Nurses are Pivotal in Stemming Unnecessary Opioid Use, Report Shows

22 May, 2019 Nancy Grover


Sarasota, FL ( - A workers’ compensation insurance carrier reduced unnecessary opioid prescriptions by 13,000 in a 6-month period. A managed care provider is having success identifying and addressing pre-injury substance abusers. The reason in both cases: intervention by nurses.

Insurer Partnership

“Opioid prescriptions that may be unsafe or unnecessary are flagged and sent to nurses for review, reducing the percentage of prescription claims that include opioids from 60 percent in Q4 of 2017 to just 25 percent in Q4 of 2018 – resulting in 13,000 less opioid prescriptions over the last six months of 2018.”

The statement was included in the AmTrust Opioid Prescription Risk Report. The results came on the heels of AmTrust’s partnership last year with Optum Workers’ Comp and Auto No-Fault, a pharmacy care management company.

“Our adjusters are partnering with licensed nurses at Optum to review prescriptions to determine if medications are safe and necessary to ensure appropriate medication management for our injured employees,” said Dr. Melissa Burke, head of Managed Care and Clinical at AmTrust Financial. “We value the impact that medications can have on a claim outcome, and that’s why as soon as a prescription is requested, we present it to a medical professional — a nurse with a pharmaceutical focus.”

Since the partnership began in mid-2018, the insurer has seen a 57.3 percent decrease in average day supply of opioids and a 21.6 percent reduction in average transactions per injured worker.

“With AmTrust now funneling prescription opioid scripts to trained clinicians, pharmacists and nurses, they are assuring that claimants are receiving the right treatment, at the right time, for the right duration,” said Tron Emptage, Chief Clinical Officer, Optum Workers’ Comp. “This process affords the claims handler the opportunity to focus more on the claim issues and getting the injured party on a path to return to work and function.”

Pre-Injury Addiction

An estimated 14.8 million Americans are using drugs, illegal drugs, and 70 percent of those are employed. The National Council of Alcoholism and Drug Dependence also says employees with alcohol problems are nearly three-times more likely to have injury-related absences than other workers.

“Whatever issues the worker had before the injury would only get worse after the injury,” said Marianna Kritsberg, branch manager and Mental Health Professional with Genex in a recent blogpost. “We do have and we do see a large population who have substance abuse issues before they got injured, and those issues continue and often get worse after injury.”

Injured workers with substance abuse issues should not be prescribed opioids or other addictive medications when possible, especially as a first line treatment. However, identifying them is challenging.

“They say that people who have had addiction problems for a while are the best liars, and I have seen this many times when I worked in inpatient and outpatient rehab,” Kritsberg said. “They have an illness, and they're trying to live with this illness, so they have become very creative in how to, not overcome the illness, but how to live with it, and how to make other people believe that they don't have an issue.”

There are certain indications that case managers and employers may spot, however. Among them are:

  • Chronic lateness to work
  • Not showing up to work at all
  • Missing work excessively
  • Leaving work early

“For those injured workers who are working either full duty or modified duty, we’re also looking at someone who's appearing to be busy, but not really accomplishing anything,” she added.

Additional factors that may be apparent to nurses are physical characteristics, such as the smell of alcohol, bloodshot eyes, red nose and cheeks, or sudden unexplained weight loss. During an appointment nurses can also spot trembling hands, irritability, mood swings, headache, insomnia, temporary blackouts or memory loss. Some of these signs may be related to substance abuse.

“Also something that our nurses look for is polypharmacy, those injured workers who use multiple pharmacies,” Kritsberg said. “That's a red flag for sure, because they might be trying to fill some scripts from their personal doctors and their workers’ comp doctors for narcotics, so doctor‑pharmacy shopping is an issue as well. This also includes people who go to different ERs, people who go to different clinics, who often change primary treating physicians, those are all signs of a person who is looking to obtain more narcotics, more pain killers.”

In addition to identifying injured workers with substance abuse issues is the challenge how to address the situation. Nurses, however, have some leverage.

“A nurse is a non‑threatening role, most of the time, and it's also medical,” Kritsberg said. “So, a case manager with training can approach the injured worker and talk to him or her in a non‑punitive way, explore what the issues are, and offer help.”

Case managers are limited in what they can share with employers. However, a nurse case manager could share information about a substance abusing injured worker with a claims adjuster. Ideally  the nurse can first approach the injured worker.

“As an experienced nurse case manager, you would assess the situation and determine how you think the injured worker would react if you challenged him, or if you talked to him about it,” Kritsberg said. “It could go both ways. You could talk to the injured worker and try to address your suspicions and try to address the issues and see how he or she reacts, but you would also speak with the adjuster, and you would definitely also speak with the medical team.”

The nurse, for example, would tell medical providers not to prescribe narcotics because the injured worker has a substance abuse issue. Kritsberg said that case managers are advised to refer the substance abusing employee to an employee assistance program, if one exists. If not, there are generally community programs available that can help.

An advantage of having a nurse involved in such a claim is the relationship with the injured worker. Nurses are considered one of the most trusted professionals by the general public.

“In most cases, injured workers and families soon realize what our role is and love the fact that they have, what they call, a ‘personal nurse’ assigned to them,” Kritsberg said. I think case managers can and do make a difference in getting the injured worker to open up about his addiction. They see a nurse as someone they can share information with to improve their overall health.”

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    About The Author

    • Nancy Grover

      Nancy Grover is a freelance writer having recently retired as the Director, Media Services for She comes to our company with more than 35 years as a broadcast journalist and communications consultant. Grover’s specialties include insurance, workers’ compensation, financial services, substance abuse, healthcare and disability. For 12 years she served as the Program Chair of the National Workers’ Compensation and Disability Conference® & Expo. A journalism/speech graduate of Ohio Wesleyan University, Grover also holds an MBA from Palm Beach Atlantic University.

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