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Feb
4

Workers’ comp is leading the way on opioids

Welcome to the war, everyone.

Okay, so work comp is not the most progressive industry. We are – often justifiably – seen as slow-moving, overly conservative, reluctant to adopt change and averse to innovation.

Except when it comes to opioids, where work comp has been far in front – and continues to lead.  By advocating for treatment guidelines, restrictions of physician dispensing of opioids, formularies tied tightly to UR, analytics and clinical intervention, work comp has long been very active in a crisis that is only now getting real attention in the “real world”.

In a shocking statistic, opioid-related deaths in this country hit 28,647 in 2014, a 9% increase over 2013,

On the “What in hell took you so long”, it is wonderful to see the President call for $1.1 billion in funds to address the opioid crisis. The mainstream media is (finally) all over the issue.  Congresspeople are strident and passionate, finally joining Rep. Hal Rodgers R KY who has long been a leader, calling for action action action.  Presidential candidates are speaking out about the crisis.  It is an acknoledged public health emergency.  The CDC is promulgating guidelines.  Meanwhile, the opioid industry and their supporters are employing all their usual tactics in an effort to keep their profits flowing – expect them to spend whatever they need to.

For those of us in work comp who have been desperately working on the issue for years, this is welcome indeed.  We’ve been fighting this battle for at least ten years, thanks to research by CompPharmaCWCI, NCCI, and WCRI. Innovative efforts by a few insurers. Passionate and vocal leadership from pharmacists and medical directors. Washington State fund L&I’s Gary Franklin MD has been the industry’s leading voice on this issue for a decade, and the progress L&I has made under his direction (kudos to Jaymie Mai, PharmD as well) has been enormous.

The American Insurance Association’s Bruce Wood has been a forceful voice for common-sense, practical solutions, tirelessly bringing this issue to the attention of legislators, regulators, comp executives, and other stakeholders

A special shout out to PBMs, where diligent, targeted, persistent effort by execs, case managers, medical directors, clinical pharmacists, data analysts and account execs have actually led to a decrease in new claims with opioids for the last two years.

Think about that.   Working with payers, PBMs have been cutting opioid scripts for new claims by 5-7 percent per year for the last two years, likely significantly reducing adverse consequences – addiction, misuse, diversion, death.

PBMs make their money when patients are prescribed and dispensed drugs.  Yet PBMs, and their payer customers, have been working tirelessly to reduce the number of pills their patients take.

I’d be remiss if I didn’t acknowledge PBMs’ customers – adjusters and execs alike – have been a key part of the solution.  I recall a terrific program instituted by OneBeacon a decade ago that rewarded adjusters for identifying claimants on opioids and referring those claimants to a physician for review and treatment modification efforts.

Somehow the uninformed and unwilling-to-be-informed out there have not seen fit to allocate credit where credit is due.

Yes, work comp can be archaic, byzantine, frustrating, and even stupid.  And yes claimants can be mis-served for any number of reasons.

But what you’ve done about opioids is truly remarkable. Yeah, we still have a long way to go.  But we are well ahead of the rest of the world.

Note – I am president of work comp PBM consortium CompPharma.

 


16 thoughts on “Workers’ comp is leading the way on opioids”

  1. AS A NURSE CASE MANAGER FOR WORKERS’ OOMP I WORK DAILYTO GET PROVIDERS TO WEAN MY CLIENTS OFF NARCOTIS. THE ONLY THING THAT IS GOING TO HELP A LOT IS TO HAVE STATE OF MAINE GUIDELINES ENFORCABLE AS THE STATE HAS ENFORCEBALE GUIDELINES FOR THE MAINECARE SYSTEM. MAINE HAS GREAT GUIDELINES BUT THE PROVIDERS SAY THAT THE GUIDELINES ARE JUST THAT AND CONTINUE INCREASING THE AMOUNT MONTHLY. THE HUGH AMOUNT OF NARCOTICS THAT SOME OF THE PROVIDERS WRITE IN MAIN IS INSAINE WE NEED ENFORCABLE GUIDELINES. ARLINE
    NK A

  2. <<<Okay, so work comp is not the most progressive industry. We are – often justifiably – seen as slow-moving, overly conservative, reluctant to adopt change and averse to innovation.<<<

    You can say that again.

  3. This is exciting news to learn that the work and passion of W/C nurse case managers have shown great results! As part of a team effort, we have questioned and educated our medical providers regarding the pitfalls of narcotics on recovery and return to gainful employment for the last (3) three years.

  4. The only group missing above is the nurse case manager. Nurse Case Managers at our company developed specific opioid protocols including, educating the injured worker and physician on non-opioid alternatives, employing evidence based practices, working to ensure the PBM information is reviewed and addressed by the prescribing physician and asking hard questions for the past several years. Our nurses are trained to ask this first question to start the dialogue, “If the opioid being prescribed is not facilitating increased function, then why is it being prescribed?”

  5. The majority of patient are getting opiates from doctors prescriptions. Shouldn’t PBM’s work with State Medical Licensing authorities to get rid of the Doctors that are over prescribing?

  6. Liberty Mutual’s Research Institute for Safety has also published the following studies on the impact of opioid prescribing in Workers Comp:

    Webster BS, Verma S, Gatchel R. Relationship between Early Opioid Prescribing for Acute Occupational Low Back Pain and Disability Duration, Medical Costs, Subsequent Surgery and Late Opioid Use. Spine, 2007;32:2127-32.

    Webster BS, Cifuentes M, Verma S, Pransky G. Geographic Variation in Opioid Prescribing for Acute, Work-related, Low Back Pain and Associated Factors: A Multilevel Analysis. American Journal of Industrial Medicine. 2009;52:162-71.

    Cifuentes M, Webster B, Genevay S, Pransky G. The Course of Opioid Prescribing for a New Episode of Disabling Low Back Pain: Opioid Features and Dose Escalation. Pain. 2010; 151:22-9.

    Cifuentes M, Powell R, Webster B. Shorter Time between Opioid Prescriptions Associated with Reduced Work Disability among Acute Low Back Pain Opioid Users. Journal of Occupational and Environmental Medicine. 2012;54:491-96.

  7. Joe,
    Thanks for such a great article. We in the WC industry should be proud of the progress made in the past few years and resolute about continuing in this fight. Keep up the good work.

  8. ProPublica on opioids:

    The Champion of Painkillers
    http://www.propublica.org/article/the-champion-of-painkillers

    Two Leaders in Pain Treatment Have Long Ties to Drug Industry
    http://www.propublica.org/article/two-leaders-in-pain-treatment-have-long-ties-to-drug-industry

    Senate Committee Investigates Marketing of Painkillers
    http://www.propublica.org/special/senate-committee-investigates-marketing-of-painkillers

    American Pain Foundation Shuts Down as Senators Launch Investigation of Prescription Narcotics
    https://www.propublica.org/article/senate-panel-investigates-drug-company-ties-to-pain-groups

    As Controlled Substance Use Rises in Medicare, Prolific Prescribers Face More Scrutiny
    http://www.propublica.org/article/as-controlled-substance-use-rises-in-medicare-top-prescribers-face-scrutiny

    Dollars for Docs
    https://projects.propublica.org/docdollars/

    Prescriber Checkup
    https://projects.propublica.org/checkup/

    1. Good to hear from you Michael. I would note that Mr Ornstein’s efforts are laudable.

      I would also note your comment above does not address my reference to ProPublica, to wit:

    2. Somehow the uninformed and unwilling-to-be-informed (link to propublica WC story) out there have not seen fit to allocate credit where credit is due.
    3. We look forward to the day you accurately cover the great progress we in the work comp industry have made re opioids.

  9. You are absolutely right that workers’ compensation systems can be leaders in reducing the epidemic of addiction.

    In Ohio, it was the Ohio Bureau of Workers’ Compensation that first took action against pill mills, working with state and local law enforcement to shut down one of the most prolific providers of prescription drugs in Ohio. Since then, we have created a formulary, established a lock-in program to limit doctor- and pharmacy-shopping and initiated several measures to ensure our claimants receive the right drug for the right condition at the right time. The result of these efforts has been clear–total drug costs were lowered by more than $20 mil¬lion and opioid doses have decreased by 15.7 million, or 37%, since 2010.

    We have shared these learnings with others throughout Ohio as an active member of Governor John Kasich’s Opiate Action Team, which recently established strong prescription guidelines to help provide all Ohio doctors better direction for pain management. We will also be sharing our learnings at the inaugural Ohio Workers’ Comp Medical & Health Symposium in March.

    In short, we have an opportunity and obligation to be leaders in reducing addiction.

  10. Studies have shown that the United States, with less than 5% of the world’s population, uses 80% of the global supply of opioid drugs. The rest of the world doesn’t have this problem.

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Joe Paduda is the principal of Health Strategy Associates

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