Rousmaniere: Getting Off Opioids

The workers’ comp industry became something of an opioid delivery vehicle for opioids starting in the mid 1990s. Aside from anecdotes and personal narratives of individual clinicians, little was known for years about the effect of opioid prescribing. Actuaries had not said anything about any association between opioids and the more than doubling of average claims costs.

We now learn that early prescribing opioids greatly increases the risk of dependency or addiction. And many injured workers died, though claims executives haven’t revealed how many opioid-related deaths occurred. For America in whole, more than 100,000 Americans died with prescribed opioid involvement since 2000.

It took about ten years for the workers’ compensation industry to fully appreciate the scope of the epidemic. We are in very roughly the fifth year of what will be a successful campaign to contain it.

Regulators and claims payers began around 2010 to introduce a variety of voluntary and mandatory measures to influence opioid prescribing. That they can be effective is indisputable. CompPharma has reported high-single digit decreases in opioid spend year over year for three years. Particularly large declines are registered in states with very different industry approaches on opioids, such as Texas, California and Ohio. The Workers’ Compensation Research Institute reports declines in the utilization rates of prescribe opioids in many states.

But some 75,000 to 100,000 injury disabled workers today have been in opioid treatment for least a year.  (I made this national estimate by extrapolating from the Texas Department of Insurance’s informative pharmacy report, published in 2016.)  How are these workers given a chance to wean off their opioids? How many should be weaned? The anecdotal evidence, never really trustworthy, suggests the great majority of these workers would be better off without opioids.

We don’t know for sure how weaning is managed. The case of Texas is shocking. The state alerted doctors several years in advance that a formulary, first introduced to new claims, was going affect old open (legacy) claims.  Before the effective date, legacy cases showed a big decline in opioid use. On the effective date, a very small percentage of doctors asked for and were granted permission to continue. And the great majority of cases stopped prescribing – cold, with little or no substitution of other drugs, according to records available to the state. Plus, physical medicine, instead of increasing, went down in use. 

If this actually did occur, this “cold turkey” method violates any thoughtful clinician’s approach to weaning.

What did these prescribing doctors know about prescribing opioids and weaning patients off them? Mark Pew and Kimberly Verachio, in a 2014 report on opioid drug tapering.  wrote “80 to 90 percent of physicians in the United States have absolutely no training or education in the use of controlled substances…. the majority of chronic pain patients are in fact managed by primary care prescribers who are often the least prepared to navigate the complexities of tapering chronic pain medications.”

Steven Feinberg MD, of the Feinberg Medical Group in Palo Alto, wrote me that “In general, it is unconscionable to abruptly withdraw opioids and weaning is recommended.

The majority though do go through withdrawal and for the most part, survive it and just stay off their opioids. Some turn to illicit street drugs. Some turn to marijuana. Some get their opioids through their private non-workers’ compensation doctor. Some increased her use of tobacco products. For the most part, most injured workers are better off opioids, [though] there are lots of exceptions.”

The first report of a trial of tapering methods was published only last year. The authors, a team at the University of Washington, which has been in the forefront of opioid research for injured workers, took three years just to assemble enough patients for a trial.  They reported that the patients placed in a more intensive tapering program had much better outcomes, as reflected in their improved – but not eliminated – pain experience.

One of our industry’s most available resources to influence opioid use is the nurse case manager. I asked Genex how their case managers help workers wean. The firm told me that its staff or a client does a pharmacist or peer physician review of drug use and prescriber’s treatment plan. It might recommend modifying the plan. If the prescribing doctor does not agree with the recommendation, or does not follow through with it, Genex may arrange for one of its nurse case managers to visit the doctor onsite, as part of a medication safety program.

Genex reports that for 57% of the visits, some kind of actual modification results. This can be, for example, lowering the morphine equivalent dose over time, reducing or eliminating one or more narcotics, conversion to generic, and use of supportive therapies, such as physical therapy, aquatic therapy, cognitive behavior training, home exercise, home stretching program, biofeedback therapy, or work hardening.  

Since Genex’s onsite visit program happens after a failed effort to influence prescribing, I asked how the firm gets these results. Genex tells me that the physical presence of a nurse in the prescribing doctor’s office makes a positive impact.  

Getting a nurse into the prescribing doctor’s office requires approval by a claims adjuster. How interested are claims adjusters in promoting weaning? Not as much as they should, according to a few informed people with whom I’ve spoken. How can case managers become more engaged in weaning, as they may be a valuable resource the claims community can use to bring tens of thousands off opioids?

About the Author

Peter Rousmaniere is widely known throughout the workers’ compensation industry, both for his writing and consulting experience. Based in the picture perfect New England town of Woodstock, VT, he is a regular on the conference circuit, and is deeply in tune with trends and developments within the industry. His passion is writing and presenting on issues largely related to immigration, and he maintains a blog on the subject at www.workingimmigrants.com.

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