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While noting slight changes in some of the trends, the report indicates the problem is likely not going away anytime soon. Experts in the physician and pharmacy benefit management communities offer up their thoughts on strategies that are yielding positive results and where more focus is needed. Those interviewed will be speaking at the 21st National Workers' Compensation and Disability ConferenceŽ & Expo in November.

The report. NCCI looked at carriers' data for medical services between 1996 and 2009 for its latest study. Researchers noted the following key findings:

• Per claim narcotic costs were up.
• There have been changes in which narcotics are most commonly used.
• Narcotic use is concentrated among a small percentage of claimants.
• Initial narcotic use is indicative of future use.

PBMs. "PBMs have to be more proactive," said John F. Aforismo CEO/founder of RJ Health Systems in Hartford, Conn. "My personal opinion is we need to educate the prescribers on the appropriate use of the drugs."

Ensuring physicians follow clinical guidelines is one key to effectively address the increasing abuse and misuse of opioids in the workers' comp system, the experts said.

"Creating the standard of care -- that's the foundation to keep it from becoming one opinion versus another," said Mark Pew, senior vice president of PRIUM, a Georgia-based medical cost management company. "Evidence-based medicine is not a cookie-cutter approach, but at least having a standard of care, in 99 percent of cases, [one can say] this is appropriate, this is inappropriate."

Pew points to the example of Texas, which implemented a pharmacy closed formulary last year. It excludes many opioids without preauthorization.

"They put into place [a system] that said 'before anybody does anything, let's get a third-party objective opinion to see whether it is medically appropriate; let's have a physician speak with another physician and make sure it is appropriate,'" Pew said. "Physicians understand they don't have carte blanche, they must bounce this off somebody else."

The Texas Division of Workers' Compensation recently announced the program has resulted in fewer opioids being prescribed. It noted a 75 percent decrease in prescription costs specifically attributed to excluded drugs for the period September to November 2011, compared to the same period in the previous year.

"I really feel that it is the best method for addressing the opioid issue," Pew said. "For states that have a standard of care or utilization review statutes, or a combination of the two, it's a fairly easy move to do that."

Physicians. The medical community is not as well-versed on the use of opioids as it could be, suggest two physicians. Communicating with physicians can go a long way to help stem the abuse and misuse of opioids.

"Many well-intentioned physicians do not fully understand the proper role of opioids in the treatment of injured workers and they do not understand the importance of a biopsychosocial, whole person approach as promoted in all evidence-based medicine opioid guidelines," said Dr. Steven Feinberg, chief medical officer of American Pain Solutions in Palo Alto, Calif. "If someone is on massive amounts of opioids for a long time, that's a red flag. Get me, or a host of doctors who do this, involved and say, 'Do you realize your patient is on five times the amount he should be? Do you even know what the problems are?'"

Physicians also need to understand how to treat patients with acute versus chronic pain. Acute pain, for example, may warrant the use of opioids -- for the short term.

For patients suffering from chronic pain, only long-acting opioids should be used."We continue to prescribe immediate-release opioids on a standing basis," said Dr. Thomas Jan, a physician at Massapequa Pain Management & Rehab in Massapequa, N.Y. "This continual spiking of blood levels on a daily basis results in increased tolerance and subsequent dose escalations."

Jan says he is bothered by the fact that many treating physicians will not treat patients who exhibit symptoms that indicate they are becoming dependent on opioids. "Providers prescribing these medications do not have an exit strategy nor do they address abuse in any manner other than discharge," he said. "Addiction is a disease that is a potential consequential diagnosis of the use of chronic opioid therapy, and unfortunately, many providers view it as a moral failing rather than a disease."

One step physicians might consider is changing their prescribing patterns to allow only a three-day supply rather than the 30-day supply typically prescribed. That suggestion comes from the Centers for Disease Control and Prevention.

"It takes time to change a physician's prescribing habits and to try to change the entire profession is a huge task, but it can be done," said Phil Walls, clinical director of myMatrixx in Tampa, Fla. "We saw it happen with antibiotics."

Read more at the WorkersComp Forum homepage.

July 23, 2012

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