Systems take action to control opioid prescription abuses

The inappropriate use of opioids in the workers' comp system is not unique to the private sector. Federal agencies face many of the same challenges, and like some states, their solutions offer valuable insights.

"I do see that cases [in the federal sector] of people with prolonged disability have a very high chance of also having chronic opioids," said Dr. Marianne Cloeren, medical director of Maryland-based Managed Care Advisors.

Cloeren reviews and helps agencies manage workers' comp claims in the federal sector. As a member of the board of directors, fellow, and chair of the Council on Occupational and Environmental Medicine Practice of the American College of Occupational and Environmental Medicine she is also intimately familiar with the challenges plaguing the private workers' comp system. Cloeren will share her expertise and solutions at the upcoming National Workers' Compensation and Disability Conference® & Expo and the Workers' Compensation in the Federal Workplace Conference.

Use of Schedule II narcotics decreases among California injured workers (08/13/12)
IAIABC, ACOEM target state workers' comp agencies with opioid message (10/24/11)
Study shows increasing frequency, costs of physician-dispensed meds (09/06/12)
Opioids, physician dispensing continue to concern practitioners (02/25/13)
Opioids, physician dispensing are major concerns among WC payers (02/11/13)

Throughout the country, many jurisdictions are taking actions to control the inappropriate use of opioids, Cloeren said. "Some of the controls include opioid management guidelines in Washington state -- with physician and patient education, written treatment plans, and the requirement to refer to a specially trained physician if the daily opioid dose reaches a certain point."

Cloeren also points to the Colorado system that "offers reimbursement to physicians for paying attention to opioid treatment guidelines, including checking a database for evidence of prescriptions by other doctors, and performing urine drug screening," she says. "And most states have enacted or are considering prescription drug monitoring programs to help doctors identify duplicate prescriptions for controlled drugs."

She says various measures in the federal system bear noting as well.

Federal workers' comp system. Injured workers in federal agencies have a unique system for obtaining medical treatment and payment reimbursement. Unlike the private sector, all claims are funneled through the Department of Labor's Office of Workers' Compensation Programs with payments coming directly from the federal government.

But the challenges of opioid use among injured workers carry many of the same themes seen in the private sector. For example, one of the most common opioids is Oxycontin.

"Oxycontin is the gateway drug to long-term problems," Cloeren said. "Usually it is the first one picked for long-acting opioids."

Cloeren says in reviewing thousands of cases, it's not unusual for Oxycontin to be prescribed to someone who has been on short-acting opioids after several months. "I'd consider Oxycontin the red flag drug," she says, "Once prescribed, people ought to pay attention to how it's being managed."

Federal solutions. "I think the federal system has done some very good things" to deter the misuse of opioids, Cloeren said. "There is a requirement for a higher level of scrutiny."

For example, once an injured federal worker has been on opioids for more than 90 days, further prescribing requires that the case goes to an OWCP claims examiner for review.

"One of the first controls the federal system put in place was limiting the opportunity to prescribe Actiq and Fentora," two powerful and controversial narcotics in the use of chronic pain patients. "Requests from physicians prescribing either of those go through a high level review and are not routinely authorized."

New OWCP controls to limit reimbursement to physicians dispensing drugs out of their own offices took effect in June. "That's a real best practice that other systems should look at," Cloeren said. "That's probably one of the most important controls ... that's probably going to make a big difference."

Education is key. "A missing piece is patient education at the beginning, so people understand what they are getting into," Cloeren said. "If you had a back strain and your doctor told you that a drug had a long list of side effects, was potentially addictive, and did not work any better than other safer drugs according to research, would you take it?"

A large part of educating patients is educating physicians. Cloeren noted that many cases drift into chronic opioid use without any sign that this was a conscious, informed decision.She said there are "great resources to help doctors educate their patients, including those at the website of Physicians for Responsible Opioid Prescribing."

A variety of strategies and programs can help injured workers in chronic pain without the use of opioids, Cloeren said. "The most effective approaches include both behavioral management and physical exercise to restore function."

Cloeren noted that the federal system has policies covering payment for behavioral therapy, substance abuse, and comprehensive pain management programs "when that is needed to get an injured employee recovered and able to work again."

Read more at the WorkersComp Forum homepage.

October 22, 2012

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