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With annual cost estimates for employers in the neighborhood of more than $1 billion -- plus the oft devastating human toll, workers' comp stakeholders have begun to focus on the issue and look for ways to prevent and mitigate the dangers associated with opioid use. Several recent conferences have devoted considerable time to the subject, including the National Workers' Compensation and Disability ConferenceŽ & Expo, produced by LRP Publications.

As opening general session speaker Joe Paduda commented in a recent blog posting, "there are no miracle solutions, no instant results. There is just hard work, careful analysis, thorough attention to detail, and persistent efforts. That's what it will take to reduce the problem of opioids in workers' comp."

The opioid crisis. The general consensus among the participants was that everyone needs to take a look at the problem and work together to solve it. "I think the panel was pretty united in terms of there is not one stakeholder who owns the whole problem," said Maureen McCarthy, senior vice president and manager of workers' compensation claims for Liberty Mutual. "It transcends workers' comp. From a pharmaceutical perspective, we're a small player."

McCarthy believes the solution to the opioid crisis in workers' comp, and society in general, lies in changing the perception about the medications. She likens it to changing society's attitudes about cigarettes.

"It took a long time for it to be ingrained that smoking is really, really bad," McCarthy said. "There were lots of ads making people feel cool about smoking cigarettes."

A crucial part of changing attitudes about opioids is education, according to Christina Preisig, a registered nurse and senior vice president for managed care at PMA Companies.

"One week on OxyContin and you go through withdrawal. Most people don't know that," Presig said. "Educate the injured worker and promote awareness."

The onus of educating the injured worker falls largely on the provider community, the panelists said. As Presig pointed out, an injured worker who is in pain is thinking first and foremost about reducing the pain -- not the potential consequences of the medication he is taking.

"In my opinion, people in pain need somebody else to think on their behalf," Presig said. "The physician and nurse should say, 'this is a narcotic. It will take the pain away but staying on it longer than one week, you may experience signs of withdrawal.' Being injured and in pain, I need someone to tell me that because I will not remember anything else."

But in order for medical providers to educate injured workers about the potential adverse effects of opioids, they themselves must also be informed about them, something the panelists said is often lacking.

Provider support. "Physicians are trying to do the right thing, but they don't have time. They tend to be years behind current research," said Karen Caterino, risk manager for the State of Nevada. "A lot has to do with issues we're facing nationwide with these drugs instead of recognizing it's not in the best interests of the patient."

Persuading medical providers to stay abreast of current research on opioids and follow certain protocols is no simple task, several panelists said. There are few incentives for physicians to refuse to prescribe opioids for an injured worker who is in pain.

"Part of the problem is physicians will give drugs for pain because they are afraid of getting sued and their malpractice insurance is already too high," said Mark Noonan, managing principal for casualty practice at Integro Insurance Brokers. "They need support from their peers that say, 'no one is going to sue you, no one is going to file a complaint.'"

That peer support, Noonan says, can be part of standards established to control the use of opioids in the workers' comp system.

"Certainly the PPO networks or medical provider networks or whatever can say to attending physicians, 'you can't write more than 60 days for this medication without peer review. You can't write over X milligrams per day without peer review.' Then you set up peer-review physicians who are experts and who are not going to be afraid to push back on physicians or support a physician who says 'I really don't want to write the prescription.'"

Having managed care networks has helped Nevada address the issue of opioid prescriptions in the workers' comp system for state employees, Caterino said. The state will soon implement pain management protocols.

Since Nevada statutes allow risk managers to use provider networks and injured workers must go to in-network physicians, there is more monitoring and control of claimants then there might otherwise be.

"They get seven or 14 day fills and anything additional -- for opioids -- requires prior authorization and treatment plans," Caterino said. "It's very, very short term."

Caterino says having panel providers is key. She advises keeping them engaged in the workers' comp space.

"The provider community has to be on board. Because we can use managed care organizations, all providers on our panel must go through a credentialing process and have to agree to follow evidence-based medicine," Caterino said. "We use ACOEM [guidelines]. It's very clear on how to treat [patients on opioids]. That's been incredibly helpful for us."

Caterino says the current managed care organization has been in place in Nevada's government for about two and a half years. In addition to helping control the use of opioids in the workers' comp system, it has helped the bottom line.

"We've saved a significant amount of money," Caterino said, "not because we deny care, because we give appropriate care."

Government involvement. Many workers' comp stakeholders point to Washington state as a model for how to control the use of opioids in the workers' comp system. The imposition of limits on opiate prescriptions, a fee schedule, and the push to use generic drugs is seen by many as an effective way to address the problem.

The fact that Washington is one of a handful of states without a competitive workers' comp market may make such a process more difficult, if not impossible in other jurisdictions. But several other states are considering efforts to regulate the use of opioids in workers' comp -- something stakeholders reluctantly welcome.

"I don't like the idea of the states getting involved, but I'm afraid that may be an alternative," Noonan said. "Like Washington and some other states saying 'when you go over 60 days of prescribing the medications you have to justify it in writing,' that has a chilling effect because you actually have to read what you put on paper and say 'this does or doesn't make sense to me.' But at least it makes them stop and think what alternative treatments may be available."

Some say there may not be a choice as to whether governments intercede in the discussion. "The pharmaceutical industry has to take a huge responsibility as well as the medical industry. We're not, so states and governments are going to take responsibility and do it their way," said Janet Warren, managing director of Beecher Carlson in Atlanta. "I'm not sure that's the best thing."

What might be a good thing is for workers' comp stakeholders in various jurisdictions to share their strategies, said Nevada's Caterino. "There's no consistency among the states. There is no consistency in best practices," she said. "But it doesn't matter if a back hurts in Nevada or Florida, you've got to treat the back."

Caterino feels state legislatures should be more involved in the opioid discussion to add support. While she does not endorse the idea of a national platform for workers' comp, she does admit there is something to be said for having more generalized standards.

"It's a shame that some states do really well and some struggle," Caterino said. For example, "how can you have good outcomes in a state without managed care or provider panels? Personal physicians don't understand occupational health and return to work."

Other solutions. The panelists say it is incumbent upon participants in the workers' comp system to be involved in efforts to stem the abuse of opioids. For example, those managing claims can play a big role.

"We really need to make sure people handling claims are properly educated in the issues," Warren said. "To really ask the tough questions and the right questions [of medical providers], those people need to understand things like the true medical aspects of using opioids and chronic pain treatment."

Such questions include: does the medical provider have a contract with the employee, and are they doing the right drug testing to monitor their patients? "To make sure those kinds of basic, evidence-based medical guidelines are being followed," Warren said. "We often see that they are not."

Warren said she often has been in meetings where the claims adjuster produces a list of different medications prescribed for the injured worker. While the adjuster might not have a medical background, a nurse in the same meeting might be able to see that the particular medications should not be interacting.

"We hope there is a fail-safe, but often there is not," Warren said. "We're putting injured workers in jeopardy and also enabling those who use drugs inappropriately or are selling them."

Employers, for their part, can also be a vital part of the effort to minimize the abuse of opioids in the workers' comp system, says PMA Companies' Presig. She believes companies bear some responsibility to educate their workers on the risks, as part of their new employee training.

"You're stepping on people's toes when you say that," Presig said. "Years ago nobody talked about sexual harassment. You're educating the employee about what might happen and what can you do to get help."

Presig says since the problem goes way beyond the workers' comp system, it's important for employers to get involved in the discussion. In the same way employees might be directed to AA or Al-anon, companies could point workers to a group focused on prescription medication abuse.

"I would start with the employer in the sense that opioid awareness programs should be made available to assist their employees," Presig said. "Let's engage some recognizable organization because the overuse of opioids is not just a workers' comp problem it's a society problem."

Read more at the WorkersComp Forum homepage.

December 19, 2011

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