The worst of times is over. Maybe that's not saying very much. The controversial use of opioids in treating work injuries, which rose precipitously over the past 10-plus years, has begun to decline. But treatment of pain persists as the thorniest medical care problem in workers' compensation.
The American Medical Association stated it baldly: "Narcotics provide little to no benefit in acute back pain, they have no proved efficacy in chronic back pain, and 43 percent of patients have concurrent substance-abuse disorders, with aberrant medication-taking disorders as high as 24 percent of cases of chronic back pain."
What went wrong? Pressured to treat pain, doctors began prescribing opioids for injured workers, despite a notable dearth of research supporting their use (especially long-term) in treating the typical work injury, which is musculoskeletal.
Opioid-related deaths of injured workers soared, without anyone publicly counting the toll.
The most potent in a suite of prescribed drugs, opioids wreaked havoc with losses. A respected actuary told me that the industry remains substantially under-reserved on a case-reserve basis for pain cases, which make up a substantial portion -- 50 percent-plus -- of all long-tailed claim liabilities.
The opioid curve began to bend in about 2010, throughout health care and workers' compensation. Pharmacy benefit managers (PBMs) are reporting lower opioid use for injured workers. State action, such as official formularies, government drug prescribing databases and pain treatment guidelines, began to bite.
CompPharma, which surveys claims payers, said expertise in drugs has fanned out beyond relatively few highly specialized pharmacists.
PBMs give coherence to the way prescribing is monitored, and they bring discipline to drug reimbursement. But whether they have materially controlled opioid use, in the context of national health care trends and government strategies, is unclear. The same uncertainty applies to the impact of regulatory initiatives.
Progressive Medical, in its annual drug trend report this year, noted a "15 percent reduction in morphine equivalence per claim" after a new intervention program began. And, "use of long-acting and immediate-release opioid analgesics is down, while use of anti-inflammatory medications, anticonvulsant and antidepressant medications is either flat or up."
I asked Progressive Medical what happens when states introduce new opioid-related regulation. It looked, not at poster children of opioid reform such as Texas and Washington state, but at states where the content of reform was less dramatic. It chose New York, Tennessee and Kentucky based on the availability of data and the similarity of the legislation.
Looking at drug patterns for these states six months before and after reforms, its initial findings were inconclusive with regard to the regulatory effects.
The company then re-ran the data, comparing out-of-network data with in-network data in an effort to illustrate the difference between a contractual and a non-contractual relationship between a PBM and a carrier.
As with the first analysis, there was little to no evidence of change as a result of the legislation in any of the test cases reviewed.
The firm believes a host of factors can affect compliance with regulation.
The ultimate solution, it suggests, is a coordinated approach in hitting the issues from numerous sides -- legislation, regulation and the industry stakeholders themselves.
PETER ROUSMANIERE is an expert on the workers' compensation industry.
October 1, 2013
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