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.”
A New Dawn in Civil Construction Underwriting
Pennsylvania school children know the tunnels on the Pennsylvania Turnpike by name — Blue Mountain, Kittatinny, Tuscarora, and Allegheny.
San Francisco owes much of its allure to the Golden Gate Bridge. The Delaware Memorial Bridge commemorates our fallen soldiers.
Our public sector infrastructure is much more than its function as a path for trucks and automobiles. It is part of our national and regional identity.
Yet it’s widely known that much of our infrastructure is inadequate. Given the number of structures designated as substandard, the task ahead is substantial.
The Civil Construction projects that can meet these challenges, however, carry a unique set of risks compared to other forms of construction.
“The bottom line is that there is always risk in a Civil Construction project. If the parties involved don’t understand what risk they carry, then the chances are there are going to be some problems, and the insurers would ideally like to understand the potential for these problems in advance.”
– Paul Hampshire, Vice President – Civil Construction, LIU
The good news is that recent developments in construction standards and risk management techniques provide a solid foundation for the type and risk allocation of Civil Construction projects they are underwriting. Carriers need to be able to adequately assess the client and design and construction teams that are involved.
For Builder’s Risk Programs, a successful approach prioritizes a focus on four key factors. These factors are looked at not only during the underwriting phase of the project but also in the all-important site construction phase, under the umbrella of a Risk Management Program, or RMP.
Four key factors
Four key factors that LIU focuses on in underwriting and providing risk management services on a Civil Construction project include:
1. Resource knowledge and experience: When creating a coverage plan, carriers work to understand who is delivering the project and how well suited key staff members are to addressing the project’s technical and management challenges. Research has shown that the knowledge and experience of those key players, combined with their ability to communicate effectively, is a big factor in the project’s success.
“We look to understand who is delivering a project, their expertise and experience in delivering projects of similar technical complexity in similar working conditions, even down to looking at the resumés of people in key positions,” said Paul Hampshire, Houston-based Vice President with Liberty International Underwriters.
2. Ground conditions and water: Soil and rock composition, the influence of ground and surface water, and foundation stability are key additional considerations in the construction of bridges, tunnels, and transit systems. If a suitable level of relevant ground (geotechnical) investigation and study has not been undertaken, or the results of such work not clearly interpreted, then it’s a red flag to underwriters, who would then question whether the project risk profile has been adequately evaluated and risks clearly and transparently allocated via suitable contract conditions.
“As we all know, ground is very rarely a homogenous element within Civil Construction projects,” LIU’s Hampshire said.
“It tends to vary from any proposed geotechnical baseline specification with the consequential potential for changes in behavior during construction. We need to understand who has assessed the condition of the ground, its behavior and design parameters when compared with a particular method of construction, and all importantly, who has been allocated the ground risk in a project and the upfront mechanisms for contractual ground risk sharing, if applicable,” he said.
Knowing how much water is associated with the in-situ ground conditions as well as the intensity, distribution and adequate accommodation (both in the temporary as well as in the permanent project configurations) of rainfall for a site location and topography are also key. Tunneling projects, for example, can be hampered by the presence of too much or unforeseen quantities of groundwater.
“In major tunneling infrastructure projects, the influence of in-situ groundwater pressures and /or water inflows is a major factor when considering the choice of excavation method and sequence as well as tunnel lining design requirements,” LIU’s Hampshire said.
According to a recent article in Risk & Insurance, tunneling under a body of water is one of the most challenging risk engineering feats. Adequate drainage layouts and their installation sequence for highway projects and, in particular, the protection of sub-grade works are also important. “But under all circumstances, we need to understand how the water conditions have been evaluated,” Hampshire said.
3. Technical Challenges: This risk factor encompasses the assessment of the technical novelty or prototypical nature of the project (or more often, specific elements of it) and how well the previously demonstrated experience of both the design and construction teams aligns with the project’s technical requirements and the form of contract determined for the project. The client can choose the team, but savvy underwriters will conduct their own assessment to see how well-suited the team is to technical demands of the project.
4. Evaluation of Time and Cost: With limited information generally provided, we need to be able to verify as best as possible the adequacy of both the time and cost elements of the project. Our belief is simply that projects that are insufficient in either one or both of these elements potentially pose an increased risk, as the construction consortium tries to compensate for these deficiencies during construction.
Small diameter Tunnel Boring Machine designed for mixed ground conditions and water pressures in excess of 2.5 bar.
In the 1990s and early years of this millennium, a series of high-profile tunnel failures across the globe resulted in major losses for Civil Construction underwriters and their insureds.
In the early 2000s, both the tunnel and insurance industries worked together to create new standards for high-risk tunneling projects.
A Code of Practice for the Risk Management of Tunnel Works (TCoP) is increasingly relied on by project managers and underwriters to define the best practices in tunnel construction projects. This process ideally starts at project inception (conceptual design stage or equivalent) and continues to the hand-over of the completed project.
LIU’s Hampshire said alongside TCoP, the project-specific Geotechnical Baseline Report and its interpretation and reference within the project contract conditions gives the underwriter greater clarity as to who recognizes and carries the ground risk and how it’s allocated.
“The bottom line is that there is always risk in a Civil Construction project,” Hampshire said. “Is the risk transparently allocated or is it buried? If the parties involved don’t understand what risk they carry, then the chances are there are going to be some problems, and the insurers would ideally like to understand the potential for these problems in advance,” Hampshire said.
Paul Hampshire can be reached at Paul.Hampshire@libertyiu.com.
To learn more about how Liberty International Underwriters can help you conduct a Civil Construction risk assessment before your next project, contact your broker.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Liberty International Underwriters. The editorial staff of Risk & Insurance had no role in its preparation.