Managing Chronic Pain Requires a Holistic Strategy
Chronic, intractable pain within workers’ compensation is a serious problem.
The National Center for Biotechnology Information, part of the National Institutes of Health, reports that when chronic pain occurs in the context of workers’ comp, greater clinical complexity is almost sure to follow.
At the same time, Workers’ Compensation Research Institute (WCRI) studies show that 75 percent of injured workers get opioids, but don’t get opioid management services. The result is an epidemic of debilitating addiction within the workers’ compensation landscape.
As CEO and founder of Integrated Prescription Solutions Inc. (IPS), Greg Todd understands how pain is a serious challenge for workers’ compensation-related medical care. Todd sees a related, and alarming, trend as well – the incidence rate for injured workers seeking permanent or partial disability because of chronic pain continues to rise.
Challenges aside, managing chronic pain so both the payer and the injured worker can get the best possible outcomes is doable, Todd said, but it requires a holistic, start-to-finish process.
Todd explained that there are several critical components to managing chronic pain, involving both prospective and retrospective solutions.
Prospective View: Fast, Early Action
“Having the wrong treatment protocol on day one can contribute significantly to bad outcomes with injured workers,” Todd said. “Referred to as outliers, many of these ’red flag’ cases never return to work.”
Best practice care begins with the use of evidence-based UR recommendations such as ODG. Using a proven pharmacological safety and monitoring opioid management program is a top priority, but needs to be combined with an evidence-based medical treatment and rehabilitative process-focused plan. That means coordinating every aspect of care, including programs such as quality network diagnostics, in-network physical therapy, appropriate durable medical equipment (DME) and in more severe cases work hardening, which uses work (real or simulated) as a treatment modality.
Todd emphasized working closely with the primary treating physician, getting the doctor on board as soon as possible with plans for proven programs such as opioid Safety and Monitoring, EB PT facilities, patient progress monitoring and return-to-work or modified work duty recommendations.
“It comes down to doing the right thing for the right reasons for the right injury at the right time. To manage chronic pain successfully – mitigating disability and maximizing return-to-work – you have to offer a comprehensive approach.”
— Greg Todd, CEO and founder, Integrated Prescription Solutions Inc. (IPS)
Alternative Pain Management Strategies
Unfortunately, pain management today is practically an automatic move to a narcotic approach, versus a non-invasive, non-narcotic option. To manage that scenario, IPS’ pain management is in line with ODG as the most effective, polymodal approach to treatment. That includes N-drug formularies, adherence to therapy regiment guidelines and inclusive of appropriate alternative physical modalities (electrotherapy, hot/cold therapy, massage, exercise and acupuncture) that may help the claimant mitigate the pain while maximizing their ongoing overall recovery plan.
IPS encourages physicians to consider the least narcotic and non-invasive approach to treatment first and then work up the ladder in strength – versus the other way around.
“You can’t expect that you can give someone Percocet or Oxycontin for two months and then tell them to try Tramadol with NSAIDS or a TENS unit to see which one worked better; it makes no sense,” Todd explained.
He added that in many cases, using a “bottom up” treatment strategy alone can help injured workers return to work in accordance with best practice guidelines. They won’t need to be weaned off a long-acting opioid, which many times they’re prohibited to use while on the job anyway.
Chronic Pain: An Elusive Condition
Soft tissue injuries – whether a tear, sprain or strain – end up with some level of chronic pain. Often, it turns out that it’s due to a vascular component to the pain – not the original cause of the pain resulting from the injury. For example, it can be due to collagen (scar tissue) build up and improper blood flow in the area, particularly in post-surgical cases.
“Pain exists even though the surgery was successful,” Todd said.
The challenge here is simply managing the pain while helping the claimant get back to work. Sometimes the systemic effect of oral opioid-based drugs prohibits the person from going to work by its highly addictive nature. In a 2014 report, “A Nation in Pain,” St. Louis-based Express Scripts found that nearly half of those who took opioid medications for more than a month in their first year of treatment then refilled their prescriptions for three years or longer. Many studies confirm that chronic opioid use has led to declining functionality with reduced ability to recover.
This can be challenging if certain pain killers are being used to manage the pain but are prohibitive in performing work duties. This is where topical compound prescriptions – controversial due to high cost and a lack of control – may be used. IPS works with a reputable, highly cost-effective network of compound prescription providers, with costs about 30-50 percent less than the traditional compound prescription
In particular compounded Non-Systemic Transdermal (NST) pain creams are proving to be an effective treatment for chronic pain syndromes. There is much that is poorly understood about this treatment modality with the science and outcomes now emerging.
Retrospective Strategies: Staying on Top of the Claim
IPS’ retrospective approach includes components such as periodic letters of medical necessity sent to the physician, peer-to-peer and pharmacological reviews when necessary, toxicology monitoring and reporting, and even addiction rehab programs specifically tailored toward injured workers.
Todd said that the most effective WC pharmacy benefit manager (PBM) provides much more than just drug benefits, but rather combines pharmacy benefits with a comprehensive ancillary suite of services in a single portal assisting all medical care from onset of injury to RTW. IPS puts the tools at the adjustor fingertips and automates initial recommendations as soon as the claim in entered into its system through dashboard alerts. Claimant scheduling and progress reporting is made available to clients 24/7/365.
“It comes down to doing the right thing for the right reasons for the right injury at the right time,” Todd said, “To manage chronic pain successfully – mitigating disability and maximizing return-to-work – you have to offer a comprehensive approach,” he said.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with IPS. The editorial staff of Risk & Insurance had no role in its preparation.
More Comp Claimants Turning to Heroin
An increasing number of workers’ comp patients who are addicted to opioid painkillers are now turning to heroin.
Experts talk about the growing problem, and how it could lead to more lawsuits against employers and others within the workers’ comp system. They also discuss how to spot red flags of possible heroin abuse, and ways to minimize use among workers’ comp patients — starting with more responsible painkiller prescribing to reduce opioid painkiller addiction, “the strongest risk factor for heroin addiction,” according to the Centers for Disease Control.
Indeed, 45 percent of people who used heroin were also addicted to prescription opioid painkillers, the CDC contends. Between 2002 and 2013, the rate of heroin-related overdose deaths nearly quadrupled, and more than 8,200 people died in 2013.
Switching to heroin could “absolutely” lead to lawsuits, said Joseph Paduda, principal of Health Strategy Associates in Syracuse, N.Y. and president at the PBM consortium, CompPharma LLC.
“If an injured worker is on opioids and the workers’ comp payer cuts them off, then they might switch to heroin,” Paduda said. “Potentially the payer could find out and not cover their claim anymore, which could trigger a lawsuit for getting them addicted in the first place. I have no idea if it’s a viable case, but attorneys in many states can be quite creative.”
While utilization of opioids has dropped considerably in states like Texas that have made it more difficult for workers’ comp patients to get opioids, there is concern that some patients who had their opioid prescriptions cancelled are now resorting to heroin, he said. Other states like Ohio are now adopting a much more rigorous approval process for the initial use of opioids, with an even greater focus on patients prescribed long-acting opioids and renewals of prescriptions for longer than a few weeks.
“Ohio is doing something fundamentally different,” Paduda said. “The state is carefully planning its approach to addressing long-term opioid patients with an eye towards ensuring addiction treatment is available if and when workers’ comp patients need it.”
“Potentially the payer could find out and not cover their claim anymore, which could trigger a lawsuit for getting them addicted in the first place. … attorneys in many states can be quite creative.” — Joseph Paduda, principal, Health Strategy Associates; president, CompPharma
Andrew Kolodny, chief medical officer at New York City-based Phoenix House substance abuse treatment centers, said that people who become addicted to opioids and are having trouble maintaining a supply of painkillers are likely to switch to heroin if they live in an area where it is available. However, even though they may switch to heroin, prescription opioids are usually preferred because the medications are pure and the people are less likely to be arrested than if they were buying heroin from a drug dealer.
“Heroin use increased because the number of people who developed opioid addiction from exposure to prescription opioids increased sharply over the past 20 years,” Kolodny said. “The medical community needs to prescribe more cautiously so that we stop creating new cases of addiction.”
Mark Pew, senior vice president at Prium in Duluth, Ga., said that as it becomes more difficult for workers’ comp patients to secure opioids if they are misusing or abusing them, many of those patients switch to heroin because it’s less expensive and easier to obtain on the street than prescription drugs.
“There is great concern, and rightfully so, that lawsuits on parties within the workers’ comp system could be forthcoming from patients claiming it was the doctor’s fault they became addicted to opioids and then heroin,” Pew said. “The liability costs associated with lawsuits and death benefits could be even greater with the addition of heroin because of its even higher possibility of abuse and misuse.”
Brigette Nelson, senior vice president, Workers’ Compensation Clinical Management Express Scripts in Cave Creek, Az. said that it’s really important to flag problematic claims, when workers “may be going off the rails before they start using heroin.”
“Physicians can monitor for medication abuse, as well as heroin use, with urine drug testing,” Nelson said. “Physicians can also check for needle tracks.”
“The medical community needs to prescribe more cautiously so that we stop creating new cases of addiction.” — Andrew Kolodny, chief medical officer, Phoenix House
Workers’ comp specialists can also check if the use of multiple medications is overly high, which can also lead to use of illicit drugs, she said. Express Scripts’ Morphine Equivalent Dose (MED) management program can help them with this, she said. The potency of various opioids can be equated to one another and to morphine. If someone is taking a strong opioid or multiple prescriptions, the values can be added to determine if the person is over a particular trigger limit.
The MED value can be calculated at the point of sale for a particular prescription, and other prescriptions coming from other pharmacies can be added, to determine if all of the prescriptions are over the recommended guidelines.
“We can flag these claims, and then the workers’ comp adjuster would need to authorize the prescription fill is it is appropriate for the patient,” Nelson said. “We also reach out to physicians to let them know the patient has exceeded the MED limit. This is also good in that it gives physicians a prescription history, as sometimes they may not know about prescriptions from different physicians.”
It’s really important that payers proactively manage opioid utilization and review concurrent therapy to ensure safe use, she said.
“The key is early intervention before it comes a problem,” Nelson said. “That’s where we come in as the PBM. Our programs can help prevent abuse or misuse of opioids, which in turn can prevent the potential for downstream addictions to illicit drugs like heroin.”
The most important thing is to prevent patients who do not have severe conditions from receiving opioids — “period,” said Gary M. Franklin, research professor in the Department of Environmental and Occupational Health Sciences at the University of Washington.
“There is no evidence supporting the use of opioids for non-specific musculoskeletal conditions, headaches or fibromyalgia,” Franklin said. “If a prescription is needed, generally it should not go beyond 30 days. If a patient takes opoids for four to six weeks and then tries to withdraw, they will experience physical withdrawal because they are already very likely dependent, and that is the first step towards addiction.”
The CDC also recommends that health care providers use prescription drug monitoring programs and ask patients about past or current drug and alcohol use prior to considering opioid treatment; prescribe the lowest effective dose and only the quantity needed for each patient; link patients with substance use disorders to effective substance abuse treatment services; and support the use of FDA-approved MAT options (methadone, buprenorphine, and naltrexone) in patients addicted to prescription opioid painkillers or heroin.
Detention Risks Grow for Traveling Employees
It used to be that most kidnapping events were driven by economic motives. The bad guys kidnapped corporate employees and then demanded a ransom.
These situations are always very dangerous and serious. But the bad guys’ profit motive helps ensure the safety of their hostages in order to collect a ransom.
Recently, an even more dangerous trend has emerged. Governments, insurgents and terrorist organizations are abducting employees not to make money, but to gain notoriety or for political reasons.
Without a ransom demand, an involuntarily confined person is referred to as ‘detained.’ Each detention event requires a specialized approach to try and negotiate the safe return of the hostage, depending on the ideology or motivation of the abductors.
And the risk is not just faced by global corporations but by companies of all sizes.
“The world is changing. We see many more occasions where governments are getting involved in detentions and insurgent/terrorist groups are growing in size and scope. It’s the right time for a discussion about detention risks.”
— Tom Dunlap, Assistant Vice President, Liberty International Underwriters (LIU)
“Practically any company with employees traveling abroad or operations overseas can be a target for a detention risk,” said Tom Dunlap, assistant vice president at Liberty International Underwriters (LIU). “Whether you are setting up a foreign operation, sourcing raw materials or equipment overseas, or trying to establish an overseas sales contract, people are traveling everywhere today for so many reasons.”
Emerging Threats Driven By New Groups Using New Tools
Many of the groups who pose the most dangerous detention threats are well versed in how to use the Internet and social media for PR, recruiting and communication. ISIS, for example, generates worldwide publicity with their gruesome videos that are distributed through multiple electronic channels.
Bad guys leverage their digital skills to identify companies and their employees who conduct business overseas. Corporate websites and personal social media often provide enough information to target employees who are working abroad.
And if executives are too well protected to abduct, these tools can also be used to identify and target family members who may be less well protected.
The explosion of new groups who pose the most dangerous risks are generally classified into three categories:
Insurgents – Detentions by these groups are most often intended to keep a government or humanitarian group from delivering services or aid to certain populations, usually in a specific territory, for political reasons. They also take hostages to make a political statement and, on occasion, will ask for a ransom.
In other cases, insurgent groups detain aid workers in order to provide the aid themselves (to win over locals to their cause). They also attempt prisoner swaps by offering to trade their hostages for prisoners held by the government.
The most dangerous groups include FARC (Colombia), ISIS (Syria and Iraq), Boko Haram (Nigeria), Taliban (Pakistan and Afghanistan) and Al Shabab (Somalia).
Governments – Often use detention as a way to hide illegal or suspect activities. In Iran, an American woman was working with Iranian professors to organize a cultural exchange program for Iranian students. Without notice, she was arrested and accused of subversion to overthrow the government. In a separate incident, a journalist was thrown in jail for not presenting proper credentials when he entered the country.
“Government allegations against detainees vary but in most cases are unfounded or untrue,” said Dunlap. “Often these detentions are attempts to prevent the monitoring of elections or conducting inspections.”
Even local city and town governments present an increased detention risk. In one recent case, a local manager of a foreign company was arrested in order to try and force a favorable settlement in a commercial dispute.
Ideology-driven terrorists – Extremist groups such as Boko Haram and ISIS are grabbing most of today’s headlines with their public displays of ultra-violence and unwillingness to compromise. The threat from these groups is particularly dangerous because their motives are based on pure ideology and, at the same time, they seek media exposure as a recruiting tool.
These groups don’t care who they abduct — journalist, aid worker, student or private employee – they just need hostages.
“The main idea here is to shock people and show how governments and businesses are powerless to protect their citizens and employees,” observed Dunlap.
Mitigating the Risks
Even if no ransom demands are made, an LIU kidnap and ransom policy will deliver benefits to employers and their employees encountering a detention scenario.
For instance, the policy provides a hostage’s family with salary continuation for the duration of their captivity. For a family who’s already dealing with the terror of abduction, ensuring financial stability is an important benefit.
In addition, coverage provides for security for the family if they, too, may be at risk. It also pays for travel and accommodations if the family, employees or consultants need to travel to the detention location. Then there are potential medical and psychological care costs for the employee when they are released as well as litigation defense costs for the company.
LIU coverage also includes expert consultant and response services from red24, a leading global crisis management assistance firm. Even without a ransom negotiation to manage, the services of expert consultants are vital.
“We have witnessed a marked increase in wrongful detentions involving the business traveler. In some regions of the world wrongful detentions are referred to as “business kidnappings.” The victim is often held against their will because of a business dispute. Assisting a client who falls victim to such a scheme requires an experienced crisis management consultant,” said Jack Cloonan, head of special risks for red24.
Without coverage, the fees for experienced consultants can run as high as $3,000 per day.
Given the growing threat, it is more important than ever to be well versed about the country your company is working in. Threats vary by region and country. For example, in some locales safety dictates to always call for a cab instead of hailing one off the street. And in other countries it is never safe to use public transportation.
LIU’s coverage includes thorough pre-travel services, which are free of charge. As part of that effort, LIU makes its crisis consultants available to collaborate with insureds on potential exposures ahead of time.
Every insured employee traveling or working overseas can access vital information from the red24 website. The site contains information on individual countries or regions and what a traveler needs to know in terms of security/safety threats, documents to help avoid detention, and even medical information about risks such as pandemics, etc.
“Anyone who is a risk manager, security director, CFO or an HR leader has to think about the detention issue when they are about to send people abroad or establish operations overseas,” Dunlap said. “The world is changing. We see many more occasions where governments are getting involved in detentions and insurgent/terrorist groups are growing in size and scope. It’s the right time for a discussion about detention risks.”
For more information about the benefits LIU kidnap and ransom policies offer, please visit the website or contact your broker.
Liberty International Underwriters is the marketing name for the broker-distributed specialty lines business operations of Liberty Mutual Insurance. Certain coverage may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds and insureds are therefore not protected by such funds. This literature is a summary only and does not include all terms, conditions, or exclusions of the coverage described. Please refer to the actual policy issued for complete details of coverage and exclusions.
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.