Tag Archives: addiction

The True Face of Opioid Addiction

It’s likely that when people hear about the growing opioid addiction problem in America, the face that comes to mind is the one commonly shown on TV and in the movies, which is a very broad generalization : the young, strung-out heroin addict living on the streets. Or dying of an overdose.

Heroin abuse is definitely a growing problem in America. But it’s not the only opioid-related issue we’re facing. In 2012, an estimated 2.1 million people were suffering from substance abuse disorders from prescription opioid use, and deaths from accidental overdoses of prescription pain relievers quadrupled between 1999 and 2015. Sales of prescription opioids also quadrupled during this period.

While prescription pain killers are often seen as a gateway drug to heroin among the young, the issue is much broader than just one demographic group. The reality is that the face of opioid addiction could be the soccer mom down the block who has been experiencing back pain. It could be the marathon runner who is trying to come back after knee surgery. It could be your grandmother baking cookies as she works on recovering from hip replacement surgery.

In fact, it could be anyone. And that diversity is what has made prescription opioid addiction so difficult to manage.

Drivers of addiction

What is driving this explosive growth of such a potentially dangerous substance? Part of it, quite frankly, has been the incredible improvements in healthcare over the last 20-some years. Hip replacements, knee replacements, spinal surgery and other procedures that were once rare are now fairly common. More surgeries mean more patients who need pain relievers to help them with recovery.

The greater focus on patient satisfaction, especially as the healthcare industry shifts from fee-for-service to value-based care, has also had some unintended consequences. Physicians concerned about patient feedback from Healthcare Effectiveness Data and Information Set (HEDIS) measures or Medicare Star ratings have additional incentive to ensure patients leave the hospital pain-free. Physicians may prescribe opioids, particularly if patients request them, rather than relying on less addictive forms of pain management.

See also: In Opioid Guidelines We Trust?  

Here’s how that translates to real numbers. An analysis of 800,000 Medicaid patients in a reasonably affluent state showed that 10,000 of them were taking a medication used to wean patients off a dependency on opiates. This particular medication is very expensive and difficult to obtain – physicians need a specific certification to prescribe it. So it is safe to assume that the actual number of patients using prescription opiates is two to three times higher.

Those numbers aren’t always obvious, however, because the prescriptions may be obscured under diagnoses for other conditions such as depression. Indeed, more than half of uninsured nonelderly adults with opioid addiction had a mental illness in the prior year and more than 20% had a serious mental illness, such as depression, bipolar disorder or schizophrenia, according to the Kaiser Family Foundation. The result is that, without sophisticated behavioral analytics, it can be difficult to determine all the patients who are addicted to opioids. And what you don’t know can have a significant impact on care, costs and risk.

Complications, risk, and prioritization

Opioid addiction tends to interfere with the treatment of other concerns, especially chronic conditions such as depression, congestive heart failure, blindness/eye impairment and diabetes. As a result, physicians must first take care of the addiction before they can effectively treat these other conditions.

That is what makes identifying patients with an addiction, and prioritizing their care, so critical. Failure to do so can be devastating, not just clinically but financially – especially as healthcare organizations take on more risk in the shift to value-based care.

Take two patients with an opioid addiction who are on a withdrawal medication. Patient A also has eye impairment while Patient B is a diabetic. If the baseline for cost is 1, analytics have shown that Patient A will typically have a risk factor of 1.5 times the norm while Patient B, the diabetic, will have a risk factor of 5 times.

Under value-based care, especially an Accountable Care Organization (ACO) where the payment is fixed, the organization can lose a significant amount of money on patients who are costing five times the contracted amount. For example, if the per member per month (PMPM) reimbursement for the year is $2,000, this patient — who is using this medication for withdrawal from an opiate dependency and is a diabetic — will end up costing $10,000.

It is easy to see why that is unsustainable, especially when multiplied across hundreds or thousands of patients. Yet the underlying reason for failure to treat the diabetes effectively – the opioid addiction – may not be obvious.

Healthcare organizations that can use behavioral analytics to uncover patients with hidden opioid dependencies, including those on withdrawal medications, will know they need to address the addiction first, removing it as a barrier to treating other chronic conditions. That will make patients more receptive to managing conditions such as diabetes, helping lower the total cost of care.

They can also use the analytics to demonstrate to funding sources why they need more money to manage these higher-risk patients successfully. They can demonstrate why an investment in treating the addiction first will pay dividends in the long term with a variety of chronic conditions.

See also: How to Attack the Opioid Crisis  

Many faces

It’s easy to see that opioid abuse in all forms has reached epidemic levels within the U.S. What is not so easy to see at face value is who the addicts are — or could be.

Despite popular media images, the reality is that opioid addition in America has many faces. Some of them may be closer to us than we think. Behavioral analytics can help us identify with much greater clarity who the likely candidates are so we can reverse the trend more effectively.

Opioids: A Stumbling Block to WC Outcomes

On a weekly if not daily basis, there are media reports about the growing impacts of addiction to opioids. The Centers for Disease Control and Prevention (CDC) reports that 78 people a day are dying from the effects of opioid overdose. Families are being systematically destroyed by the multiplicity of effects of this increasingly pervasive problem. In 2014, there were more than 47,000 drug overdose deaths in the U.S., and more than 28,000 of those deaths were caused by opioids (including heroin). The current overdose epidemic is unfortunately only one symptom of a greater problem in the U.S. Our nation consumes 80% of all opioids produced in the world, yet the American population makes up only 5% of the total world population. This strongly implies there is a societal, cultural profile in America that is unlike anywhere in the world, driving such demand and overuse.

As the national “epidemic” of opioid abuse continues to get increasing attention, it’s important to realize the effect it has on employers. Prescription opioid abuse alone cost employers more than $25 billion in 2007. Even if the injured worker never develops an opioid misuse disorder, long-term opioid use is still extremely problematic. The evidence tells us that the effectiveness of chronic opioid therapy to address pain is modest and that effect on function is minimal. In addition, when injured workers are prescribed opioids long-term, the length of the claim increases dramatically and even more so when other addictive medications like benzodiazepines (alprazolam, lorazepam) are prescribed. Perhaps the most troubling statistic of all: 60% of injured workers on opioids 90 days post-injury will still be on opioids at five years.

See also: Potential Key to Tackling Opioid Issues

Workers’ compensation stakeholders are increasing efforts to call more attention to the use of these potent pain-relieving drugs by injured workers. In the highly complex and diverse field of workers’ compensation, entities from state governments to insurers and other workers’ compensation stakeholders are stepping up to address the issues and impacts of opioid use by injured workers in varying degrees through a myriad of methods.

Most work-related injuries involve the musculoskeletal system, and doctors increasingly prescribe short- and long-term opioids to address even minor to modest pain despite broad medical recommendations against long-term use. Because of the prevalence of back injuries in the workplace, opioids are increasingly becoming the treatment of choice for what often starts as a short-term treatment, but frequently becomes long-term, with the likelihood of addiction occurring before treatment is completed.

Claims professionals should understand that there are many variations of opioids, including fentanyl; morphine; codeine; hydrocodone (Vicodin, Lortab); methadone; oxycodone, (Percocet, OxyContin); hydromorphone (Dilaudid) – each with different levels of potency. For example, fentanyl is 50 to 100 times more potent than heroin. No wonder addiction is so often the result.

Paul Peak, PharmD, assistant vice president of clinical pharmacy at Sedgwick, notes that opioids act on receptors in the brain; therefore, it’s expected that certain changes will occur over time as use continues. Each one of us would realize both opioid dependence (this means withdrawal symptoms occur when the drug is stopped) and opioid tolerance (this means more drug is needed to get the same effect as use continues) if we were to take opioids consistently for weeks or months. In many cases, patients who are prescribed opioids chronically will experience a worsening of pain that is actually caused by the opioids themselves.

Because opioids have these profound effects on our brains, engaging injured workers in their own recovery is a best-claim practice, and it is critical to achieving the best outcomes. This should begin early, and a key part of the process includes encouraging workers to ask their doctors questions when they are being treated with drugs for pain. Some of these questions should include:

  • Is this prescription for pain medicine an opioid?

Doctors should educate patients on what an opioid is and how to use it safely to relieve pain.

  • What are some of the potential adverse effects of opioids?

Opioids can affect breathing and should be used with great caution in patients with respiratory issues. They most often cause moderate to severe constipation. Even short-term use can decrease sleep quality and impair one’s ability while driving.

  • Where can I safely dispose of remaining pills?

To protect others from potential misuse, any excess supply should not be saved for later use. Injured workers should be advised not to give them to friends or family, and to dispose of unused pills appropriately. States often provide disposal options/locations for opioids to reduce the chance of leftovers getting into the hands of unintended users. In addition, CDC guidelines now recommend patients are only given a three-day or seven-day supply of opioids, and some states are now putting laws in place following this recommendation.

  • Am I at risk for abuse?

Providers can use risk assessments to help determine those people at greatest risk for abusing opioids if prescribed. Peak notes that opioids do have some benefit in the acute phase post-injury, say within four to six weeks after injury. However, when improvement doesn’t occur in this time frame, continuing use of opioids is not appropriate, as addiction becomes increasingly assured.

These are among the key questions for treating physicians that injured workers should ask. While engagement is a vital part of patient accountability, physician education is even more critical. Peak explains that more is expected of doctors because they are providing the care. Patients and physicians working together in a close relationship is key.

Injured workers and family members should talk to the treating physician immediately if they see signs of addiction or dependence. There are some possible warning signs of addiction, such as craving the pain pills without pain or when pain is less severe, requesting early refills or stockpiling medication, taking more pills at one time or taking them more often than prescribed, or going to multiple prescribers for opioids or other controlled substances. Early detection can help stop the destructive cycle of addiction before it becomes too powerful to resist. Injured workers can also contact an addiction counseling organization.

A note of caution for all whose accountabilities touch this area of treatment – terminating prescription opioids “cold turkey” can be dangerous and even fatal. Throughout the life of the claim and at the end of the day for injured workers using opioids, the relationship with their doctors will be the primary factor in determining how the treatment will end and the outcome that is achieved.

Strategies for the claims team

So where does all this leave claims professionals who want to see injured workers recover successfully and appropriately from their workplace injuries?

See also: Opioids Are the Opiates of the Masses  

Claims professionals must define a strategy for identifying and then monitoring physician prescribing patterns and the specific use patterns in each case. Some of the tactics that should be considered include:

  • Leveraging pharmacy utilization review services
  • Directing patients to doctors who won’t overprescribe opioids; and those who use prescription drug monitoring programs and tools, which are available in most states
  • Engaging nurse case managers early and regularly; their involvement and intervention can help deter addiction; nurses can advocate for other more clinically appropriate options and advocate for best practices including risk assessments, opioid contracts, pill counts and random drug screens
  • Ensuring that injured workers are getting prescriptions through pharmacy benefit management networks
  • Leveraging fraud and investigative resources that are often useful in uncovering underlying, unrelated patterns of behavior that would indicate a propensity for opioid abuse
  • Considering the cost of opioids versus alternatives; while many alternate treatments are more expensive on the front end, certain drugs may be much more expensive in the long term, especially if they lead to addiction
  • Addressing the opioid issue well before case settlement; as with most longer-term open claims scenarios, those with opioid use will only produce worse outcomes and get more expensive over time without appropriate early interventions

Continued vigilance by claims professionals can enable and facilitate a better result at closure and avoid a lot of potential pain for the injured worker along the recovery path.

Opioids Are the Opiates of the Masses

One day in 2014, before most people could even spell “opioids” (two “i’s), the CEO of a company named Healthentic asked me to review a white paper based on the output of its new analytics tool. Healthentic’s tool is far more focused on the “80” of the “80-20” rule than competing tools are. So, rather than drowning readers in data, the tool is supposed to help certain figures jump off the pages and lead to action.

As my role in life appears to be the thankless task of finding errors in other people’s work, I was pleasantly surprised that Healthentic called me to plausibility-check the tool early in the process, rather than disseminate it and wait for me to publish “highlights” of my analysis after the fact, as I am wont to do.

As usual, I noticed some highly suspect information. In this case, it was prescriptions for Tramadol, Oxycontin and Hydrocodone. With my usual charm, grace and humility, I said: “These figures can’t possibly be right. This isn’t an NFL team in constant pain. If these figures were correct, it would mean that 40% of their employees filled a prescription for a synthetic opioid in a single year.” We rechecked the figure and the raw data several times. And yet the original statistic refused to bend. It was accurate.

See also: Paging Dr. Evil: The War Over Opioids

Ironically, the particular Healthentic customer profiled in the white paper was obsessed with employee health. Its staff could recite how many employees had high blood pressure or high cholesterol, participated in the “steps challenge” or the “biggest loser contest” or didn’t buckle their seat belts. But opiates and synthetic opioids — the elephant in the room capable of magnitudes more damage to employee health and productivity than any of the wellness vendor siren songs — had been completely overlooked.

In the days that followed, we talked through four possible scenarios and ruled out three:

  1. Employees were being injured due to safety hazards and accidents — but the company’s OSHA reports were clean and, in any event, those prescriptions would have shown up in workers’ compensation, not group benefits;
  2. Certain local doctors were prescribing way too many of these pills — but the prescriptions seemed to be coming from many different doctors;
  3. Employees were reselling their prescription meds — but if that were the case they’d have enough sense not to purchase these pills through the PBM;
  4. A sizable number of employees were at-risk or already addicted to opiates.

It was definitely the last. Little did we know this was the leading edge of the belatedly discovered synthetic opioid epidemic.

Healthentic analysis consistently finds that opioids are some of the most prescribed drugs for all employers. “Take two aspirin and call me in the morning” has become: “Take some Oxy and text me in the morning.” It wasn’t hard for a person with a few dental or medical procedures to have several months’ supply of the drug.

Pain is no laughing matter. It is human nature to ease suffering. But the cost and consequences of treating chronic pain so freely with opioids is shockingly high. Not a week goes by without more national news being made on the topic, such as Prince’s death. Of course it isn’t just famous people who are susceptible. Opioids — synthetically designed cousins of heroin — are so addictive there’s a Super Bowl commercial for another drug to treat constipation from chronic use. Obviously a market has to be quite sizable to merit a Super Bowl ad.

See also: Progress on Opioids — but Now Heroin?

The good news is that it doesn’t have to be this way. Pursuing early detection of a large supply of opioids and putting treatment goals in place will help a great deal in avoiding chronic use and addiction. Employers can help to head off chronic use before it turns into addiction. Independent analysis of your data should identify the three key risk factors for this population:

  1. a 45-day or greater supply;
  2. 10 or more prescription refills; or
  3. overlapping synthetic opioid and benzodiazepine prescriptions.

As brokers and employers, you can flag this population to the medical carriers and providers. You yourselves won’t be aware who is at risk, in conformance with the new CDC guidelines.

I emphasize the word “independent” because of how far behind the curve the payers are. One insurance carrier told an employer not to worry about the 150 people Healthentic had tagged for being at risk for chronic opioid use. “We know about these people. They are in our medication compliance program. Most are on palliative care.” That would be an obvious whopper even if these employees had worked at Chernobyl, and a quick analysis confirmed there wasn’t a single palliative care referral in the group.

Employers’ obsession with wellness, and carriers’ unwillingness to run the data, is great for my business, and for Healthentic’s. Unfortunately, it is not so great for employees at risk for opioid addiction. The only good news is that at least they won’t be constipated.

Progress on Opioids — but Now Heroin?

You’ve probably noticed recent reports, within the workers’ comp pharmacy benefits manager (PBM) industry and elsewhere, that prescription opioid use and overdoses are on the decline. It is a long journey, and we cannot yet see the destination, but progress is being made. One of the goals has been to make it more difficult to secure clinically inappropriate prescription opioids through legitimate (physician, dentist) and illegitimate (pill mills, street sales) means. Abuse deterrent formulations have also helped, creating a hassle factor for those who want to abuse them. The increase in focus on the subject in the media and government has made it more top-of-mind. Although even one death or the creation of one addict is too many, and we have lots of cleanup to do today on the damage already done to individuals and communities, the trends are heartening.

However, for every intended consequence, there are also unpredictable unintended consequences. And one of those that I’ve been following for some time, that two recent clinical studies have codified as accurate, is the dramatic increase in the abuse and misuse of heroin. A good amount of that increase is theorized to be coming from those who may have become addicted or highly dependent upon the euphoric effect or dulling of the pain from opioids. Because today’s heroin is “pharma quality” and less expensive than opioids on the street, heroin has become the primary alternative choice. If you think this is a recent issue, this USA Today article titled “OxyContin a gateway to heroin for upper-income addicts” was my initial warning, on June 28, 2013.

The reasons for this switch are multiple and complicated. An excellent article on this issue was published in the June 2015 edition of “Pain Medicine News.”

Three quotes that struck me the most:

  • “Fewer than 20% of chronic pain patients benefit from opioids.”
  • “The prolific normalization of opioid use for chronic pain within primary care has seeded the epidemic of heroin addiction.”
  • “We are going to see the biggest explosion of heroin addiction ever in the next five years.”

Obviously, heroin is an illegal drug and therefore cannot be tracked or managed within a PBM. But everyone needs to be watching. While heroin use may not be a “workers’ comp problem,” it is a societal problem, which ultimately always rebounds as an issue for everyone (and everything) else.

The CDC just published (or at least publicized on Twitter) a “Vital Signs” report specifically on the subject. This should be required reading for everyone concerned with the epidemic of substance abuse in the U.S. Note that I said “substance abuse,” because as has been clearly stated the issue is not specific to prescription drugs or heroin or cocaine or alcohol binge drinking — it is a cultural issue of people either wanting to have a good time or just to check out from life or pain. According to this CDC report, more than 8,200 people died from heroin overdoses in 2013. When you add that to the more than 175,000 people who have died from prescription drug overdoses since 1999, the people affected is staggering. Not just those who lost their lives, but friends and family left behind and communities (and, in some cases, employers) dealing with the aftermath.

While there is a treasure trove of information included in the CDC’s report, the most important point for me (given my focus since 2003) was the advice to states:

  • Address the strongest risk factor for heroin addiction: addiction to prescription opioid painkillers

If you still don’t believe that opioid use and the abuse of heroin (and other drugs) are related, you just aren’t paying attention. Or you don’t want to connect the dots. I will let the CDC prove my point …

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The use of heroin is no respecter of income level, age, gender, education or geographic location. However, the CDC did outline those most at risk for use:

  • People who are addicted to prescription opioid painkillers
  • People who are addicted to cocaine
  • People without insurance or enrolled in Medicaid
  • Non-Hispanic whites
  • Males
  • People who are addicted to marijuana and alcohol
  • People living in a large metropolitan area
  • 18- to 25-year-olds

Do yourself a favor. Take 10 minutes and read the report from the CDC. It will only be wasted time if the information does not influence you to action.

‘Un-Healthcare’ Work Deserves Focus

Some, like me, who have dedicated their lives to the maintenance and improvement of physical and mental health, may not consider themselves traditional, clinical “healthcare workers.” We may feel as if we work on the fringe, on the outside. We are not nurses or physicians. We work in public health, wellness, nutrition, occupational safety, health economics, fitness, risk management, pharmacy, laboratory, research, insurance and other similar non-traditional clinical professions. We may feel we make a lesser impact on patient care and overall community wellness and vitality. Given historical reference, however, this is absolutely untrue.

The term “healthcare” (whether one word or two) has not been used at all in books, papers, references or published text over hundreds of years, until the mid-1980s. But since the late 1700s, those of us “living on the fringes” have been healthcare workers in the true sense of the practice.

We may not provide bedside patient care in a healthcare or hospital setting, but we do:

  • Prevent infectious disease by promoting the use of vaccines;
  • Protect the public from pathogenic organisms through water and food sanitation;
  • Prevent addiction and antibiotic resistance through pharmaceutical stewardship;
  • Manage repercussions from post-traumatic stress with mental health interventions;
  • Research global disease trends to stop them in their tracks;
  • Manage risk by improving safety, security and improving quality;
  • Decrease work-related injury and illness by creating safe workplaces, and
  • Prevent heart disease and weight-related cancers by promoting regular exercise.

Those efforts ensure that a population’s health (both physical and mental) does not suffer, that it is either maintained or, better yet, improved. We are the “Un-Healthcare Workers.”

It is especially important that traditional healthcare organizations and healthcare workers know this now. As healthcare systems around the world are caring for patients with emerging infectious diseases like Ebola and re-emerging vaccine-preventable diseases like measles, they need to consider that we un-healthcare workers have responsibility for protecting our communities. If we can prevent diseases from becoming epidemic in our communities, healthcare providers working in healthcare settings like hospitals can focus more on providing needed care to those with emergent injuries and chronic disease.

The American Public Health Association (APHA), which has represented people protecting the public since 1872, announced a policy in November on preventing Ebola and “globally emerging infectious disease threats” that marked a significant change in the recognition of the “un-healthcare worker.” The APHA identified the need to focus efforts on preventing infectious disease in the community and workplaces as a means to protect healthcare systems from exposure to diseases that may change the overall landscape of inpatient care. In the process, the APHA advocates for the role that we “un-healthcare workers” have in maintaining and improving the physical and mental health of our population so that healthcare workers can focus on medical interventions for those who really need it.

Sound, science-based public policy and fiscally grounded public health funding can do what it did for the hundreds of years prior to the mid-1980s; it can protect our communities from disease, so that we can protect the vitality of our healthcare systems.