Tag Archives: opioids

Potential Risks of Illicit Drug Residue

As we continue to face a national opioid crisis, insurance adjusters need to keep their safety top of mind during the inspection of a drug-related claim. It is essential to be aware of the potential health risks you could be facing, especially if the property or vehicle you are dealing with may be contaminated with an illicit drug. When you first step on the scene, remember to think whether the property could have been contaminated by the insured, a third party involved in the claim or an unknown party.

Take a situation where an adjuster is inspecting a property damaged by the renter, and a mysterious white powder is discovered. This powder could be a number of substances –flour, drywall compound, cocaine or even fentanyl. It is important to treat it with caution while identifying the substance, as this will affect the claim and your safety. Another example is water damage that has occurred to a home where recreational drug use or pill pressing occurs. Adjusters must ask themselves and their teams what the contents or mixture of those pills were. Moreover, what if a car is stolen and damaged by individuals high on drugs? What is the risk is to the repair facility?

It’s important to mitigate and manage these types of losses. How do we protect ourselves and our sub trades and rehabilitate the risk? Start by asking yourself, do I really know what the risks are and who can help assess and clean it up? Next, think about the risks by asking yourself, how can we best manage the salvage? As the fentanyl crisis continues, these questions are all crucial.

Fentanyl and carfentanil are both now being cut into to illicit drugs like cocaine, heroin and counterfeit pills, which are made to look like prescription opioids. For this reason, there is no easy way to know if carfentanil was used in the making of a drug – especially because you can’t see, smell or taste it. This causes additional problems, as it is essential to know if there is even a very small amount of fentanyl when handling a substance because of its danger due to the high level of toxicity.

See also: Better Treatments for Opioid Addiction  

What level of exposure from opioids increases health risks? The answer isn’t clear-cut, as it depends on the types of drug that are present – scenes are highly variable if inspections are uncontrolled and unregulated. With fentanyl being 50 to 100 times more potent than morphine, and carfentanil approximately 100 times more potent than fentanyl, the risk is apparent. As little as a grain of salt of carfentanil could be lethal.

If faced with a situation possibly involving illicit drugs, it is important to do your homework and make sure that qualified and experienced firms are used for the testing and decontaminating of fentanyl or carfentanil. Cleaning can create hazardous wastes or other issues if not done properly. Documenting the work and results by designated professionals is another way to limit a potential liability.

In any case, next time you’re walking through a property and notice a strange powder on your clothes, think twice before simply brushing it off. The results could be fatal, not only to you but to whomever you may come in contact with.

Better Treatments for Opioid Addiction

The opioid epidemic is a moral hazard of existential proportions.

A test of the moral health of the insurance industry in which the question is, Will insurers acknowledge the severity of this threat by subsidizing better ways to treat this threat?

Will insurers accept what patients concede and even cynics confess, that specific treatments for opioid addiction outside the U.S. are more effective than the many but mostly unsuccessful treatment options in the U.S.?

Will insurers admit that it is more expensive to cover what does not work than it is to underwrite what returns people—healthy and strong—to the workforce?

To ask these questions is to know that it is smarter to insure domestic tranquility by experiencing it abroad, that it is easier to promote the general welfare by supporting programs that lessen dependency on welfare, not because these programs are wrong, but because it is wrong to abandon tens of millions of people—including mothers and military veterans—to short, nasty and brutish lives of addiction.

The answers to these questions are available to all.

See also: Alternatives to Opioids for Pain Management  

The answers, thanks to my correspondence with staffers at Clear Sky Recovery, raise the ultimate question of whether we will exist half-slave or half-free, whether we will succumb to the ravages of opioid addiction or avoid this descent altogether, whether we will cause our health to worsen or rally to the cause of health and wellness.

What I ask of insurers is no different than what insurers should ask of themselves: help.

Let us be unafraid to seek help.

Let us also be aware that help is achievable, that help is available, that help is accessible.

Let us free ourselves from the false promises of what is a racket rather than a legitimate means of rehabilitation, what with the bombardment of ads and commercials, what with the inundation of junk mail and junk science—an audiovisual overdose of empty words and meaningless slogans.

Let us wake up to the reality of this situation, that we face a do-or-die decision; a dire choice, indeed.

Either we do what is necessary, either we do what is right, or we plead guilty to the fast death of minds and the slow loss of bodies: a sight too painful to witness but too profound to ignore, a sight too traumatic to forget but sometimes too awful to recall.

Either we unite against opioid addiction, or we allow our divisions to destroy us.

Either we encourage patients to get treatment abroad, or we stop demanding that insurers pay for treatment whose efficacy is questionable and whose rate of failure is so high as to be unquestionable.

We must choose what is just, in lieu of what is popular or convenient.

See also: Is There an Answer to Opioid Crisis?  

That standard should determine not only treatment for opioid addiction but how insurers treat all matters of health and wellness.

With truth as our guide, we can stop the advance of opioid addiction.

With insurers on our side, we can win this war.

Maine Says: Buy Your Own Marijuana

Bourgoin v. Twin Rivers Paper Co. (SJC Maine, June 14, 2018)

Maine has just joined the list of states that preclude worker’s compensation coverage for the cost of medical marijuana used to treat a workplace injury.

Bourgoin sustained a workplace injury that caused him to suffer chronic back pain and total disability. After receiving a certification to use medical marijuana, he obtained an order from the Worker’s Compensation Board directing Twin Rivers, his former employer, to pay for the cost of the marijuana. He found that marijuana was more effective and had fewer side effects than the opioid drugs he had been prescribed.

Twin Rivers appealed, arguing that the federal Controlled Substances Act (“CSA”) prevented an employer from paying for marijuana even when it is legal under state law. The Maine Supreme Court acknowledged that the CSA expressly disclaimed “field preemption” but held that there was an inevitable conflict between state law that ordered an employer to pay for marijuana and the CSA, which criminalizes marijuana.

The court concluded that, if Twin Rivers subsidized the cost of marijuana as a worker’s compensation benefit, it would inevitably be aiding and abetting a federal crime, which is itself criminal activity. The court emphasized that “the magnitude of the risk of criminal prosecution is immaterial in this case. Prosecuted or not, Twin Rivers would be forced to commit a federal crime if it complied with the directive of the Worker’s Compensation Board.” Two justices dissented.

This article was written with Meghan Shiner.

Alternatives to Opioids for Pain Management

One of the areas of focus on Out Front Ideas with Kimberly and Mark has been addressing chronic pain without opioids. The workers’ compensation industry’s approach to chronic pain has historically been trying drugs and other medical procedures first. Then, if the pain has not subsided or has worsened, we look for psychological factors. If we truly want to help injured workers in pain and prevent opioid abuse and other unnecessary measures, we need to reverse that protocol. To learn more, we spoke with two of the nation’s most highly respected pain management experts, who gave us great insights into the experience of pain, how it can be best treated and non-pharmaceutical ways to treat pain.

Beth Darnell is a clinical associate professor in the division of pain management at Stanford; a clinical pain psychologist at the Stanford Pain Management Center; an NIH-funded scientist doing research on psychological treatment for chronic pain; one of the co-chairs of the Pain Psychology Task Force at the American Academy of Pain Medicine; one of the co-authors of the 2017 Chronic Pain Guideline updates from the American College of Occupational and Environmental Medicine; and author of multiple books on the subject: “Less Pain, Fewer Pills” and “The Opioid-Free Pain Relief Kit” — both written for patients. Dr. Darnell also recently co-published a research paper on The JAMA Network titled “Patient-Centered Prescription Opioid Tapering in Community Outpatients with Chronic Pain”

Dr. Steve Stanos is the medical director of pain management services for the Swedish Medical System in Seattle and runs the pain services for five hospitals in the system; the director of Occupational Medicine Services at Swedish; the president of the American Academy of Pain Medicine; and the medical director for myMatrixx. He was also a reviewer for the CDC’s Guidelines for Opioid Management and was involved in the National Pain Strategy.

Myths and Facts

Many of us have preconceived ideas about pain — what it is and how it should be treated. Unfortunately, many of these ideas are misconceptions and have led us to where we are today.

We think of pain as solely a physical experience. But our experts explained that pain is really a negative sensory and emotional experience. Psychology is an integral part of the pain experience, and, if we ignore that, we are not adequately addressing an injured worker’s pain.

Pain is very helpful in alerting us to situations where our bodies are at risk. If you put your hand on a hot stove, for example, the pain signals your brain to remove your hand. However, that does not work well for chronic pain when the continuing pain alert does not help us. Instead, it causes us fear and stress, which can actually exacerbate the pain. Those fears and stress are what we need to address in injured workers with chronic pain.

Another misconception is that people in pain are powerless to do anything about it and are at the mercy of drugs or other medical procedures. That simply is not true. There are teachable skills patients can use to assuage their own pain. These are learned skills.

See also: Is There an Answer to Opioid Crisis?  

We need to help injured workers understand and deal with the psychology of their pain experience up front, instead of waiting until the claim deteriorates. Medical providers, payers and others involved in a claim need to be aware of that and work with the injured worker to empower him or her to reduce their fears and stress and, in doing so, reduce their pain.

That leads us to another misconception — that dealing with the psychology of pain requires a specialist for extended sessions. Actually, non-behavioral health individuals can teach valuable skills to help cope with pain.

Again, this should be done early in the claim process for the best outcomes. The best predictor of outcomes in a pain program is early intervention with psychosocial factors. We need to have an early emphasis on behavioral health.

Yet another falsehood is that using drugs and medical procedures first is better for the patient because it does not assume he or she has any psychological issues. Instead, we are missing the elephant in the room, and, when the injured worker is finally sent for psychological intervention, it can be demoralizing. It sends a message to the injured worker that he or she is a failure and that the pain is all in his or her head. It does a terrible disservice to the injured worker.

We asked our experts whether all patients in chronic pain need psychological intervention. The answer was, yes, anyone in chronic pain can benefit from some level of behavioral intervention. That does not mean long-term, expensive, one-on-one treatments with a trained psychologist. Again, there are teachable skills to deal with chronic pain. The focus is on changing behavior.

Non-Pharma Pain Treatments

There are a variety of programs to help people deal with pain, many of which are based on cognitive behavioral therapy (CBT). This short-term treatment is goal-oriented and takes a practical approach to problem solving by changing patterns of thinking and behavior. Doing so helps change the way patients feel.

CBT is considered the gold standard of psychological treatment for chronic pain. It teaches concrete information and skills with action plans to move forward. It helps in creating care pathways that promote organized and efficient patient care based on evidence-based medicine. It helps patients become engaged and active in their own treatment so they rely on themselves more than the medical system.

Patients can learn the skills of behavioral health principles through classes and videos as well as by talking with therapists and others. Again, it is something anyone in pain can and should learn — not just those who are profoundly depressed or have other, more serious psychosocial issues. It is active management of pain.

Some newer treatments include mindfulness training, acceptance and commitment therapy and chronic pain self-management. These are all based somewhat on CBT, although not necessarily on pain management. Acceptance and commitment therapy trains you to stay focused in the moment so you do not react to pain. Negatively reacting to pain can be more distressing than the pain itself.

These programs teach people how to self-soothe. They also help establish meaningful goals and the steps to achieve them so people are not stuck in a passive mindset about their pain.

Functional restoration programs incorporate many of these aspects and can also be great, not only for at-risk patients already struggling with chronic pain, but also for early intervention. These programs have been around for years and typically involve physical and occupational therapy, psychology, relaxation training, exercise and vocational rehabilitation. The cost is fairly inexpensive when you compare them to unnecessary surgeries, so they can be helpful.

There are also certain medical procedures and services that have been overused in the past but can actually have a role as part of an overall pain management plan. Spinal cord stimulators and injections are among them, along with chiropractic care and spinal manipulation. These can help with function for certain patients, such as those with acute pain. But they must be integrated into an overall plan, and they are only appropriate for certain individuals.

Passive treatments, such as acupuncture and massage therapy, might be helpful for some pain patients, at least in the short term. But again, it needs to be used in conjunction with an active therapy program in which the patient is helping to manage his own pain through skills learned from CBT and other techniques.

One treatment on which both experts are hesitant to recommend at this point is medical marijuana, mostly because of its classification as a Schedule I drug under federal law. The science on it is just too sparse; there is no safety regimen around it and no protocols for when to use it, what type to use and how much could help.

“Prehab” is a relatively new term that might hold some promise. Think of rehab before the fact. It focuses on things like wellness, how to relax during the day and stress reduction techniques. The idea is to intervene with patients prior to surgery or other treatments and prevent poor outcomes. Patients who have fear avoidance or catastrophic thinking can be taught skills so they are better able to deal with their pain and stress later on.

Education programs are key in helping pain patients to avoid overuse of medications and services. Because so many do not understand pain or how to control it, they may seek multiple treatments to eliminate the pain.

Opioid Guidelines

The 2017 revisions to the ACOEM Chronic Pain Guidelines, released in May 2017, included an extensive section on behavioral health, the role of psychology and recommendations to integrate psychological principles in chronic pain.

The CDC’s guidelines for managing opioids have been invaluable in the attention they have brought to the opioid issue since they were released last year. However there has been some confusion and pushback, especially on the recommendations that deal with the morphine equivalent dose. The CDC recommends providers avoid or carefully justify prescriptions of more than 90 MED. Some payers have incorrectly interpreted that to mean physicians cannot prescribe above the 90 MED.

Another controversial recommendation says providers should only prescribe opioids for the duration of expected pain, typically between three and seven days. But some providers have been mistakenly told they can only prescribe the drugs for a specific number of days.

See also: Misconception That Leads to Opioids  

The Future

Both experts say a shift from fee-for-service to outcomes-based care could be a huge benefit because it would allow for a more holistic approach, including the integration of behavioral health. Putting behavioral health efforts on the front end of the claim is one of the biggest changes that they believe would help chronic pain patients. This would be a game changer in the workers’ compensation system and would cost more up front, but the speakers believe it would pay off in dividends.

Precision medicine is an emerging field that the speakers say could provide great promise for treating injured workers with chronic pain. It involves deep phenotyping patients on the front end and at each point of care. It includes an array of psychosocial variables and assessments to determine the specific needs of each patient for targeted interventions. It moves beyond the one-size-fits-all approach.

Technological advancements will allow for more and better treatment, such as apps and videos that reinforce behavioral health techniques. Telemedicine is a way to help keep patients engaged. Telehealth can allow for virtual face-to-face meetings between patients and psychologists. Virtual reality also holds promise as a way to help decrease pain levels during treatments.

Clearly there is much that the industry can do to reap better outcomes for our injured workers and, in turn, their employers. However, we need new ways of thinking; a change in the way we have been doing things. All stakeholders need to truly understand pain and what we can do to address it better and faster.

Is There an Answer to Opioid Crisis?

What a difference two words make.

Last week, President Trump declared the opioid epidemic a “national public health emergency.” The declaration will speed up how quickly specialized personnel can be hired, expand access to treatment for some addicts and make some HIV/AIDS programs more flexible.

But many people wish he’d left out the words “public health.” That’s because a “national emergency” would have freed up money, and lots of it. The Public Health Emergency Fund at Health and Human Services currently contains only $57,000. And the president did not ask Congress to refill it.

But we shouldn’t entertain the idea that the federal government, or any other entity, is going to “fix” the opioid epidemic, just as you can’t pin blame for the crisis on a single entity. The epidemic is all-encompassing, far-flung and complex, and it unfolded over two decades and millions of bad decisions.

See also: 6 Shocking Facts on Opioid Abuse  

Pharmaceutical manufacturers are partly to blame because they marketed opioids as safe when taken as prescribed. Doctors and medical institutions compounded the problem because they didn’t adequately question and research these false claims. Drug distributors shipped massive amounts of drugs to places that obviously didn’t need them, and pharmacists looked the other way when filling prescriptions that were clearly too large. The Drug Enforcement Administration allowed manufacturers to make more and more opioids, even as overdose death rates skyrocketed. And many patients and drug users didn’t take responsibility for their own health.

There’s no one person or organization responsible for the crisis, and there’s no easy fix, no magic bullet.

I was disturbed by the recent reports that the Trump administration was “scrambling” to formulate an opioid plan. This epidemic didn’t have simple causes, and the response to it should not be rushed out. Meaningful change will require a response that recognizes millions of addictions have been created that aren’t going anywhere.

Each of the parties that took part in creating of this epidemic must be a part of the solution.

For instance, doctors and medical schools need to develop drastically different prescribing protocols to avoid creating addictions. Their far-more-challenging task will be to develop ways to deal with all of the patients who have been prescribed high doses of opioids for many years and are understandably terrified that they will be taken off their meds, even though the drugs are probably sapping their lives of vitality. How do you treat those patients so they don’t turn to street drugs?

The federal government does have one big stick in its arsenal that hasn’t been used, which is the fact that the DEA is in charge of setting manufacturing quotas for all controlled substances. The DEA could use this power to force drugmakers to better track where their opioids are ending up. This hasn’t happened, and in fact, the DEA permitted hike after hike in manufacturing quotas, finally cutting the rates only in the last two years.

See also: Opioids: Invading the Workplace  

In the end, I think the gathering tsunami of lawsuits against the drug companies may prove to be more effective than the federal government’s response. The eventual settlements could dwarf the $206 billion in Big Tobacco settlements from 1998. We need to make sure that any settlement provides lots of money for research and treatment.

But neither the federal government nor plaintiffs’ lawyers are going to “solve” this epidemic. Addictions, once created, don’t die easily. The opioid crisis is going to be a part of life in the U.S. for a long time.