"Insidious Incrementalism" of Opioid Use in Workers' Compensation
The majority of studies show growth and negative results of opioid use -- but is there anything that can be done to begin to reverse these trends or proactively identify which claims are about to head down the wrong path?The answer is yes, but the solutions require extensive analysis combined with a comprehensive strategy.
It's important to understand how we got here.While opioid use certainly has its place in managing acute, severe pain, according to Dr. Michael Seise, PharmD, MBA and manager of clinical services at Healthesystems, the spike in opioid growth can be attributed to several things.Chief among these is the shift in societal perception towards the use of opioids, which no longer carry the stigma that was associated with their use 20-50 years ago; further, aggressive marketing for the liberal use of opioids in virtually all painful conditions (led primarily by the pharmaceutical industry) has fueled the growth in prescription numbers, and cost. As a specialty provider of pharmacy (PBM) and ancillary benefits management solutions for the workers' compensation industry, Healthesystems, a Tampa, Fla based company, is acutely aware of how complex these challenges have become.
"Many may remember that during the early days of its release, Oxycontin was described, because of its slow-release properties, as being abuse-resistant," Seise said.
Today, that scenario has changed dramatically. Not only are opioids potentially addicting, but they also have fueled the creation of an underground, illegal black market. Unfortunately, it has extended past the drug dealers on street corners and has become a major challenge for employers regardless of whether it directly or indirectly is connected to a workers' compensation claim. In fact, within the past month, Federal agents raided a manufacturing plant of a major aircraft company in suburban Philadelphia and charged 37 people, many of them workers and former employees, with distributing or trying to obtain prescription drugs. Among the list of drugs confiscated were powerful painkillers including fentanyl and oxycodone -- another clear sign that the use and abuse of these powerful painkillers has gotten out of control.
In 1991, there were 40 million prescriptions written for opioids. By 2007, that number skyrocketed to 180 million. Up to 20 percent of all doctor office visits include an opioid prescription.In 2009, more than 310,000 Americans were admitted to emergency rooms due to an opioid overdose, and the amount of Oxycontin dispensed in 2009 alone was enough to give every man, woman and child in America 100 mg.
On the cost side, Dr. Seise notes that, according to medical industry studies, patients abusing opioids have a substantially higher annual healthcare spend than opioid non-abusers ? with per-patient costs of abusers at $15,884 per year, compared to $1,830 for non-abusers.When relating it directly to workers' comp, depending on the payer, opioids can comprise anywhere from 30 to 45 percent of the total annual prescription drug cost.
Seise makes it clear that opioids have their place in treating pain in the appropriate situations. But, he noted, as much as the use of opioids has led to both the staggering financial and societal costs within workers' compensation, there are some very visible signs pointing to the early stages of opioid abuse or overuse that often go unnoticed.
"If you go beneath the surface of a claim," he said, "and you begin to apply a more proactive opioid management approach to your claims population, you can begin to detect where a treatment is showing signs of going out of control,"or what he refers to as the early stage of an 'insidious incrementalism'."
Seise explained that insidious incrementalism is evident when looking at an entire population of claims and seeing the cost, prescription volume, and dosage level growth of opioids that occur between the initial year of service, after 5 years and then 13 to 15 years.The dollar impact of older claims is pretty clear -- for most payers approximately 75 percent of the drug costs are caused by claims that are older than five years, but 75 percent of all claims are less than five years old. When you look at the actual drivers of opioid cost over time, the major contributors are the increases in drug mix (potency) and in dosage amounts, while utilization (i.e., the number of pills dispensed per prescription), by comparison, is relatively small.For example, when comparing the opioid cost per claim for claims in service during their first year versus year 14, utilization increases the cost per claim by 289% by year 14 but higher dosages and the use of increasingly more potent agents (drug mix) increase the cost per claim by 855% and 2,700% respectively.It's the "incremental" increase in dosage and drug mix that begin manifesting during years 3 to 5 where the dramatic growth in costs per claim occur.Therefore, solely focusing on the number of prescriptions and more peripheral type of information doesn't tell the full story nor does it provide the targets upon which you should build your strategies.
"While you absolutely want to maintain focus on older claims since they are still driving the majority of your costs today, the most critical focus of an Opioid Management Program has to be trained on newer claims, by monitoring all aspects and changes occurring in the drug treatments and proactively addressing them," Seise said. "Intervention -- that is, outreach to the prescriber and/or the patient -- can arguably play the most important role in altering the cost trajectory of claims, especially when you are seeing high dose opioid regimens."
Physician-level intervention has demonstrated success whenever it has been used.The earlier the intervention occurs, the better the success rate. The hazards of long-term opioid use are well-documented, and it is critical that prescribers be made aware of the potentially serious consequences of their use."Initiating opioid therapy," Seise notes, "should 'begin with the end in mind.' Payors have a responsibility to ensure that opioid treatment is predicated on documented functional goals, and that an exit strategy (for opioid discontinuation) is planned.Intervening with prescribers soon after the initiation of opioid therapy may be crucial to altering this trajectory that can very often lead to a costly and very often clinically inappropriate drug regimen."
The core message is that damage resulting from long-term opioid use causes significant impact as soon as it is prescribed, as it can quickly grow and escalate costs over the life of a claim.
Seise said payers must work with their PBMs to track these types of claims from the initial opioid prescription, even to the point where prescribers are contacted early on to strategize the therapy goals. At Healthesystems, the company's VigilantRx Clinical Services program focuses on the entire process, right from the point of sale and specifically includes proactive opioid management tools to address these critical issues. Their PharmD physician outreach program provides education to all three key parties -- physician, payer and claimant (when necessary).
"You need to make sure your Opioid Management Program allows the capability to identify and manage these cases as they occur, not late in the claim history, and especially before the five-year mark," Seise said. According to data Healthesystems continues to analyze, 68 percent of patients who use opioid medications for pain relief for 90 days are likely to remain on opioids 52 weeks later -- another indicator of the importance of early intervention. "What happens in the first three to six months often sets the stage for what the claim will look like in five years, ten years and beyond."
For more information, visit www.healthesystems.com.
(The above piece is part of our continuing Insights series designed to highlight key products and services to our readers. This paid-for Insights was written and edited by Risk & Insurance®
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October 14, 2011
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