Tag Archives: opioid epidemic

In Opioid Guidelines We Trust?

A common recommendation to combat the current opioid epidemic is to provide physicians with opioid prescribing guidelines. Opioid guidelines synthesize the available research to inform judicious prescribing behaviors and safe dosages when opioids are needed. Given the seriousness of the opioid epidemic, it is not surprising that multiple organizations currently produce opioid prescribing guidelines. Opioid guidelines are based on evaluations of the research, but the guidelines themselves need to be evaluated critically, as well.

Guideline Evaluation

Fortunately, there are multiple standards currently available to evaluate guidelines, including AGREE (Appraisal of Guidelines, Research and Evaluation), IOM (Institute of Medicine), GRADE (Grading of Recommendations Assessment, Development and Evaluation) and AMSTAR (A Measurement Tool to Assess Systematic Reviews). For example, the AGREE consortium’s latest standard (AGREE II) provides a 23-point checklist covering six domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability and editorial independence. While some AGREE II domains are obvious criteria including “rigor of development” and “editorial independence,” other domains such as “applicability” are less obvious but important.

See also: Who’s Going to Pay for the Opioid Crisis?  

For example, one part of “applicability” is about providing advice or tools for translating recommendations into practice. This point is important considering opioid prescribing guidelines will only work if practitioners can integrate use of the guidelines into their workflow and can apply them effectively to the appropriate individuals. Most chronic opioid users’ first exposure to opioids is through a physician’s prescription, and physicians’ opioid-prescribing patterns have been shown to be associated with opioid abuse and deaths. Therefore, preventing unnecessary first exposure to opioids is crucial.

Guideline standards have shown that not all opioid treatment guidelines are of equal quality. For example, Nuckols et al. (2014) assessed 13 opioid guidelines using the AGREE II and AMSTAR instruments. The authors found AGREE II scores ranged from 3.00 to 6.20 on a 1 to 7 scale, and AMSTAR ratings ranged from poor to high. Four of the guidelines were “recommended against using … because of limited confidence in development methods, lack of evidence summaries or concerns about readability.” This research proves that the quality of opioid guidelines does vary.

The National Guidelines Clearinghouse (www.guideline.gov) is a publicly available resource that provides summaries of guidelines that comply with IOM standards. Although not all guidelines are available free on the National Guidelines Clearinghouse website, it could be a good starting point for finding organizations with guidelines that adhere to a guideline standard.

Jim Smith’s Story

Jim Smith’s occupational injury provides a useful example of how being prescribed opioids contrary to high-quality treatment recommendations may lead to serious health and economic consequences. Jim is a 38-year-old construction worker who suffered an extremely painful lower back strain while attempting to lift a heavy box. Against most guidelines’ recommendations, he was treated from the start with a long-acting opioid, on which he became first dependent and then addicted, taking increasingly higher doses. Even on doses exceeding most guidelines’ recommendations, Jim still suffered from pain and limited mobility. In addition, he began to require supplemental medication to treat the side effects of his opioid use, such as constipation. He subsequently underwent surgery on his lumbar spine, which did not provide him relief from his pain, and he ended up a chronic user of opioids, permanently disabled and housebound.

If Jim had been treated according to any of the current, high-quality opioid treatment guidelines, he would not have received a prescription for an opioid as an initial measure. He would have been counseled to try over-the-counter medications such as ibuprofen or acetaminophen, sent to physical therapy, prescribed exercise and perhaps offered a course in cognitive behavioral therapy (CBT). If opioids had been truly necessary in the acute phase of Jim’s injury, he would have been prescribed a limited course and then been gradually tapered off.

See also: 3 Perspectives on Opioid Crisis in WC  

Conclusion

It is very important to find guidelines that both reduce initial use of opioids and serve to guide the physician in tapering chronic opioid users off these drugs. For someone who has been on opioids for a long time, the tapering process could take many months or years, and there could be both physical and psychological complications during the taper. The process for weaning someone off chronic opioid usage will be discussed in the next article in this series.

In conclusion, users of treatment guidelines put a lot of trust into the recommendations provided. Using only opioid treatment guidelines with sound quality and content helps keep that vital trust so clinicians can continue to use guidelines in combating the prescription opioid epidemic.

If It Walks Like a Duck, Talks Like a Duck…

Everyone is talking about the dangers of “opioid addiction.” It’s been a topic of conversation among pain management specialists, chiropractors and other healthcare providers for years, but constant news coverage of “opioids” has made it water-cooler talk. Thanks to the media, we’re all experts on the issue.

But here’s the thing: the media – and the public – are missing the point entirely. Even the expression “opioid addiction” is completely off the mark. Because we’re not talking about “opioids” – we’re talking about addiction to heroin derivatives.

“Opioid” is a much safer word than heroin – not nearly as hair-raising or dangerous. But using the word “opioid” is like putting icing on a mud pie – it’s a cover-up at best. And when you make the connection that opioids are actually heroin derivatives, you understand why the addiction has become an epidemic in this country.

The problem, though, is much more sinister than we realize. For one, patients now expect their doctors to prescribe morphine or oxycodone for pain management. Second, there’s money to be made in “opioid addiction.”

See also: Opioids Are the Opiates of the Masses  

As reported in Risk & Insurance, a new study finds that a majority of patients still believe opioids are the most effective remedy for pain. In fact, a full two-thirds of physicians surveyed said their patients expect them to prescribe drugs. And in spite of the highly addictive nature of these drugs, doctors are still influenced by their patients’ expectations.

It gets worse. Despite evidence that oxycodone and morphine are not the most effective medications for pain relief, almost all of the physicians who were surveyed – 98 percent of them – prescribe some form of opioids for pain control. What’s more, the National Safety Council reports that 99 percent of the providers prescribe opioids for longer than the three-day course of treatment the Centers for Disease Control recommends.

Here’s the icing on this mud pie: nearly 90 percent of physicians say they find it difficult to refer patients to treatment for drug abuse or addiction, even when it’s clear their patients need help. It’s a vicious cycle with no easy solution.

Like almost everything in healthcare, we’re overlooking the most important part of the story.

The same doctor who prescribes opioids that lead to addiction can make his best money on the mandatory drug/toxicology testing he performs every month. Many good doctors recognize this as a conflict of interest – they also see that their patients are requiring higher and higher doses to feed their additions – and they intervene in the best interests of their patients. Unfortunately, there are plenty of other physicians who aren’t concerned about scruples. They are perfectly willing to pick up where others leave off. It has become a lucrative, albeit perverse, business model today.

I wish that were the end of it, but we’ve only scratched the surface. The story gets much worse from here. When patients no longer can afford opioids and drug testing (which can cost them $4,000-$10,000 each year), many have resorted to selling a couple of pills on the street in order to cover their costs. In essence, decent, respectable people become law-breaking drug dealers. Some people don’t want to sell their prescription drugs, but still must feed their addiction. Broke and desperate, they buy a cheap, street version of their opioid. This is called heroin.

It’s a trap, and it’s snaring people who never realized they were abusing heroin derivatives. They believed they were treating their pain with safe, physician-recommended oxycodone or morphine. They believe it was their best option for managing their symptoms.

Heroin derivatives are ruining the lives of good, hardworking people across the country. In recent months, I saw the horror firsthand when heroin overdoses stole the lives of two young men in my community – men with their whole lives in front of them. They weren’t your stereotypical druggies – they were addicted to pain meds.

See also: How to Help Reverse the Opioid Epidemic  

I believe addiction to heroin derivatives is far worse than anyone realizes. Someone must throw a wrench in a problem that’s wreaking havoc on families and entire communities. Here’s how Redirect Health is addressing the issue:

1. Strike “opioids” from the discourse: Never call these highly addictive prescriptions “opioids” or “pain killers.” Instead, call them “heroin derivatives,” because if it walks like a duck and it talks like a duck…

Far fewer people will want to start taking these drugs if they understand they’re a form of heroin. Simply changing the semantics will also give providers pause; they won’t be so quick to prescribe heroin derivatives.

2. Provide alternative forms of pain relief: We make it easy and affordable ($0 copays) for people to access other, safer and more effective pain management services. Our chiropractors and primary care physicians work together to help members with practical and customized virtual rehabilitation programs that don’t cost a penny out-of-pocket, don’t require them to miss work, and will provide a long-term, tenable solution to managing their pain.

It’s common sense, but not commonly done.

Workers’ Comp Issues to Watch in 2015

Tis the season for reflections on the past and predictions for the future. As we kick off 2015, here are my thoughts on the workers’ compensation issues to watch this year.

What Does TRIA’s Non-Renewal Mean for Workers’ Compensation?

Thanks to congressional inaction, a last-minute rewrite added this subject to the issues for this year. I’m not about to predict what Congress will do with TRIA legislation in 2015, as there are no sure things in the legislative process. We have already seen the reaction from the marketplace. Back in February 2014, carriers started issuing policies that contemplated coverage without the TRIA backstops. We saw some carriers pull back from certain geographic locations, and we also saw some carriers change the terms of their policies and only bind coverage through the end of the year, giving themselves the flexibility to renegotiate terms or terminate coverage if TRIA wasn’t renewed. But while some carriers pulled back in certain locations, others stepped up to take their place. While some carriers tied their policy expiration to the expiration of TRIA, other carriers did not.  Going forward, some employers may see fewer carrier choices and higher prices without the TRIA backstop, but ultimately most employers will still be able to obtain workers’ compensation coverage in the private marketplace. Those that cannot will have to turn to the State Fund or assigned risk pool.

Rising Generic Drug Prices

The opioid epidemic, physician dispensing and the increased use of compound drugs are issues the industry has faced for years. While these issues continue to be a problem, I want to focus on something that is getting less attention. Have you noticed that the costs for generic prescription drugs are increasing, sometimes significantly? In the past, the focus was on substituting generic drugs for brand names, which provided the same therapeutic benefit at a fraction of the costs.  But now the rising costs of these generic medications will drive costs in 2015. These price increases are being investigated by the Federal Drug Administration (FDA) and Congress, but I do not expect this trend to change soon.

Medical Treatment Guidelines

Another issue to watch on the medical side is the continued development of medical treatment guidelines and drug formularies in states around the country. This is a very positive trend and one that our industry should be pushing for. There is no reason that the same diagnosis under workers’ comp should result in more treatment and longer disability than the same condition under group health. One troubling issue that I see here is the politics that come into play. Sorry, but I do not accept that human anatomy is different in California or Florida than in other states. I feel the focus should be on adopting universally accepted treatment guidelines, such as Official Disability Guidelines, or “ODG,” rather than trying to develop state-specific guides. The ODG have been developed by leading experts and are updated frequently. State-based guidelines often are influenced by politics instead of evidence-based medicine, and they are usually not updated in a timely manner.

How Advances in Medical Treatment Can Increase Workers’ Comp Costs

There is one area in which advances in medicine are actually having an adverse impact on workers’ compensation costs, and that is in the area of catastrophic injury claims. Specifically, I’m referring to things such as brain injuries, spinal cord injuries and severe burns. Back in 1995, Christopher Reeve suffered a spinal cord injury that left him a quadriplegic. He received the best care money could buy from experts around the world, and he died less than 10 years after his injury.  But as medicine advances, we are now seeing that a quadriplegic can live close to normal life expectancy if complications can be avoided. Injuries that used to be fatal are now survivable. That’s great news. The downside for those paying the bills is that surviving these injuries is very costly. The cost of catastrophic medical claims used to top off around $5 million, with a $10 million claim being a rarity. Now, that $10 million price tag is becoming more the norm.

The Evolving Healthcare Model

For years, workers’ comp medical networks focused on two things: discount and penetration.  Sign up as many physicians as you can as long as they will agree to accept a discount below fee schedule for their services. I’m happy to say that we are slowly, finally, evolving away from that model. Payers are realizing that a better medical outcome for the injured worker results in lower overall workers’ compensation costs, even if that means paying a little more on a per-visit basis. We are now seeing larger employers developing outcome-based networks, not only for workers’ compensation, but for their group health, as well. Employers are also starting to embrace less traditional approaches such as telemedicine. Finally, more and more employers are recognizing the importance that mental health plays in the overall wellness of their workforce. In the end, we are slowly starting to see is a wellness revolution.

The Need for Integrated Disability Management

The evolving healthcare model is tied directly to an evolving viewpoint on disability management. More employers are realizing the importance of managing all disability, not just that associated with workers’ compensation claims. Employees are a valued asset to the company, and their absence, for any reason, decreases productivity and increases costs. I feel this integrated disability management model is the future of claims administration. Employers who retain risk on the workers’ comp side usually do the same thing with non-occupational disability. These employers are looking for third-party administrators (TPAs) that can manage their integrated disability management programs. And make no mistake: Having an integrated disability management program is essential for employers. Human resource issues such as the Americans With Disabilities Act (ADA) and the Family and Medical Leave Act (FMLA) cross over into the workers’ compensation realm. The same interactive process required on non-occupational disability is required in workers’ compensation. Employers must be consistent with how they handle any type of disability management, regardless of whether the cause is a workers’ compensation injury or non-occupational.

Will We See a Push for ‘Opt Out’ in Other States?

Most people know that non-subscription, or opt out, has been allowed in Texas for many years. The Oklahoma Option that started last year is viewed as a much more exportable version of opt out. Under this system, employers can opt out of workers’ compensation, but they must replace it with a benefit plan that provides the same (or better) benefits available under traditional workers’ compensation. While some view the Oklahoma Option as the start of an opt-out revolution, it is just too early to tell what impact it will ultimately have. But, make no mistake, discussions about opting out are spreading to other states. A group called the Association for Responsible Alternatives to Workers’ Compensation is currently investigating the possibility of bringing opt out to other states. I expect to see opt-out legislation in a handful of other states in the next three to five years.

Marijuana

Marijuana legislation is a very hot topic these days.  In national polls, the majority of Americans favors legalization of marijuana in some form.  Recreational use of marijuana is now legal in four states (Colorado, Washington, Oregon and Alaska), and 23 states allow medical marijuana. When it comes to workers’ compensation, much of the attention has been focused on medical marijuana as a treatment option for workers’ comp because a judge in New Mexico allowed this last year. My concern is around employment practices. Employment policies around marijuana have been centered on the fact that it is illegal, so any trace in the system is unacceptable. That is going to change. I fully expect the government to reclassify marijuana from Schedule I to Schedule II in the next few years. When that happens, zero-tolerance policies in the workplace will no longer be valid. Instead, the focus will have to be like it currently is with alcohol: whether the person is impaired.

The Next Pandemic

Another hot topic these days is Ebola. While the threat from this particular disease seems to be subsiding, the concerns about Ebola last year showed we are not ready for that next pandemic. People who were exposed to the disease were allowed to interact with the general population and even use commercial travel. Government agencies debated whether travel to certain countries should be limited. The problem is, diseases don’t wait for a bureaucracy to make decisions. While this threat didn’t materialize, you can see how easily it could have. With work forces that travel around the globe, the threat of a global pandemic is very real. You know where you send your workers as part of their job, but do you know where they go on vacation? As an employer, are you allowed to ask about what employees do during their personal time? Are you allowed to quarantine an employee who traveled to an infected country during vacation? These are very complex legal questions that I cannot answer, but these are discussions we need to be having. How do we protect our employees from the next pandemic?

Rates and Market Cycle

You cannot have a discussion around issues to watch without talking about insurance premium rates in workers’ compensation. After several years of increasing rates around the country, the National Council on Compensation Insurance (NCCI) is projecting that, in 2014, workers’ compensation combined ratios were below 100% for the first time since 2006. This means that, as an industry, writing workers’ compensation is profitable again. So what should buyers expect in 2015? Well, it depends. California continues to be a very challenging state for workers’ compensation costs. New York is challenging, as well. Given the percentage of the U.S. workforce in those two states, they have significant influence on the entire industry. Some employers will see rate reductions this year, and some will not. In the end, your individual loss experiences will determine what happens with your premiums. That seems to be the one constant when it comes to pricing. Employers with favorable loss experiences get lower rates, so it pays to stay diligent in the areas of loss prevention and claims management.

Will We See More Constitutional Challenges Similar to Padgett in Florida?

While I don’t think the Padgett case will be upheld on appeal, I am concerned that the case is the first of many similar ones we could see around the country. Look at the main arguments in Padgett: The workers’ compensation system is a grand bargain between injured workers and employers. Workers gave up their constitutional right to sue in civil courts in exchange for statutorily guaranteed, no-fault benefits. Over the last 20 years, many workers’ comp reform efforts around the country have focused on lowering employer costs. Standards of compensability have been tightened. Caps have been put on benefits. The judge in Padgett looked at these law changes and ruled that workers’ compensation benefits in Florida had been eroded to the point where it was no longer a grand bargain for injured workers. He ruled that the workers’ compensation statutes were unconstitutional on their merits because the benefits provided are no longer an adequate replacement for the right to sue in civil court that that the workers gave up. Attorneys tend to mimic what succeeds in other courts, so I expect we are going to be seeing more constitutional arguments in the future.

Impact of the Evolving Workforce

One of the biggest issues I see affecting workers’ compensation in 2015 and beyond is the evolving workforce. This takes many forms. First, we are seeing technology replace workers more and more. When was the last time you went to a bank instead of an ATM? I have seen both fast food and sit-down restaurants using ordering kiosks. Also, we are seeing more use of part-time vs. full-time workers. Some of this is driven by concerns around the Affordable Care Act. But part-time workers also have fewer human resource issues, and their use allows employers to easily vary their workforce based on business needs. Unfortunately, part-time workers are also less-trained, which could lead to higher injury frequency. Finally, the mobile work force is also creating concerns around workers’ compensation. Where is the line between work and personal life when you are using a company cell phone, tablet or computer to check e-mails any place, any time? Where do you draw the line for someone who works from home regularly? There have been numerous court cases around the nation trying to determine where that line is. This is a very complex and evolving issue.

To view a webinar that goes into these topics in more detail, click here: https://www.safetynational.com/webinars.html