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Opioid Management
Sub-par Compliance With Opioid Guidelines
Lack of adherence to opioid prescription and monitoring guidelines has obvious negative repercussions for workers’ comp payers. Unmonitored opioid use is more likely to result in addiction, misuse or abuse, lengthening claim duration and piling on extra costs.
A study published in the March 2015 edition of the journal Pain Medicine (Vol. 16, Issue 3) found that resident and attending physicians were “only partly compliant with national guidelines” concerning prescription opioid monitoring.
The retrospective study, “Adherence to Prescription Opioid Monitoring Guidelines Among Residents and Attending Physicians in the Primary Care Setting,” gathered data from electronic medical records from one primary practice unit in a New England hospital. Due to the specificity of the setting and relatively small sample size, the authors note that the findings are not necessarily applicable to other settings. They are indicative, however, of a greater need for education and awareness among the medical community around opioid guidelines.
This study in particular looked at the differences in practice between residents and attending physicians, finding that patients of resident physicians were more likely to be on chronic opioid treatment and also to receive early refills.
This may be due to the nature of residency, which has turnover every three years. This makes it easier for patients abusing opioids to seek new prescriptions from different doctors. Attending physicians have longer-term relationships with patients, as well as more experience, which could mean they are able to better manage their patients’ opioid therapy and therefore see less evidence of opioid misuse or abuse.
Unrealistic Expectations
Ultimately, the report concluded that “the levels of monitoring observed in our study are still significantly lower than endorsed by clinical guidelines,” and “our findings highlight the need to improve monitoring of patients with chronic pain on opioids.”
Terrence Wilson, MD, utilization review medical director and pain management expert at GENEX Services, said, “One of the reasons for this relative explosion in opiate pharmacotherapy use is the emphasis at the turn of the century on pain as the fifth vital sign. This became a Joint Commission standard in 2001 because pain was allegedly being undertreated.”
The increased demand to treat pain is fed in part by unrealistic patient expectations.
“Patients won’t be 100 percent pain free. The goal is increased function with decreased pain, as supported by ODG and ACOEM guidelines,” said Jennifer Kaburick, senior vice president, workers’ compensation product, compliance and strategic initiatives at Express Scripts.
“Opioids and narcotics are effective, but should be given at lowest possible for shortest duration. Simply having ongoing pain without improving function is not a good enough reason to continue prescribing opioids.”
The subjectivity of pain, however, and the wishes of well-meaning family and friends make it difficult for treating physicians to lower dosage or discontinue a prescription if a patient is still reporting intense pain.
“As to the overall acceptance and execution of these practices among physicians, there remains a great disparity throughout the profession,” Wilson said.
“Some physicians, especially those that have chosen to focus on the general management of painful conditions, are more likely to abide by these standards. However, as this study shows, even in an academic setting, there remains a great deal of work to be done before one can consider the management and monitoring of pain therapy second nature.”
The Pain Medicine study authors recommend the use of prescription monitoring programs to identify patients at risk for misuse, the implementation of an informed consent and opioid agreement, and “at least one urine drug test per year” to check for signs of abuse.
“The incorporation of the formal signed controlled substance agreement into the general practice setting serves as an informal and educational resource for the patient and family,” Wilson said, “while setting forth the ground rules for monitoring, altering and in some cases discontinuing the prescribing of an opiate or other controlled substance.”
Despite these recommendations and growing national awareness of the issue, opioid abuse remains an ongoing challenge. This suggests that perhaps workers’ comp claims handlers and payers should step up their role in the process, enforcing stricter adherence to clinical guidelines and paying closer attention to opioid usage earlier in the claim.
As Kaburick says, this issue should be addressed both “proactive and retroactively.”
“[Express Scripts] goes to the point of sale, before the prescription is even filled,” she said.
“The payer can set a threshold for morphine equivalent dose for narcotics. If the prescription exceeds that threshold, the client — usually a nurse case manager — will have to approve it.”
Express Scripts also informs the treating physician if the threshold is exceeded. “We also make them aware of other medications the patient is taking form other doctors, especially if those medications are in different therapy classes,” Kaburick said.
At GENEX Services, “the practice that is evolving, often with the assistance of pharmacy benefit managers, is a consolidation of pharmacy data which provides the health care professional the opportunity to voluntarily participate in a comprehensive pharmacy review that serves to benefit the injured worker and the treating physician,” Wilson said.
“This includes examples of more than one physician prescribing similar or identical medications as well as examples of prescribing medications that should not be taken together.”
The emergence of electronic medical records should help physicians be aware of a patient’s drug history and any concurrent medications, but the technology is far from perfect. Different practices use different EMR systems that utilize different formats and templates, which makes it difficult to integrate information when patients move from specialist to specialist.
In the meantime, continuing to encourage familiarity with national guidelines among network physicians — and require documented adherence — may be the best foot the workers’ comp industry can put forward.
