New research takes opioid discussion to higher level

While the idea that opioid use is an independent risk factor for the development of catastrophic claims may not be surprising, the scientific confirmation that opioids are driving up workers' comp claims costs has led at least one insurer to consider alternative ways of treating injured workers who have chronic pain.

"It opened our eyes," said Jeffrey Austin White, director of medical management strategy for Accident Fund Holdings. "It was a realization that these claims can get expensive ... maybe it makes a lot of sense to consider things like detox or more expensive alternative therapies. Those are things we might not have considered before until we were really sure." White is among the speakers at the upcoming National Workers' Compensation and Disability Conference® & Expo in November.

As a consultant to Accident Fund, White analyzed a "gigantic" data set to help the company determine what was driving medical costs. He noticed strong correlations of high claims costs and opioids, antidepressants, and anticonvulsants.

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"Industry reports focus on aggregate costs of drugs as a driver of medical costs," White said. "But when you link pharmacy records with outcomes, you see certain classes of drugs that are driving medical costs. Opioids stick out like a sore thumb."

White teamed up with researchers from Johns Hopkins University to investigate the association between opioid utilization and catastrophic claims -- those costing upwards of $100,000. Their resulting study, The Effect of Opioid Use on Workers' Compensation Claim Cost in the State of Michigan, was published in the August edition of the Journal of Occupational and Environmental Medicine. The results, White said, should serve as a wake-up call for the industry.

"There was a clear independent relationship of opioids to drive claim costs," he said. "We think it's the first time where anybody has distinguished short-acting and long-acting [opioids] from each other and the fact that opioids in itself drive claim costs."

The study. The researchers used multivariate logistic regression analyses on more than 12,000 workers' comp indemnity claims from the state of Michigan for the time period January 2006 to Feb. 28, 2010. They controlled for sex, age, claim duration, number of distinct classification codes per claim, and legal involvement to equalize the claims and determine the independent effects of opioids.

"What we saw was pretty compelling," White said. "When we looked at the multivariate analysis to see claims that go to $100,000, which is generally used as a catastrophic claim threshold, we saw the relationship."

The researchers found that claims with SA opioids prescribed were nearly twice as likely to become catastrophic while claims with LA opioids were almost four times as likely to develop into catastrophic claims. Overall, SA prescriptions drove up the cost of a claim by three times while the presence of a LA opioid prescription increased the cost nine times.

White says the different effects of LA vs. SA opioids was eye opening. Many people wondered why the research differentiated between SA and LA opioids.

"Doctors assume it to be safer and that patient compliance will be higher if they take one pill a day and let it release rather than having to remember to take the pill every few hours. It makes sense," he said. "It's actually had a completely different effect on the worker."

Next steps. Armed with the information, workers' comp stakeholders might be inclined to act differently. At least, that's been the case at Accident Fund.

"Because we know these can lead to large claim costs, we should consider more aggressive therapies," White said. "We ultimately are now."

White said the company is looking at more sophisticated ways to monitor drug utilization, such as urine monitoring, and peer-to-peer reviews among physicians. They are also asking different questions than they did before the research was concluded.

"Of providers, 'did they sign a treatment contract with the patient?'" he said. "We ask providers if they're consulting with the drug monitoring database in the state to make sure [the injured worker] is not getting drugs from multiple sources.

"Have they set up functional improvement treatment goals," White said. "They are providing the drugs, monitoring the patient, but what is the end goal? We didn't ask these questions before because we didn't know the scope of this."

Additional questions concern noncompliant medical providers, uncooperative injured workers, and inadequate or a lack of state regulatory controls. "There are physicians dispensing these drugs out of their offices, or recombining or compounding them," White said. "What do you do there?"

While more research is needed to determine how opioids are driving workers' comp claims costs, the study takes the discussion of opioids in the workers' comp space to a higher level, White said.

"It's not that we've just restated the obvious," White said. "The question should be, 'what are you doing about it?'"

Read more at the WorkersComp Forum homepage.

October 15, 2012

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