Opioid Paradox: The Drugs Can Cause Pain
Research suggests that the long-term use of opioid pain medications can paradoxically induce or worsen chronic pain instead of relieving it.
It is one more reason to cheer recent report findings that the nationwide rate of opioid consumption may no longer be trending upward, although it has not decreased significantly.
By now, everyone in the workers’ comp industry should know that opioid pain killers are associated with longer claims durations, addiction, and overdose deaths.
But there is also a growing body of research on a phenomena called opioid-induced hyperalgesia that is associated with the long-term use of the pain medications. Marcos A. Iglesias, M.D., medical director for Midwest Employers Casualty Co., discussed this recently at the Risk and Insurance Management Society Inc.’s annual conference.
“A lot of claimants who are on high doses of opiods are still in a lot of pain. A big reason for that is the opioids. Once they are weaned off the opioids, they feel much better and their pain will actually decrease. So ironically, one of the ways to help their pain is to take away their painkiller.” — Marcos A. Iglesias
The condition is also called “paradoxical hyperalgesia” because a patient may experience more pain resulting from their opioid treatment rather than a decrease in pain. The phenomena can encourage dangerous dose escalation as doctors struggle to control a patient’s chronic pain.
It can also be difficult to distinguish whether a patient continues to experience chronic pain because of an increasing dose tolerance or because of opioid-induced hyperalgesia, according to literature on the topic.
The literature also states that opioid-induced hyperalgesia can worsen with increased opioid doses.
Dr. Iglesias said that opioid-induced hyperalgesia is another reason to stop providing the pain medications to certain patients.
“A lot of claimants who are on high doses of opiods are still in a lot of pain,” he said. “A big reason for that is the opioids. Once they are weaned off the opioids, they feel much better and their pain will actually decrease. So ironically, one of the ways to help their pain is to take away their painkiller.”
The good news, though, is that recent workers’ comp drug trend reports produced by pharmacy benefit managers show decreases in the amount of opioids prescribed to workers’ comp claimants.
St. Louis, Mo.-based Express Scripts, for instance, released its 2013 Workers’ Compensation Drug Trend Report in April. The report states that the “per-user-per-year” utilization of opioids decreased 3 percent from 2012 to 2013. Express Scripts attributed the decline to government, payer, and pharmacy benefit manager attention to opioid consumption.
Similarly, a 2014 Workers’ Compensation Drug Trend Report released in April by Westerville, Ohio-based Progressive Medical Inc. and PMSI states that 62.1 percent of injured workers prescribed medications in 2013 used opioids. That was down from 64.2 percent during the prior year.
The decrease is a “true success,” considering opioid consumption had been increasing during past years, said Robert Hall, M.D. and medical director for Progressive Medical and PMSI. But increased accountability and awareness on the part of prescribes as well as improvement in medical quality have helped counter the problem, he added.
“Based on where things were headed [and] what we were seeing across the country, definitely the [growth] trend being stopped and taken in a different direction is a positive,” Dr. Hall said.
Yet the trend in opioid consumption can also be viewed as not having changed much.
Cambridge, Mass.-based Workers Compensation Research Institute recently looked at long-term opioid use in 25 states and compared the 2008/2010 time period to 2010/2012. It found a decrease within 2 percent in most of the states studied, but concluded that change amounted to “little reduction in the prevalence of longer-term opioid use.”
Wal-Mart’s Workers’ Compensation Litigation Strategy
Wal-Mart Stores Inc. benchmarks attorney performance as part of its workers’ compensation-litigation strategy.
The “outcomes-based” approach to litigation management the employer embarked on relies on claims data analysis and metrics to consolidate the number of workers’ comp attorney firms it hires, while forming tighter relations with a smaller number of lawyers it partners with, speakers told the Risk and Insurance Management Society Inc.’s annual conference held April 27-30 in Denver.
“The very first thing that you need to have a good litigation strategy is to have a strong partnership with your attorneys,” said Janice Van Allen, director, risk management at Wal-Mart in Rogers, Ark.
Litigated claims are among the most complex and costly workers’ comp files employers face as the claims age and grow, said Misty Price, director of analytics at Westlake Village, Calif.-based law firm Adelson, Testan, Brundo, Novell, & Jimenez.
“They become the tail that wags the dog,” she said.
Typically, however, workers’ comp litigation is managed one claim at a time by adjusters working without an overall litigation strategy, Price said. That slows claim resolution and impedes workers’ comp program performance, she added.
“A lot of us feel like our hands are tied because the TPA sometimes decides who the attorneys are or we have carriers [who say] we have to pick from [a certain] panel. But as the employer, as the client, you really do have an opportunity to drive that and determine what firms you want to have as part of your program.” – - Janice Van Allen, Wal-Mart director, risk management.
Adjusters generally select lawyers to litigate a case based on their relations with specific attorneys. Meanwhile, employers often do not receive direct attorney feedback on a case’s progress, despite practices such as holding employer and adjuster claims reviews, Price said.
An outcomes-based litigation strategy, in contrast, relies on a multivariate analysis using an employer’s claims data. Metrics are used to benchmark attorney performance and align specific lawyers with cases, depending on claim facts and knowledge about an attorney’s skill sets and experience.
“What I can tell you [after] spending a lot of time modeling data is that a claimant attorney [selected for a case] tells you a whole lot about where that claim is going,” Price said.
Employers should take charge of selecting attorneys to partner with even though third party administrators or insurers often assume that responsibility, Van Allen said.
“A lot of us feel like our hands are tied because the TPA sometimes decides who the attorneys are or we have carriers [who say] we have to pick from [a certain] panel,” she explained. “But as the employer, as the client, you really do have an opportunity to drive that and determine what firms you want to have as part of your program.”
As part of its overall litigation strategy Wal-Mart has consolidated the number of attorney firms it works with nationwide. In California alone, for example, the retailer reduced the number from more than 20 to three “of our solid firms,” Van Allen said.
The consolidation efforts required considerable work including deciding whether the employer should leave open files with the attorneys that had been working them or transfer them to a vetted firm.
“We looked at each file individually, but for the most part we did move them,” Van Allen said. “In doing that we have seen huge results over the last few years, improving our litigation, lowering the number of files we have currently in litigation.”
Other aspects of Wal-Mart’s strategy include avoiding litigation by taking care of its employees with quality care early on. But for litigated cases, knowing a law firm’s practices, such as their case load and lawyer compensation arrangements, is vital, Van Allen said.
Wal-Mart has also found success in requiring its selected law firms in large states such as California and Florida to cooperate with each other in a “one team approach.”
“They are all representing us, we are the client,” Van Allen said. “We want to make sure it doesn’t matter which firm we are going to that they have the same philosophy, the same strategy and understand what our expectations are and we are working toward the same common goal.”
Six Best Practices For Effective WC Management
It’s no secret that the professionals responsible for managing workers compensation programs need to be constantly vigilant.
Rising health care costs, complex state regulation, opioid-based prescription drug use and other scary trends tend to keep workers comp managers awake at night.
“Risk managers can never be comfortable because it’s the nature of the beast,” said Debbie Michel, president of Helmsman Management Services LLC, a third-party claims administrator (and a subsidiary of Liberty Mutual Insurance). “To manage comp requires a laser-like, constant focus on following best practices across the continuum.”
Michel pointed to two notable industry trends — rises in loss severity and overall medical spending — that will combine to drive comp costs higher. For example, loss severity is predicted to increase in 2014-2015, mainly due to those rising medical costs.
Debbie discusses the top workers’ comp challenge facing buyers and brokers.
The nation’s annual medical spending, for its part, is expected to grow 6.1 percent in 2014 and 6.2 percent on average from 2015 through 2022, according to the Federal Government’s Centers for Medicare and Medicaid Services. This increase is expected to be driven partially by increased medical services demand among the nation’s aging population – many of whom are baby boomers who have remained in the workplace longer.
Other emerging trends also can have a potential negative impact on comp costs. For example, the recent classification of obesity as a disease (and the corresponding rise of obesity in the U.S.) may increase both workers comp claim frequency and severity.
“The true goal here is to think about injured employees. Everyone needs to focus on helping them get well, back to work and functioning at their best. At the same time, following a best practices approach can reduce overall comp costs, and help risk managers get a much better night’s sleep.”
– Debbie Michel, President, Helmsman Management Services LLC (a subsidiary of Liberty Mutual)
“These are just some factors affecting the workers compensation loss dollar,” she added. “Risk managers, working with their TPAs and carriers, must focus on constant improvement. The good news is there are proven best practices to make it happen.”
Michel outlined some of those best practices risk managers can take to ensure they get the most value from their workers comp spending and help their employees receive the best possible medical outcomes:
1. Workplace Partnering
Risk managers should look to partner with workplace wellness/health programs. While typically managed by different departments, there is an obvious need for risk management and health and wellness programs to be aligned in understanding workforce demographics, health patterns and other claim red flags. These are the factors that often drive claims or impede recovery.
“A workforce might have a higher percentage of smokers or diabetics than the norm, something you can learn from health and wellness programs. Comp managers can collaborate with health and wellness programs to help mitigate the potential impact,” Michel said, adding that there needs to be a direct line between the workers compensation goals and overall employee health and wellness goals.
Debbie discusses the second biggest challenge facing buyers and brokers.
2. Financing Alternatives
Risk managers must constantly re-evaluate how they finance workers compensation insurance programs. For example, there could be an opportunity to reduce costs by moving to higher retention or deductible levels, or creating a captive. Taking on a larger financial, more direct stake in a workers comp program can drive positive changes in safety and related areas.
“We saw this trend grow in 2012-2013 during comp rate increases,” Michel said. “When you have something to lose, you naturally are more focused on safety and other pre-loss issues.”
3. TPA Training, Tenure and Resources
Businesses need to look for a tailored relationship with their TPA or carrier, where they work together to identify and build positive, strategic workers compensation programs. Also, they must exercise due diligence when choosing a TPA by taking a hard look at its training, experience and tools, which ultimately drive program performance.
For instance, Michel said, does the TPA hold regular monthly or quarterly meetings with clients and brokers to gauge progress or address issues? Or, does the TPA help create specific initiatives in a quest to take the workers compensation program to a higher level?
4. Analytics to Drive Positive Outcomes, Lower Loss Costs
Michel explained that best practices for an effective comp claims management process involve taking advantage of today’s powerful analytics tools, especially sophisticated predictive modeling. When woven into an overall claims management strategy, analytics can pinpoint where to focus resources on a high-cost claim, or they can capture the best data to be used for future safety and accident prevention efforts.
“Big data and advanced analytics drive a better understanding of the claims process to bring down the total cost of risk,” Michel added.
5. Provider Network Reach, Collaboration
Risk managers must pay close attention to provider networks and specifically work with outcome-based networks – in those states that allow employers to direct the care of injured workers. Such providers understand workers compensation and how to achieve optimal outcomes.
Risk managers should also understand if and how the TPA interacts with treating physicians. For example, Helmsman offers a peer-to-peer process with its 10 regional medical directors (one in each claims office). While the medical directors work closely with claims case professionals, they also interact directly, “peer-to-peer,” with treatment providers to create effective care paths or considerations.
“We have seen a lot of value here for our clients,” Michel said. “It’s a true differentiator.”
6. Strategic Outlook
Most of all, Michel said, it’s important for risk managers, brokers and TPAs to think strategically – from pre-loss and prevention to a claims process that delivers the best possible outcome for injured workers.
Debbie explains the value of working with Helmsman Management Services.
Helmsman, which provides claims management, managed care and risk control solutions for businesses with 50 employees or more, offers clients what it calls the Account Management Stewardship Program. The program coordinates the “right” resources within an organization and brings together all critical players – risk manager, safety and claims professionals, broker, account manager, etc. The program also frequently utilizes subject matter experts (pharma, networks, nurses, etc.) to help increase knowledge levels for risk and safety managers.
“The true goal here is to think about injured employees,” Michel said. “Everyone needs to focus on helping them get well, back to work and functioning at their best.
“At the same time, following a best practices approach can reduce overall comp costs, and help risk managers get a much better night’s sleep,” she said.
To learn more about how a third-party administrator like Helmsman Management Services LLC (a subsidiary of Liberty Mutual) can help manage your workers compensation costs, contact your broker.
Debbie discusses how Helmsman drives outcomes for risk managers.
Debbie explains how to manage medical outcomes.
Debbie discusses considerations when selecting a TPA.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Helmsman Management Services. The editorial staff of Risk & Insurance had no role in its preparation.