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.
Qualified Medical Evaluators
The Division of Workers’ Compensation proposed modifications to its proposed regulations regarding qualified medical evaluators. The modifications state that initial represented panel requests postmarked after Sept. 3 will not be accepted or processed by the medical unit for initial represented panel requests only. The last day to mail in panel requests will be Sept. 3. Effective Oct. 1, all initial panel requests must be submitted electronically.
Under the proposed modifications, parties will have 10 days from service of the panel list to strike a doctor. Also, disputes regarding the validity of panel requests must be resolved by a workers’ compensation judge. Disputes regarding the appropriateness of the specialty designated must be resolved by the medical director. Either party may appeal the decision with a workers’ compensation judge.
Medical Billing and Payment Guide
The Division of Workers’ Compensation proposed to modify rules to transition from the International Classification of Diseases, 9th Revision diagnosis and inpatient procedure coding systems to the ICD-10 diagnosis and inpatient procedure systems. The change will go into effect on Oct. 1. The proposed amendments also adopt new forms and amend the medical billing and payment guide to adopt the ICD-10 code tables and index. Additional updates were proposed to the medical billing and payment guide to adopt more current versions of instruction manuals for professional and facility paper billing forms and updated dental codes.
Medical Fee Schedule
The Division of Workers’ Compensation proposed amendments to rules regarding the medical fee schedule. The rules revise the standard terminology and the administrative procedures and requirements necessary to implement the medical treatment guidelines and medical fee schedule. The proposed rule amendments also update the language of the medical fee schedule, revise the billing codes systems, and update the fees and relative values. The amendments also revise the medical requirements, procedures, and payments as they relate to the medical fee schedule.
The Workers’ Compensation Board proposed to repeal and replace a rule regarding medical fees and amend rules regarding formal hearings and expenses and fees.
The rule states that in the event that the employer or insurer contends that the medical records and information, preexisting and subsequent to the workplace injury, are relevant for determination of compensability and disability, it may obtain from the worker and the employee is obliged to within 14 calendar days execute a limited authorization for focused written medical records. Also, an employer or insurer must pay a worker’s travel expenses incurred for medical treatment, including actual costs for overnight lodging, parking, tolls, and public transportation if accompanied by a receipt.
The Workers’ Compensation Board announced the elimination of a number of fees. Starting April 1, fees for licensing compensation medical bureaus and laboratories were eliminated. Fees were also eliminated for physician arbitration, psychologist arbitration, chiropractor arbitration, and podiatrist arbitration. Licensed third-party administrator fees and licensed hearing representative fees were also eliminated.
Claims Procedure Rules
The Bureau of Workers’ Compensation proposed amendments to the claims procedure rules regarding lump-sum advancements. The rule states that an injured worker or surviving spouse must file an application requesting a lump-sum advancement with the bureau. The injured worker or surviving spouse must provide proof that the lump-sum advancement is advisable for the purpose of providing financial relief or furthering the injured worker’s rehabilitation. The bureau will not grant a lump-sum advancement in a claim where the allowance of the award of compensation is on appeal.
The Workers’ Compensation Division proposed amendments to rules regarding medical services. The rules clarify that the dispute record packet must include certification whether there is or is not an issue of compensability of the underlying claim or condition. The rules limit the denial of reimbursement based on the late submission of a treatment plan by an ancillary service provider to those services provided before the treatment plan is sent.
The amendments also require that an insurer approve or disapprove a health care provider’s request for preauthorization of a diagnostic study within 14 days of receipt of the request. The division scheduled a public hearing on July 21 at 9 a.m. at 350 Winter Street NE, Room B, in Salem.
The Department of Labor and Industries amended rules to meet new measures for calculating penalties set by the Occupational Safety and Health Administration. The amendments add a minimum penalty amount of $2,500 for violations issued when contributing to a fatality. In a rule regarding base penalty adjustments, the language was modified to state that no reduction will be given if the violations are classified as willful, repeat, failure to abate, or violations contributing to an inpatient hospitalization or a fatality. The rule also added clarifying language on how to determine an employer’s good faith. The rule goes into effect on Sept. 1.
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.