Tag Archives: opioid

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.

3 Perspectives on Opioid Crisis in WC

Over the past two decades, there has been a dramatic increase in the use of opioids in workers’ compensation. Opioids are being prescribed for many conditions for which they were not originally intended. Efforts have begun across the U.S. to create opioid treatment guidelines, change medical practice patterns and curb the opioid epidemic. While much has been written recently about the unintended consequences of opioid use, such as how they increase pain sensitivity and level of disability and can lead to addiction, there is little information available about the perspectives of the key players in workers’ compensation on the opioid issue.

Mark Pew, a prominent managed care organization’s spokesman, has said, “Using opioids as a crutch really is the wrong thing. What you need to be focusing on is coping with it and managing it like the vast majority of humanity does with chronic pain or just the fact of getting old.” But what do the injured workers, physicians and claims adjusters say? I conducted confidential interviews with members of each of these groups to get the perspectives of those who so far have had less of a voice in the debate.

Physicians

Physicians must balance their desire to control their patients’ pain against the known drawbacks of opioids. One physician told me, “When I was in medical school 20 years ago, we were told that we were undertreating pain. Pain was named ‘the fifth vital sign’ (along with blood pressure, heart rate, respiratory rate and temperature), and we were trained to ask patients about their level of pain on a 10-point scale at every visit. At that time, very little was known about the dangers of long-term opioid use. Now, patients with any kind of pain have come to expect to get that narcotics prescription when they see the doctor.”

See also: How to Attack the Opioid Crisis  

Interestingly, in response to the current opioid crisis, delegates at the 2016 annual meeting of the American Medical Association passed a resolution recommending that pain be removed as the fifth vital sign in professional medical standards. Critics, many of them pain management specialists, say the move “will make it even more difficult for pain sufferers to have their pain properly diagnosed and treated.” However, a 2006 study in the Journal of General Internal Medicine concluded that “routinely measuring pain by the fifth vital sign did not increase the quality of pain management.”

Another physician, a medical director at an insurance carrier, said, “When I see the second opioid prescription come through the system, I start reserving for detox.” She meant the second opioid prescription is an indication to her that there is a high likelihood the injured worker is going to become addicted to the opioids.

Claims Adjusters

Claims adjusters have a unique perspective on the direction a workers’ comp claim takes. They usually speak with both the injured worker and the provider and can influence the process to a certain extent. One claims adjuster said, “I’ve been watching the whole opioid crisis unfold for the last 10 years. We see the opioid prescriptions coming through, and we know that many of them are not indicated by the patient’s condition, but we have limited options for preventing problems. It would be nice if we could identify the providers with good prescribing patterns and direct injured workers to those providers.”

Another claims adjuster told me, “In states with drug formularies, where opioids require prior approval, we are seeing much less opioid use on new claims. Our biggest problems are the older claims where the injured workers have been taking opioids for long periods of time. Then we start to see the prescribing of additional drugs just to treat the side effects of the opioids. The worker is already addicted, is not even getting adequate pain relief anymore, and the claim just goes on and on.”

This claims adjuster thought the best approach to the opioid problem would be to have a claims management system that alerted managers every time a new claim had an opioid prescribed. That way, “we could immediately contact the physician and make sure there was an understanding of the opioid treatment guidelines and a plan in place, right from the start, for weaning the injured worker off the drugs at the appropriate time.”

Injured Workers

In the current climate of awareness about the risks and dangers of opioids, injured workers are often caught in the middle. They must balance their desire for pain control against their growing concerns about side effects and long-term adverse effects. One injured worker said, “I know I’m getting less pain relief than I used to from the pills, but I’m reluctant to tell my physician because I’m afraid of having to deal with my pain on my own. I’d rather suffer with the side effects I’m accustomed to than risk being in constant pain again.”

Another injured worker told me, “I went from eight pills a day to being totally opioid-free, but it took two stints in rehab and a whole lot of willpower. It’s a seductive thought, to place your trust regarding pain relief in a pill, but it’s not a long-term solution. The pills have too many disadvantages. Sooner or later you have to get off the pills and take control of your pain using other methods.” This injured worker has achieved an acceptable level of pain relief using over-the-counter medication and by practicing mindfulness.

A third injured worker reported, “I’ve been on opioids for two years now. My doctor keeps refilling the prescription, so I keep taking the pills. I have a lot of side effects, but it’s worth it to keep my pain under control. I don’t want to make any changes in my regimen and risk being in pain again. I find the negative publicity about opioids very scary. I guess someday I’ll quit them, but just not right now.”

In conclusion, injured workers, providers and claims adjusters are all seeking the right way to deal with pain. Injured workers in pain need pain relief, but they also need non-pharmacologic pain management techniques. Most treatment guidelines in workers’ compensation now recommend opioids only for acute, post-surgical pain relief for three to seven days, ideally. They are not recommended for chronic, musculoskeletal pain, e.g., for pain lasting longer than three months. Providers must take responsibility for engaging their injured workers in an active pain-management process. It doesn’t have to be a formal program; it can be an agreement between doctor and patient. Doctors have to be ready for this responsibility if they prescribe opioids; it’s poor practice — and violates the physician’s imperative to “do no harm” — to prescribe something addictive if you are not able to assist the injured worker with the weaning process.

See also: Opioids: A Stumbling Block to WC Outcomes  

For their part, injured workers must accept the necessity of being actively involved in their pain management and buy into not taking pills long-term that are going to result in more harm than good. They should demand that their prescribing physician discuss the medication plan with them, what the adverse effects are and what the weaning process will be like.

Finally, claims adjusters have the responsibility to be on the lookout for opioid prescriptions and to make sure that providers are prescribing them within guidelines. There are technological solutions for this. The best approach to the opioid crisis is a team approach: providers, claims adjusters and injured workers working together to avoid opioid dependence and maximize recovery, restoration of function and lasting relief from pain.

Industry Trends for 2017

Every day, our colleagues take care of people facing uncertain situations. Whether they have a workplace injury, need time away for the birth of a child, experience a medical situation that will lead to time off, are in an auto accident or suffer product or property damage, we are here to let them know that it’s going to be okay.

Part of our job in caring for these people is to simplify and clarify the process and to explain what consumers can expect. An evolving system, shifting regulations, rapidly advancing technology and economic uncertainties add to the complexities they face. Key areas in the spotlight for the coming year include good health empowerments, regulation transformations, consumer-centric progressions, risk circumventions and tech modernisms.

We will continue to offer our insights as we monitor the following business advancements and challenges throughout 2017:

Good health empowerments

Accessing care via technology

Technology advancements will continue to influence healthcare delivery. Connecting a specific injury or condition with a quality provider in a virtual setting for more immediate treatment will make these advancements more readily acceptable and increase demand.

Balancing the scale of pain management

Increasing opioid addiction and the legalization of medical marijuana will ensure pain management remains at the forefront of industry discussions. Increased education about the dangers of opioid abuse, the availability of marijuana as a medical alternative and the introduction of alternative pain management techniques will continue to dominate the conversation.

Supporting mental health initiatives

The pressures to reduce stigma and strengthen initiatives aimed at psychosocial issues and behavioral health will continue to mount. The linkage between absence at the workplace and mental health will continue to be highlighted.

See also: 10 Insurance Questions for 2017  

Regulation transformations

Compliance enforcement

Employers will continue to manage compliance-related issues as they respond to changes in the ADA/ADAAA, FMLA and other federal and state laws affecting our industry. Political reorganization and shifting administrative priorities may also create regulatory shifts for OSHA and the EEOC.

Navigating regulatory changes

Assessing the impact of provisions introduced by newly elected officials from the federal and state level in the areas of healthcare, workers’ compensation and parental leave will be at the forefront. It will be necessary to monitor newly introduced legislation in key states such as California, New York and Florida to determine how best to respond and comply with new regulations.

Workers’ compensation strategies

Primary steps among industry leaders include finding common ground and developing strategies focused on benefiting all key stakeholders. Those who favor a federal workers’ compensation option point to inconsistent benefits, rules and regulations among the states. Others believe the state systems have proven to be effective and simply need to be updated. By understanding what should be changed or replicated, legislators can work to revitalize workers’ compensation and help ensure that it continues to fulfill its original purpose.

Consumer-centric progressions

Enhancing the claims experience

The current claims paradigm will continue to shift and be characterized by an increasing focus on the consumer. The needs of injured or ill employees and other consumers will assume center stage. Claims expectations will be established early on; information and resources to support the consumers’ needs will become more readily available; and care and concern will drive and transform the claims experience.

Bridging benefit models

Integrated benefit plans have long been discussed, but not widely implemented. Pushing the boundary between various benefit providers, administrators, payers and employers through advanced online platforms could be at the forefront of many discussions. In addition to technology advancements, there is a renewed health, wellness and compliance mindset that is fostering increased interest in integration.

On-demand consumerism

Consumer and customer expectations are on the rise, and providing an immediate response has become expected in many industries. Increased connectivity and immediate communication are now the standard. In the past, it was enough to provide claim and case details through push technology, seamless payment processing and direct bank deposits. Now, the gold standard is to provide a consumer-focused experience where access to resources and data are a click away. With enhanced consumer engagement comes faster resolution, reduced litigation and reallocation of resources to focus on more complex matters.

Risk circumventions

Crisis plans

Building resiliency through new predictive models in pre-catastrophic events and using new technologies in post-disaster recoveries is on the mind of many employers. Whether the emergency is natural or man-made, cyber- or product-related or a supply chain interruption, having the right pre-catastrophe plan in place continues to be a discussion among employers, brokers, carriers and payers.

Geo risks

More organizations are likely to consider an enterprise-wide response to growing political, economic and global risks as customer markets expand. There is also an increasing need to address travel risks for employees servicing global customers on a short-term or interim basis, and ensure preparedness plans are in place.

Talent strategies

There continues to be a need to attract, train and retain new talent as baby boomers enter retirement years. Employers must learn how to accommodate multiple generations with varied preferences – from telecommuting to technology – and ensure successful integration with the existing workforce. Creating strategies and using new tools for knowledge sharing will help enhance communication and understanding.

See also: 2017 Priorities for Innovation, Automation  

Tech modernisms

Artificial and emotional intelligence

The rapid advancement of technology has led to conversations and interest in artificial and emotional intelligence. Developments in these areas and others such as new connected health technologies, Internet of Things, drones, driverless cars and services using virtual technology are contributing to privacy law and ethical guideline debates.

Explosion in actionable data

With today’s technology advancements and increasing number of connected devices come an explosion in actionable data, creating a need for more data miners. There is a growing demand for data scientists and engineers who can interpret actionable information. The use and expectation of having more refined predictive analytics to drive decisions will continue to increase and underscore the need for this specialized talent. Deciphering actionable insights as more data pours in from various connected devices will continue to be an important topic of discussion.

Self-service innovations

Having been introduced in the banking and airlines industries early on, consumer self-service options are becoming increasingly popular in the risk and benefits industry. Consumers of claims services are seeking the same user experiences that they have become accustomed to in the B2C world, including instant information access, connectivity to tech support and two-way communication when and how they want it.

You can find the original report here.

Potential Key to Tackling Opioid Issues

The use of urine drug testing (UDT) for injured workers raises challenges and questions for workers’ compensation stakeholders. Who should be tested? How many tests are too many? Too few? How often should the tests be performed? And, perhaps most importantly, what — if any — action should be taken in response to test results?

These questions have been brought to the forefront with the rise of opioid-related challenges — the same challenges that led a large workers’ compensation insurer to turn to experts for help.

The carrier saw a significant increase in opioid use among injured workers. Claims adjusters did not have the expertise on their own to aid in the problem.

See also: Opioids Are the Opiates of the Masses

Over the past several years, the insurer has aligned with Optum (its pharmacy benefit manager) and Millennium Health (a health solutions company that specializes in medication monitoring) to create a program that identifies and works with injured workers who are potentially at risk for poor recoveries. The insurer has reported impressive results, with reductions on spending for opioid analgesics and decreases in the number of supply days of the medications. Using the clinical experts and toxicologists of Millennium to help interpret test results has helped the clinical pharmacists at Optum provide recommendations to the adjusters and providers.

Medical treatment guidelines increasingly include UDTs for injured workers who are prescribed opioids; however, the decision of how often to test is largely left to the medical provider’s discretion. Experts say UDT, used in conjunction with other tools, can provide objective information regarding current medication, as well as illicit substance use. The results can help identify injured workers who may be abusing, misusing or diverting prescribed opioids.

“The clinical utility of UDT has been well established and is promoted in several medical guidelines. However, in some segments, there is still an underutilization for various reasons,” said Maria Chianta, director for clinical affairs and managed markets at Millennium Health. “It could be a lack of awareness or a lack of time — it takes time to perform the tests and interpret them.”

(Chianta will lead a discussion at the National Workers’ Compensation and Disability Conference & Expo on Dec. 2 in New Orleans. The discussion will cover the use of UDT in workers’ compensation; explain what led the insurer to enlist the help of its pharmacy benefit manager and Millennium Health; and show the results the company has achieved.)

Non-adherence to guidelines

The latest research from the Workers’ Compensation Research Institute bears out the inconsistent use of UDTs in workers’ compensation. A study of 25 states showed that the percentage of injured workers with longer-term use of opioids receiving drug testing was lower than recommended by treatment guidelines. At the same time, however, the frequency of drug tests was unusually high among the top 5% of injured workers who received opioids on a longer-term basis and had drug testing.

A lack of understanding of what actions to take based on UDT results is perhaps one of the major barriers. “It takes time to walk through those results,” Chianta said. “If you get something unexpected, you have to try to get to the cause of that, which takes time. Some providers may not know the best ways to respond to the test results.”

Follow-up is among the key issues for the effective use of UDT. Depending on the results of the tests, the insurer, for example, may engage the services of a telephonic case manager or conduct a pain management program review.

See also: Urine Drug Testing Must Get Smarter

Another area of confusion over UDTs concerns the types of tests available. “Primarily, there is immunoassay technology and mass spectrometry,” Chianta said. “Immunoassay is a presumptive screening, and mass spectrometry is a definitive or confirmation test.”

Chianta will discuss the types of tests in more detail. Some people on the health plan side may be seeing drug tests coming in and paying for them — and that’s the end of the process. The speakers aim to give session attendees an appreciation of the value of becoming more involved with the outcomes of the tests and follow-up actions that are necessary.

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.