Avoid Rush to Judgement on Opioid Strategies, Liberty Mutual Medical Director Advises

Boston, MA (WorkersCompensation.com) – The fact that unnecessary opioid prescriptions in the workers’ compensation system are down is good news. But does anyone really know what’s driving that decrease? Are formularies the answer? What about peer-to-peer physician reviews, is that the key? Is educating injured workers the driver?

“There’s a temptation to identify something obvious and close to us that has changed at the same time as causal. But not everything correlated is causal,” noted Joseph Pachman, VP and National Medical Director of Liberty Mutual Insurance. “To understand what actually produces better outcomes for injured workers, we need to look past correlations and test what levers work.”

During a session at RIMS, Pachman explained that the workers’ compensation industry often rushes to judgement and acts without solid evidence. The danger is that other effective strategies may be overlooked, or the system may become too dependent on an idea that has only limited effectiveness.

A case in point is Washington State. A decrease in overdose hospital admissions correlated with the legalization of medical marijuana. That led to efforts to establish a causal relationship and support it through regulation as an evidence based substitute for opioids. The problem is that the evidence wasn’t and still is not there

“An article in the Journal of the American Medical Association said that the substitution of cannabis for opioids is not supported,” Pachman said. “It needs to be studied.”

In fact, the JAMA article from February said the suggestion to substitute one drug for the other “has not been subjected to a single clinical trial for opioid addiction,” and called it “irresponsible.” There are many alternatives to opioids for chronic pain besides cannabis. “Nonopioid medications appear to have similar efficacy, and behavioral, voluntary, slow-tapering interventions can improve function and well-being while reducing pain.”

Not a New Phenomenon

Problems surrounding the overprescribing of opioids have been seen before. Morphine was the drug of choice during the civil war, as it helped alleviate the pain of injuries to soldiers. After the war, liquid opium became a significantly prescribed drug for middle class women to help with conditions such as “diseases of the nervous character.”  But these remedies were addictive and often resulted in overdoses.

A ‘safe alternative’ developed by Bayer pharmaceutical company came on the market in 1898. It was called heroin. It was used for many conditions – including addiction to morphine. The rise of heroin addicts, particularly in New York City, resulted in legislation to restrict use of it, along with cocaine and cannabis.

States’ Solutions

The recent battles with opioid abuse and misuse have led to states adopting a variety of strategies, all of which have contributed to the recent decrease in prescriptions among injured worker. They include:

• Formularies, or rules that direct providers on specific drugs. States such as Colorado and Texas “saw significant reductions in opioid prescriptions” with the implementation of formularies.
• Drug restrictions, that limit the number of pills that can be prescribed without preauthorization have also helped curb prescriptions, and are in effect in 40 states.
•  Prescription Drug Monitoring Programs are in effect in nearly all states. However, “not all states have prescriber use mandates,” Pachman said. But states such as “Kentucky, Ohio, Florida and New York saw opioid prescriptions reduced” due to these programs.
• Peer to peer physician reviews “reduce friction,” Pachman said. These discussions between physicians also “can accelerate prescriptions for those who really do need opioids. They do exist.”
• Education for injured workers about the dangers of the drugs.
• Litigation against providers or manufacturers have also been seen in several states.

 "’It’s’ working, but what is ‘it’?” Pachman said. “There are a lot of strategies, but the big picture doesn’t always tell us what we really need to know.”

 Pachman said instead of focusing on one or two strategies, risk managers can adopt best practices based on lessons learned from the state efforts. They include: 

• ·Develop training programs to be delivered by nurses and physicians on the Centers for Disease Control and Prevention’s opiate guidelines and mitigation strategies, supported by data analytics.   
• Participate in public affairs discussions and connect with your State Medical Advisory Committees regarding opioid mitigation.   
• Be a trusted partner: Help educate providers about limits on supply without prior authorization, as well as state medical treatment guidelines. 
• Evaluate impacts to assess efficient use of resources.

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