directly into the airways, where they trigger inflammation that can lead to the development of chronic conditions.
Little clinical research has been conducted on the safety of these vapors, and the long-term health effects may not be seen for another 20-30 years.
“From the FDA’s point of view, they’re waiting to see if e-cigarettes can reduce the number of smoking deaths. They want to see the whole picture before they take a firm stance on the issue,” said Markus Kalin, head of casualty risk engineering at XL Group.
Another problem is the lack of age restrictions, coupled with flavorings like cherry vanilla and blue raspberry, which make these products highly appealing to those under 18.
In a customer base that has never or rarely smoked traditional cigarettes, long-term use of e-cigarettes could increase, rather than reduce, the likelihood of health issues.
“The purpose of e-cigarettes is to get people off smoking in a safer way. They are not absolutely safe,” Siegel said.
Current high-school vapers could be in their 40s or 50s before any ill effects emerge. It may not be lung cancer or emphysema, but perhaps higher rates of asthma, bronchitis, cystic fibrosis or other inflammatory pulmonary diseases.
And distributors of vaping products could be held liable, in much the same way tobacco companies faced massive lawsuits after smoking was definitively linked to lung cancer.
The fact that most e-cigarette manufacturers are based in China also “puts distributors and retailers in the U.S. at higher risk,” said Randy Nornes, executive vice president at Aon Risk Solutions.
“If you’re the only link between a non-U.S. manufacturer and the customer, you’re an obvious target for plaintiffs.”
Wood said that distributors “can subrogate that claim against a contract manufacturer or supplier, but it’s more difficult to do that against an entity in a different country subject to different laws.”
Given the huge settlements with tobacco companies, plaintiffs’ attorneys will be more than willing to take on the e-cigarette industry.
“They look for market opportunities,” Nornes said, “anything that potentially has harm in it and involves a lot of people.”
Vaping distributors could face product liability suits for improper labeling of e-liquid cartridges or false advertising concerning its health benefits. Kalin of XL Group said parents of e-cigarette users could pursue advertising litigation against distributors for failure to protect young people.
“But the next stage will be, if you start to see health issues emerge and more studies trickling out, and younger people developing diseases like lung cancer, that will be the catalyst for mass tort,” Nornes said.
E-cigarette distributors and retailers need proactive risk management, experts said.
“You really have to understand your supply chain,” said Aaron Ammar, risk manager at XL Group. “Make sure you have appropriate age restrictions and proper labeling about potential health effects. Where are the component parts coming from? Do you understand it?”
“I’m sure they’re all doing contractual risk management, to make sure risk stays with the manufacturer,” Nornes said.
“The second issue is making sure the manufacturer has adequate levels of insurance in the event you get sued for distributing someone else’s product. That’s where issues will creep in, because you’re relying on a third party’s insurance.”
Complete coverage of 2015’s Most Dangerous Emerging Risks:
Corporate Privacy: Nowhere to Hide. Rapid advances in technology are ushering in an era of hyper-transparency.
Implantable Devices: Medical Devices Open to Cyber Threats. The threat of hacking implantable defibrillators and other devices is growing.
Athletic Head Injuries: An Increasing Liability. Liability for brain injury and disease isn’t limited to professional sports organizations.
Vaping: Smoking Gun. As e-cigarette usage rises, danger lies in the lack of regulations and unknown long-term health effects.
Aquifer: Nothing in the Bank. Once we deplete our aquifers, there is nothing helping us get through extended droughts.
Most Dangerous Emerging Risks: A Look Back. Each year since 2011, we identified and reported on the Most Dangerous Emerging Risks. Here’s how we did on some of them.
Sub-par Compliance With Opioid Guidelines
Lack of adherence to opioid prescription and monitoring guidelines has obvious negative repercussions for workers’ comp payers. Unmonitored opioid use is more likely to result in addiction, misuse or abuse, lengthening claim duration and piling on extra costs.
A study published in the March 2015 edition of the journal Pain Medicine (Vol. 16, Issue 3) found that resident and attending physicians were “only partly compliant with national guidelines” concerning prescription opioid monitoring.
The retrospective study, “Adherence to Prescription Opioid Monitoring Guidelines Among Residents and Attending Physicians in the Primary Care Setting,” gathered data from electronic medical records from one primary practice unit in a New England hospital. Due to the specificity of the setting and relatively small sample size, the authors note that the findings are not necessarily applicable to other settings. They are indicative, however, of a greater need for education and awareness among the medical community around opioid guidelines.
This study in particular looked at the differences in practice between residents and attending physicians, finding that patients of resident physicians were more likely to be on chronic opioid treatment and also to receive early refills.
This may be due to the nature of residency, which has turnover every three years. This makes it easier for patients abusing opioids to seek new prescriptions from different doctors. Attending physicians have longer-term relationships with patients, as well as more experience, which could mean they are able to better manage their patients’ opioid therapy and therefore see less evidence of opioid misuse or abuse.
Ultimately, the report concluded that “the levels of monitoring observed in our study are still significantly lower than endorsed by clinical guidelines,” and “our findings highlight the need to improve monitoring of patients with chronic pain on opioids.”
Terrence Wilson, MD, utilization review medical director and pain management expert at GENEX Services, said, “One of the reasons for this relative explosion in opiate pharmacotherapy use is the emphasis at the turn of the century on pain as the fifth vital sign. This became a Joint Commission standard in 2001 because pain was allegedly being undertreated.”
The increased demand to treat pain is fed in part by unrealistic patient expectations.
“Patients won’t be 100 percent pain free. The goal is increased function with decreased pain, as supported by ODG and ACOEM guidelines,” said Jennifer Kaburick, senior vice president, workers’ compensation product, compliance and strategic initiatives at Express Scripts.
“Opioids and narcotics are effective, but should be given at lowest possible for shortest duration. Simply having ongoing pain without improving function is not a good enough reason to continue prescribing opioids.”
The subjectivity of pain, however, and the wishes of well-meaning family and friends make it difficult for treating physicians to lower dosage or discontinue a prescription if a patient is still reporting intense pain.
“As to the overall acceptance and execution of these practices among physicians, there remains a great disparity throughout the profession,” Wilson said.
“Some physicians, especially those that have chosen to focus on the general management of painful conditions, are more likely to abide by these standards. However, as this study shows, even in an academic setting, there remains a great deal of work to be done before one can consider the management and monitoring of pain therapy second nature.”
The Pain Medicine study authors recommend the use of prescription monitoring programs to identify patients at risk for misuse, the implementation of an informed consent and opioid agreement, and “at least one urine drug test per year” to check for signs of abuse.
“The incorporation of the formal signed controlled substance agreement into the general practice setting serves as an informal and educational resource for the patient and family,” Wilson said, “while setting forth the ground rules for monitoring, altering and in some cases discontinuing the prescribing of an opiate or other controlled substance.”
Despite these recommendations and growing national awareness of the issue, opioid abuse remains an ongoing challenge. This suggests that perhaps workers’ comp claims handlers and payers should step up their role in the process, enforcing stricter adherence to clinical guidelines and paying closer attention to opioid usage earlier in the claim.
As Kaburick says, this issue should be addressed both “proactive and retroactively.”
“[Express Scripts] goes to the point of sale, before the prescription is even filled,” she said.
“The payer can set a threshold for morphine equivalent dose for narcotics. If the prescription exceeds that threshold, the client — usually a nurse case manager — will have to approve it.”
Express Scripts also informs the treating physician if the threshold is exceeded. “We also make them aware of other medications the patient is taking form other doctors, especially if those medications are in different therapy classes,” Kaburick said.
At GENEX Services, “the practice that is evolving, often with the assistance of pharmacy benefit managers, is a consolidation of pharmacy data which provides the health care professional the opportunity to voluntarily participate in a comprehensive pharmacy review that serves to benefit the injured worker and the treating physician,” Wilson said.
“This includes examples of more than one physician prescribing similar or identical medications as well as examples of prescribing medications that should not be taken together.”
The emergence of electronic medical records should help physicians be aware of a patient’s drug history and any concurrent medications, but the technology is far from perfect. Different practices use different EMR systems that utilize different formats and templates, which makes it difficult to integrate information when patients move from specialist to specialist.
In the meantime, continuing to encourage familiarity with national guidelines among network physicians — and require documented adherence — may be the best foot the workers’ comp industry can put forward.