Opioid Strategies

Bluegrass State Leads the Opioid Fight

Kentucky, long embroiled in the opioid epidemic, is turning its challenges into strategies that can help other states drive change.
By: | July 5, 2016 • 6 min read
Welcome to Kentucky state road sign

Central Appalachia earned a distinction as the epicenter of the nation’s opioid-addiction epidemic for a number of reasons.

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Two key factors are the complex injuries suffered by coal miners and the physical demands placed on workers toiling in other hazardous industries in that region such as logging and trucking.

Others include the region’s economic misfortunes, lax prescribing practices, access to pill mills, and pharmaceutical company marketing.  All led to an ongoing drug-abuse scourge that surfaced there in the 1990s, studies and observers report.

“Central Appalachia, which for us is eastern Kentucky, was one of the first areas to see the opioid epidemic explode in the 1990s,” said former Bluegrass State attorney general Jack Conway.

Jack Conway, former attorney general, Kentucky

Jack Conway, former attorney general, Kentucky

“Because in Appalachia you had mining, you had a lot of heavy industry, trucking, and more workplace injuries on average than you would in other parts of the state. You saw an increase in the prescribing and utilization of opioids and it created an addiction epidemic.”

Now, as the rest of the nation experiences opioid abuse patterns seen early on across Central Appalachia, Kentucky provides examples for battling back against the epidemic.

In 2012, Kentucky became the first state among jurisdictions adopting stricter prescription-drug monitoring programs (PDMPs) with objective criteria mandating when prescribers must register and review a state database of patient prescription histories, Brandeis University’s PDMP Center of Excellence reports.

State PDMPs seek to change provider prescribing practices and prevent patients from doctor-shopping to obtain multiple prescriptions.

Kentucky’s latest PDMP was born from a 2012 comprehensive law adopted to combat opioid abuse.

“Kentucky has a great [PDMP] system,” said Tom Clark, research associate for the Brandeis Center of Excellence. “It is very well supported by the state. Of course, this is all a response to Kentucky being in the epicenter of the prescription drug abuse epidemic and it has been for a long time.”

While all states except Missouri have PDMP laws, participation in many states remains voluntary, said Brian Allen, VP of government affairs for Optum workers’ comp and auto no-fault. In the last three years or so, however, more jurisdictions are making their use mandatory.

“There has been a lot more renewed emphasis on [PDMPs] because everybody has been trying to get their heads around this opioid problem,” he said.

A May 2016 Center of Excellence report with data from Kentucky and the other states indicates that increased PDMP use immediately impacts controlled substance prescribing and doctor-shopping.

Reports linking Central Appalachia’s work injuries to drug abuse have persisted for years.

Yet only a few states have laws as strict as Kentucky’s, requiring all prescribers to register and check their PDMPs when initially prescribing opioids and benzodiazepines, and again every three months when continuing the prescriptions, the PDMP Center of Excellence reports.

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Meanwhile, reports linking Central Appalachia’s work injuries to drug abuse have persisted for years.

A 2002 combined U.S. Justice Department and Kentucky State Police assessment described a growing threat from prescription painkillers. The threat was so specific to Appalachia that opioids and opiates became known disrespectfully as “hillbilly heroin.”

“In the eastern coal mining counties of Kentucky, the large-scale diversion and abuse of painkillers are particular problems,” the report warned.

“In the past, coal miners spent hours each day crouched in narrow mine shafts. Painkillers were dispensed by coal mine camp doctors in an attempt to keep the miners working.

“Self-medicating became a way of life for miners, and this practice often led to abuse and addiction among individuals who would have been disinclined to abuse traditional illicit drugs.”

Michelle Landers, VP and general counsel, Kentucky Employers Mutual Insurance

Michelle Landers, VP and general counsel, Kentucky Employers Mutual Insurance

Michelle Landers, VP and general counsel for Kentucky Employers Mutual Insurance, agreed that eastern Kentucky’s historical dependence on coal mines, and related service industries like trucking, helped link workplace injuries and chronic pain with opioid use.

KEMI, which issues policies to coal mines, is the Bluegrass State’s largest workers’ comp insurer.

Coal operations provide one of eastern Kentucky’s few employment opportunities. Mining also produces severe workplace injuries, caused by accidents such as accidents such as cave-ins or heavy machinery malfunctions, Landers said.

“It’s not an industry where you are going to have small injuries,” she elaborated.

“They are typically severe or the chronic type of injuries you expect from people being underground.”

Kentucky’s private-industry workers, in general, experience a high injury rate. U.S. Department of Labor statistics for 2014 ranked Kentucky among 19 states with a recordable injury rate significantly higher than the national average.

Centers for Disease Control and Prevention data for the same year, meanwhile, shows Kentucky among five states with the nation’s highest rate of overdose deaths.

Early Adopter

KEMI first discovered a frequent use of the narcotic OxyContin to treat work injuries after contracting with a pharmacy benefit manager in 2001, Landers said. The PBM data revealed questionable practices, such as doctors prescribing high doses of the drugs early in the course of treatment for back strains.

“We were seeing things out there about the high levels of addiction and [overdose] deaths and we didn’t want to contribute to that,” Landers said.

A 2015 study prepared by the Institute of Pharmaceutical Outcomes and Policy at the University of Kentucky reported that since the law’s passage,prescriptions for controlled drugs decreased 4 percent to 8 percent during the same period.

So KEMI became an early adopter of measures like educating adjusters and nurse case managers about the dangers of opioids and teaching them to recognize red flags, such as doctors prescribing the drugs for longer periods than typically appropriate.

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KEMI also used PBM data to identify frequently prescribing doctors.

“If you were treating with one of those [doctors] that might be a red flag,” Landers said.

KEMI’s concerted efforts included using its attorneys to engage in medical-fee disputes challenging claims before administrative judges when inappropriate prescribing occurred.

“We have, from early on, taken the approach that if we don’t feel it’s appropriate and we don’t get cooperation from the physician, we are going to challenge it,” Landers said.

Landers will speak at the 25th Annual National Workers’ Compensation and Disability Conference® & Expo on Dec. 1, during a presentation titled “Lessons Learned From Fighting Drug Abuse in the Opioid-Crisis Epicenter.”

The 2012 Kentucky law has limited prescription abuse. In addition to requiring prescribers to report to the state PDMP, it also regulated pain clinics.

A 2015 study prepared by the Institute of Pharmaceutical Outcomes and Policy at the University of Kentucky reported that since the law’s passage, prescribers registering with the PDMP increased by 262 percent, while annual prescriber queries into the PDMP rose 650 percent.

Prescriptions for controlled drugs decreased 4 percent to 8 percent during the same period.

 Cindy Whitehouse, CEO and founder, Ascential Care

Cindy Whitehouse, CEO and founder, Ascential Care

Appalachia still has issues, but the situation is improving.

Yet there remain pockets of physicians in Appalachia who still overprescribe opioids, said Cindy Whitehouse, CEO and founder of Ascential Care, a Lexington, Ky.-based managed care company.

But she agrees the law has helped, and other states could benefit from similarly stringent measures.

“I think we have more tools in the states that have been battling this [opioid epidemic] for some time,” Whitehouse said. “That has made us stronger in the ability to control it.”

Roberto Ceniceros is senior editor at Risk & Insurance® and chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at [email protected] Read more of his columns and features.
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Injury Prevention

Going Through the Motions

Creating an obstacle course for "workplace athletes" makes fitness fun while helping to reduce on-the-job injuries.
By: | July 5, 2016 • 4 min read
Man crawling through tunnel in obstacle course

It was during a session at last year’s National Workers Compensation and Disability Conference® and Expo that Anne-Marie Amiel first heard the term “industrial athletes.”

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She was among the presenters at the session highlighting the tactics and philosophies of the 2015 Teddy Award winners. As risk manager for Columbus Consolidated Government in Georgia, Amiel was honored for substantially reducing workers’ compensation claims costs, revamping return-to-work and enhancing safety training.

But when she heard Tamara Ulufanua-Ciraulo of Stater Bros Supermarkets, another winner, talk about how the grocer supports its aging workers by treating them as industrial athletes, it stuck in her mind.

“That triggered a thought,” said Amiel.

Then, as many NWCDC attendees do, she engaged in a corridor conversation with another attendee. He mentioned obstacle courses — and the idea of a “Workplace Athlete Day” was born.

“We wanted to do something for employees and we decided to do something that apparently has not been done anywhere else in the country before,” Amiel said.

VIDEO:  The obstacle that drew the most crowd support was the duck walk, which had workers walking like ducks while holding a spoon with a softball and “waggling their tail feathers.” — Anne-Marie Amiel, risk manager, Columbus Consolidated Government, Ga.

“We wanted a day where we put our employees through an obstacle course that tests the motions they do in their jobs,” she said.

“People who take care of themselves,” said Pat Biegler, director of public works in Columbus, “take better care of the city and the citizens and their families – and that’s our goal.”

Anne-Marie Amiel, risk manager, Columbus Consolidated Government, Ga.

Anne-Marie Amiel, risk manager, Columbus Consolidated Government, Ga.

After consulting with several physical therapy companies, they put together an obstacle course “based on proper motion and safe techniques, not on speed or strength,” Amiel said.

“The physical therapists were awesome,” she said. “We talked about the different motions that are involved in different activities for different work uses. Several of them volunteered to act as judges.”

Eventually, about two dozen obstacles were created – “some hilarious and a lot of fun” – but underlying the laughter was the need “to keep employees flexible and fit throughout their careers so they have fewer injuries and are able to do their jobs until retirement age.”

That not only helps employees stay well, but it has the benefit of keeping workers’ compensation claims down, she said. “Now that we have launched this major initiative, I think we will see a significant reduction in frequency.”

The obstacles included throwing footballs and Frisbees, crawling through pipes, lifting items to several different heights, basketball, pushing wheelbarrows and stepping through a double row of tires.

But the obstacle that drew the most crowd support was the duck walk, which had workers walking like ducks while holding a spoon with a softball and “waggling their tail feathers,” Amiel said.

“It was hilarious but it was testing their ability to move when they had to squat.” And, of course, the observers felt compelled to “quack, quack, quack” at the participants the entire time.

Pat Biegler, director of public works, Columbus, Ga.

Pat Biegler, director of public works, Columbus, Ga.

The competition included about 25 teams of six employees, each of whom signed up for the day-long program, which included wellness checks, a healthy lunch, trophies and gifts, such as safety glasses, leather gloves, earplugs and sunscreen.

Next year, Amiel and Biegler plan to open the competition to more of the 450 full-time public works employees.

“Seven of the top 10 dangerous jobs in the country are public works jobs,” Amiel said.

“Workplace Athlete Day” is important, Biegler said, “because prevention is so very, very critical to keeping accidents down and we want a workforce that is healthy, that’s happy and that is not injured so this will allow us to evaluate [potential problems] and allow them to do it in a fun environment.”

“Pat is extremely serious about safety,” Amiel said. “Public works is very nearly always my guinea pig [for safety training and injury prevention]. Pat is very serious about keeping employees fit and productive and is always willing to try anything.”

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Both women will be presenting a session at the NWCDC in November on return-to-work strategies.

Working with the physical therapists on the obstacle course also resulted in a new morning routine for public works employees. Supervisors lead them through an exercise session every morning to “warm up their muscles before they start using them in earnest,” Amiel said.

Amiel hopes to expand the obstacle course program to every department in the city. “Several departments have already expressed interest,” she said.

“The morale boost was huge and employees know they are going to be challenged next year even more,” Amiel said. “They had so much fun, but they all came out of it and said they learned so much.”

Anne Freedman is managing editor of Risk & Insurance. She can be reached at [email protected]
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Sponsored Content by Chubb

Electronic Waste Risks Piling Up

As new electronic devices replace older ones, electronic waste is piling up. Proper e-waste disposal poses complex environmental, regulatory and reputational challenges for risk managers.
By: | July 5, 2016 • 4 min read
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The latest electronic devices today may be obsolete by tomorrow. Outdated electronics pose a rapidly growing problem for risk managers. Telecommunications equipment, computers, printers, copiers, mobile devices and other electronics often contain toxic metals such as mercury and lead. Improper disposal of this electronic waste not only harms the environment, it can lead to heavy fines and reputation-damaging publicity.

Federal and state regulators are increasingly concerned about e-waste. Settlements in improper disposal cases have reached into the millions of dollars. Fines aren’t the only risk. Sensitive data inadvertently left on discarded equipment can lead to data breaches.

To avoid potentially serious claims and legal action, risk managers need to understand the risks of e-waste and to develop a strategy for recycling and disposal that complies with local, state and federal regulations.

The Risks Are Rising

E-waste has been piling up at a rate that’s two to three times faster than any other waste stream, according to U.S Environmental Protection Agency estimates. Any product that contains electronic circuitry can eventually become e-waste, and the range of products with embedded electronics grows every day. Because of the toxic materials involved, special care must be taken in disposing of unwanted equipment. Broken devices can leach hazardous materials into the ground and water, creating health risks on the site and neighboring properties.

Despite the environmental dangers, much of our outdated electronics still end up in landfills. Only about 40 percent of consumer electronics were recycled in 2013, according to the EPA. Yet for every million cellphones that are recycled, the EPA estimates that about 35,000 pounds of copper, 772 pounds of silver, 75 pounds of gold and 33 pounds of palladium can be recovered.

While consumers may bring unwanted electronics to local collection sites, corporations must comply with stringent guidelines. The waste must be disposed of properly using vendors with the requisite expertise, certifications and permits. The risk doesn’t end when e-waste is turned over to a disposal vendor. Liabilities for contamination can extend back from the disposal site to the company that discarded the equipment.

Reuse and Recycle

To cut down on e-waste, more companies are seeking to adapt older equipment for reuse. New products feature designs that make it easier to recycle materials and to remove heavy metals for reuse. These strategies conserve valuable resources, reduce the amount of waste and lessen the amount of new equipment that must be purchased.

Effective risk management should focus on minimizing waste, reusing and recycling electronics, managing disposal and complying with regulations at all levels.

For equipment that cannot be reused, companies should work with a disposal vendor that can make sure that their data is protected and that all the applicable environmental regulations are met. Vendors should present evidence of the required permits and certifications. Companies seeking disposal vendors may want to look for two voluntary certifications: the Responsible Recycling (R2) Standard, and the e-Stewards certification.

The U.S. EPA also provides guidance and technical support for firms seeking to implement best practices for e-waste. Under EPA rules for the disposal of items such as batteries, mercury-containing equipment and lamps, e-waste waste typically falls under the category of “universal waste.”

About half the states have enacted their own e-waste laws, and companies that do business in multiple states may have to comply with varying regulations that cover a wider list of materials. Some materials may require handling as hazardous waste according to federal, state and local requirements. U.S. businesses may also be subject to international treaties.

Developing E-Waste Strategies

Companies of all sizes and in all industries should implement e-waste strategies. Effective risk management should focus on minimizing waste, reusing and recycling electronics, managing disposal and complying with regulations at all levels. That’s a complex task that requires understanding which laws and treaties apply to a particular type of waste, keeping proper records and meeting permitting requirements. As part of their insurance program, companies may want to work with an insurer that offers auditing, training and other risk management services tailored for e-waste.

Insurance is an essential part of e-waste risk management. Premises pollution liability policies can provide coverage for environmental risks on a particular site, including remediation when necessary, as well as for exposures arising from transportation of e-waste and disposal at third-party sites. Companies may want to consider policies that provide coverage for their entire business operations, whether on their own premises or at third-party locations. Firms involved in e-waste management may want to consider contractor’s pollution liability coverage for environmental risks at project sites owned by other entities.

The growing challenges of managing e-waste are not only financial but also reputational. Companies that operate in a sustainable manner lower the risks of pollution and associated liabilities, avoid negative publicity stemming from missteps, while building reputations as responsible environmental stewards. Effective electronic waste management strategies help to protect the environment and the company.

This article is an annotated version of the new Chubb advisory, “Electronic Waste: Managing the Environmental and Regulatory Challenges.” To learn more about how to manage and prioritize e-waste risks, download the full advisory on the Chubb website.

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This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Chubb. The editorial staff of Risk & Insurance had no role in its preparation.




With operations in 54 countries, Chubb provides commercial and personal property and casualty insurance, personal accident and supplemental health insurance, reinsurance and life insurance to a diverse group of clients.
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