Tag Archives: pdmp

How to Attack the Opioid Crisis

The vastness of the opioid crisis is all around us:

  • 259 million opioid prescriptions are made every year.
  • 91 Americans die every day of opioid overdose.
  • Workplace costs of prescription opioid use are more than $25 billion, driven by lost earnings from premature death, reduced compensation or lost employment and healthcare costs.

It’s time to take action.

See also: Opioids: A Stumbling Block to WC Outcomes  

As with any large-scale, complex phenomenon, there is no silver bullet. But a framework from the Johns Hopkins Bloomberg School of Public Health suggests three areas where we should focus our efforts: preventing new cases of opioid addiction, identifying opioid-addicted individuals early and ensuring access to effective opioid addiction treatment. We believe these areas must be attacked from a variety of clinical and operational angles.

From the clinical side, the emphasis has to be largely around better clinical training and urinary drug testing (UDT). A generation of doctors has been raised based on a curriculum emphasizing the need to manage pain aggressively. Retraining physicians on best practices is needed to reinforce safe opioid prescribing patterns. Research from Utah has shown that physician education on recommended opioid prescribing practices was associated with improved prescription patterns, including 60% to 80% fewer prescriptions for long-acting opioids for acute pain. When an opioid is prescribed, the use of UDT is a cost-effective way to monitor treatment compliance and drug misuse.

To address from the operational side, we need evidence-based opioid prescription guidelines in place and systems to track opioid prescriptions and adherence to guidelines. Further, we must ensure access to effective opioid addiction treatment.

Many health organizations and state health systems are aggressively adopting pain treatment guidelines that clearly lay out when opioids should and should not be used. And the preliminary results of implementing these guidelines are promising. For example, the introduction of opioid prescribing guidelines in the Washington state workers’ compensation system was associated with a decline in opioid prescriptions, the average morphine equivalent doses prescribed and the number of opioid-related deaths.

Prescription drug monitoring programs (PDMP) allow for health systems to analyze opioid prescribing data to find potentially inappropriate prescribing behavior and illegal activity. For example, using its PDMP, New York City found that 1% of prescribers wrote 31% of the opioid prescriptions.

While prevention of initial opioid exposure is important, the treatment of opioid addiction is an important safety net when prevention fails. Pharmacotherapies including methadone, buprenorphine and naltrexone are options for routine care of opioid dependence, but they are still in the early stages of the adoption cycle.

See also: Potential Key to Tackling Opioid Issues  

The foundation to address the clinical and operational approaches to opioid epidemic is two-fold:

  1. A strong system to determine what’s acceptable through well-defined, evidence-based guidelines; and
  2. A system to use these guidelines and trigger the right actions through processes and technology.

The next article will address the nature of these two systems.

23 Questions on the Use of Narcotics

During my Feb. 23  webinar titled “History of Heroin Use: Impact on Prescription Drug Abuse,” there were a series of questions that I could not address during the Q&A time. In fact, 23 questions. I finally finished my written responses, and One Call Care University is distributing them to the 938 confirmed attendees of the webinar. However, I thought it might be an interesting exercise to make them more broadly available here.

BTW, because of the very positive feedback from attendees, One Call Care University has scheduled another webinar on the same subject on Aug. 25 (obviously with some updated content). I appreciate their support. So, if you missed the Feb. 23 webinar, pencil in Aug. 25 on your calendar.

See Also: Progress on Opioids–but Now Heroin?

Also, in case you didn’t notice, I have written two heroin-related blogposts since February 23 that provide even more context – “Breaking Point: Heroin in America” and “The Heroin Triangle … in My Hometown.”

And now, the 23 questions … and answers. I would appreciate any additional insights you may have, so I can continue to expand my perspective and understanding, so feel free to submit comments.

  1. Will the recent conviction of Dr. Tseng in the overdose death of three patients have an impact on physicians dispensing narcotics? I certainly hope so. It is a very high-profile prosecution and conviction of a physician who was prescribing for the benefit of her pocketbook and not for the patients. As with other high-profile events, this could be used as a launching point for even further prosecution (beyond the continuing investigations that typically result in surrendering MD or DEA licenses). Whether this affects the opinions (and actions) of actual prescribers, only time will tell.
  2. As a workers’ comp adjuster, I received a request for approval of Narcan for an injured worker who is taking morphine medications. It was denied, but what would be the ramifications of approving Narcan to a workers’ comp injured worker? Would there be a chance of getting a death claim if the injured worker died after the Narcan dose? I’d be interested in knowing the rationale for denial – was it deemed unrelated/non-compensable, or were there concerns about its medical efficacy, or was it a concern along the lines of your second question as to the implications or liability? The latter is an interesting question, because by approving Narcan it could be extrapolated that you know the dangers of the drugs for which you’re approving an antidote. On the other hand, if you don’t approve the Narcan, did you not perform the necessary due diligence to ensure the patient didn’t die from an overdose. These are legal questions – I’m not an attorney, so you should probably consult yours – but I could see both respective questions and answers creating issues. Ultimately, the best thing that can be done for the patient/injured worker is to help him taper from the dangerous drugs he’s using to a treatment that does not introduce the possible side-effect of death (i.e., remove the need for Narcan by removing the drugs). As I mentioned on the webinar, we’ve made a mess, and now we have to clean it up. I believe the cleaning up process is going to be a major focus for many years to come.
  3. What can be done about the physicians who are ordering unnecessary narcotics such as hydrocodone and oxycodone and seem to be the majority? It’s upsetting when a patient goes to an urgent care and is given narcotics for simple injuries such as a small laceration to a finger, or a bumped toe – how and why is this happening? Part of the solution is better education for prescribers – they should be informed of all treatment options and focus on those with the least amount of negative side effects that helps the patient (which may mean not giving patients the drugs they think they need). Part of it is better education for the patient – own your healthcare, ask questions and if the side effects are worse than the original malady then do your own research (plenty of free resources on the Internet). Part of it is the pharmacy/pharmacist/PBM – leverage common sense (and automated triggers) to connect the potency of the drugs to the illness/injury being treated. Part of it has to be legislated – mandatory access of PDMPs where real-time access is available, CME for doctors to ensure they know everything they need to about the treatment of pain, investigations by the DEA and state and local enforcement, restrictions on physician dispensing. Ultimately, prescribing behavior needs to change. But putting the responsibility solely on the prescriber is not sufficient.
  4. How do you view chronic use of Tramadol? Tramadol was added as a Schedule IV drug as of Aug. 18, 2014. Prior to then, it had not been scheduled (i.e. was not a controlled substance). The DEA changed the classification because the long-time arguments were all disproved: that people can’t get addicted, there is no withdrawal process, and there is no possibility of overdose. If it quacks like a duck and walks like a duck and smells like a duck – it’s a duck. More research showed that Tramadol quacked and walked and smelled like a narcotic. That said, it’s less potent and has less serious side effects than Schedule II (e.g. oxycodone, methadone) or Schedule III (e.g. Vicodin, Tylenol with Codeine). Per all EBM guidelines, long-term use of narcotics can be supported if the patient has exhausted all conservative non-pharma and pharma treatment, has adequate pain control and levels of function/quality of life and is on the lowest possible dosage. That obviously leaves open the possibility of long-term use, but the bar is fairly high. Anybody in this position should talk with a doctor.
  5. How do you view long-term use of Flexeril (Benzodiazepine)? Flexeril (cyclobenzaprine) is a muscle relaxant. While it is less dangerous than Soma (carisoprodol), the side effects from any muscle relaxant can be dangerous (check out my favorite website’s assessment). In general, muscle relaxants are not recommended for long-term use, but, as with the above question on Tramadol, use should be based on the effects (positive and negative) to the patient and whether there are treatment options (non-pharma and pharma) that might equally resolve the condition without the dangers. Anybody in this position should talk with a doctor.
  6. What do we tell patients who have chronic back pain, who have failed all conservative treatment and who are unable to obtain strong-enough medication for short-term exacerbations, and their physician will not prescribe any narcotic? What choice do they have but to seek street drugs? This is the tricky part – not restricting access to drugs to the point that people who really need them can’t get them. That is often the concern raised by advocates for opioids. If the patient has not shown signs of abuse (e.g. running out of their 30-day supply in 22 days, doctor/pharmacy shopping, using illicit drugs or non-medical prescription drugs) then the doctor should consider prescribing the lowest possible dosage to resolve the issue, whether it’s chronic pain or momentary exacerbations. That prescription should be accompanied by accountability tools like pill counts and random drug tests and opioid treatment agreements. And it should also be accompanied by counseling to address the psychosocial needs of the patients (e.g. giving them methods to cope with the pain, helping them deal with problematic family situations, providing vocational rehab to provide some work outlet). In my mind, this decision starts and ends with an honest and transparent dialogue between the doctor and patient. If the patient doesn’t feel listened to, or the doctor feels like the patient isn’t being honest, bad decisions can be made. If, after all these controls have been introduced, the doctor still doesn’t feel like narcotics are the answer, then the patient should likely solicit a second opinion. Of course, in workers’ comp, that would process through the payer (carrier, TPA, self-insured) … So the circle of honest and transparent dialogue also needs to include them.
  7. Have you seen correlation for suicide for people taking Xanax and drinking alcohol? The biggest concern in combining Xanax and alcohol is accidental death from side effects such as slowed respiration and heart rates and seizures. Severe depression is another potential side effect, which could certainly lead to a suicide attempt. Suicidal thoughts as a specific side effect are not nearly as common as just going to sleep and never waking up again. My suggestion? Never mix alcohol with any opioid, benzodiazepine or muscle relaxant. Period.
  8. Do you think that decreasing the use of prescription opioids will just push more people to street heroin? It already has. And that is why we have concurrent epidemics of prescription painkiller abuse and heroin. For those who have become dependent or addicted to opioids, they need to be helped by a methodical tapering process to other methods for resolving their pain and non-pharma ways to deal with that pain (e.g. yoga, stretching exercises, an active lifestyle) and psychological treatment (e.g. CBT, establishing coping mechanisms). It is inhumane to remove drugs, especially those with high possibility of abuse and addiction, and not replace them with other mechanisms to treat their physical and psychological pain. Just detoxing or removing access will likely just force patients into finding other methods to self-medicate (heroin or other illicit drugs, alcohol, etc.) So, the answer to this Rubik’s Cube is difficult because only removing supply of opioids could create unintended consequences that could be as bad or even worse than the original problem.
  9. Why aren’t MDs (particularly pain management specialists) held more accountable for addiction? Isn’t it malpractice? That argument could certainly be made. Doctors, in general, are given great latitude to practice the art of medicine. That latitude has often resulted in great treatment that would have otherwise not been tried – the discovery of penicillin, the transition of minoxidil (Rogaine) from high blood pressure to hair growth, any number of treatments for cancer. But with latitude comes responsibility for bad choices, and once discovered taking an alternate path. At this point, it could not be argued that opioids are very dangerous and overused and that extreme care is needed to ensure that the benefits outweigh the risks. So why do physicians/prescribers, including pain management specialists, often still prescribe when the evidence is clear? And why aren’t they held accountable? We’re seeing increasing accountability by the DEA, state and local law enforcement who are actively pursuing “pill mills” and inappropriate prescribing patterns. We’re seeing increasing accountability from the use of PDMPs and prescribing profiles from PBMs to target high-quantity prescribers. We’re certainly seeing increasing accountability from investigative media who are searching for stories. When will that translate into medical malpractice (defined as “any act or omission by a physician during treatment of a patient that deviates from accepted norms of practice in the medical community and causes an injury to the patient”) is anyone’s guess, but I can see that as a natural consequence over time by patients and their attorneys.
  10. What can be done to report opioid abuse? Each state’s PDMP (prescription drug monitoring program) is a macro way of recognizing abuse and misuse by patients and prescribers — some states have combined data. However, for now, access is limited to prescribers, pharmacists and in some cases law enforcement. So the primary means of identifying abuse and misuse will be the prescriber and family/friends. So how do they report it, and to whom? The first step should be intervening directly with the abuser/misuser to help her recognize, admit and enact changes to stop her substance abuse. That intervention may require involving a professional in substance abuse or mental health. If the abuser will not admit there is a problem, the next step will be determined by the level of abuse, illegality and connectedness. If you know someone who is abusing opioids or other dangerous drugs, and he won’t respond to your private conversations about the issue, then engage with a professional.
  11. If Rx opioids are intended for post-surgical pain and end of life, why do doctors prescribe them for WC back injuries with no end game plan in sight, and why won’t the WC judges  get involved? Why are doctors not held accountable for this problem? As mentioned in an earlier answer, the motivations for prescribing and using outside the on-label uses for these drugs can be varying. As can the accountability. But I think that is changing as doctors become more aware of the epidemic and their role in it. I have seen a generational shift by new doctors who attended medical school, while media including USA Today and CNN have ensured the general population knows we have a problem. The doctors who were in practice or in medical school during the mid-1990s when advocates complained of opioid phobia and under-treatment of pain are coming to a similar conclusion. By no means has there been enough education yet, or conversion of prescribing behaviors, but pressure from the White House to the governor’s house to a mom’s house is certainly creating momentum toward appropriate use. Those of us who serve as educators will continue to be unrelenting in the battle for hearts and minds, but ultimately it comes down to individual decisions by both prescribers and patients to do the right thing.
  12. Do you know if authorities who arrested Tseng confiscated the $5 million she made? I’ve not seen any evidence they did.
  13. Why do people snort pills vs. taking them normally? Drugs like OxyContin and Opana are ER (extended release) and formulated to take effect over a period of 10 to 12 hours. That does not provide the intense and immediate high desired by people addicted to or dependent upon heroin-type euphoria. When pills are crushed and snorted or injected, users bypass the wait associated with the extended release. Abuse deterrent formulations are an important component to help make the high more difficult to obtain. I spoke at a summit on Abuse Deterrence in Alexandria, VA, on March 19, so be watching for a post on what I learned from the speakers prior to my presentation.
  14. Is Demerol similar to or it is also an opioid? Similar to morphine? Demerol (meperidine) is indeed an opioid. Morphine is 10 times more potent than Demerol, however it is NOT recommended for palliative care (i.e. for chronic pain). According to drugs.com, it has 73 major, 701 moderate and seven minor drug interactions along with 16 disease interactions. So it’s a very complicated drug.
  15. What do you recommend someone take with a chronic illness that is not life-threatening? There are many people who take, appropriately, prescription drugs to manage chronic conditions like diabetes, hypertension, rheumatoid arthritis and a variety of other ailments – and without those drugs, their health (and often their life expectancy) would be compromised. Chronic pain, physical or psychological, is real. And unique to each individual, both in the pain itself and the ability to manage it. Which means the treatment is often unique for that specific individual, and therefore the road map can be filled with trial and error. In some cases, chronic pain can be appropriately managed by prescription drugs. But likely that isn’t the only method for management, and in some cases prescription drugs create more issues (i.e. side effects) than they solve. Finding a pain management clinician who believes in the BioPsychoSocial model and thinks drugs are used only after all conservative options are exhausted is key. Following is a list of alternative treatments that is at least a starting point: Physical – An active lifestyle; seven to eight hours of sleep each night; Proper nutrition and weight management; Alternative treatments like acupuncture, massage therapy, yoga; Reducing or removinge alcohol consumption; Smoking cessation. Psychological – Cognitive Behavioral Therapy to adjust attitudes about pain; Develop coping mechanisms through methods like deep breathing, meditation, biofeedback; Dealing with the anxiety or depression that often comes with chronic pain; Developing a support system of family and friends; Decreasing avoidance by enhancing the “fight” attitude; Reducing stress. For further reading, two good articles can be found at http://www.webmd.com/pain-management/guide/11-tips-for-living-with-chronic-pain and http://www.medscape.com/viewarticle/576064
  16. How long does a person need to be on methadone for weaning? That varies on the person, the complexity and scope of the drug regimen being weaned and any co-morbidities that might complicate the process. One clinical resource I’ve read says a patient with significant risks can be tapered in a closely monitored environment over seven to 14 days, but typically it’s a slow process of 5% to 10% declination every one to two weeks (so how long it takes depends upon the starting dosage).
  17. Many providers order opioids in workers’ comp and are not willing to budge in discontinuing/weaning these medications. What recommendations do you have to assist in this process? In some cases, opioids are appropriate, so don’t automatically assume all opioids (and the corresponding drugs/classifications to address side effects) are inappropriate. If the opioids are creating more harm than good (based on levels of activity, quality of life, number/severity of side effects, subjective assessment of pain), and if evidence-based medicine indicates there are other treatment options that should be tried, that information should be relayed to the prescriber. If the prescriber will not talk to anyone, or does not accept the evidence of a better way, then the goal would be to either compel the prescriber to change the drug regimen or to change to a different provider. The path for that is different for each jurisdiction and often includes utilization review, independent medical exam (IME), forcing a provider change, a legal challenge, reporting the provider to the state’s medical association or discussion directly with the injured worker. First, every effort should be made to present objective, clinical evidence in a collegial manner to the prescriber to help him see things differently. If, given the evidence and the chance to review, the prescriber still refuses to listen or change then there is ample evidence of your due diligence that will demonstrate your desire to do the right thing for the injured worker.
  18. I have been informed that once a person is on meth he always goes back. People are never able to get off it. Is that true? If not, do you know the statistics for successful results? There are circumstances where somebody could successfully detox and stay off meth, but it is so addictive that the odds are high they will relapse or die. I found a statistic that 93% of those in rehab for meth addiction relapse, and the national rate of recovery is 16% to 0%. This article provides a good overview: http://luxury.rehabs.com/crystal-meth-addiction/recovery-statistics/.
  19. Is Hep C a germ that develops or is it an actual virus passed by dirty needles? Hepatitis C is a “virus (a type of germ) that causes liver disease.” From my study of opioids and heroin, it’s clear that Hep C can be a direct result of heroin use because of shared needles. “Dirty needles” typically means ones that have been contaminated by bacteria or blood residue from previous user(s) of that needle, and that can certainly be a method for addicts who are scrounging for resources (like needles) to continue their habit. Dirty needles are one reason why communities may have a “clean needle” program. Which is an interesting conversation – does providing clean needles encourage heroin use, or is it a helpful precaution? For more information, this can be a helpful resource: http://health.williams.edu/keephealthy/general-health-concerns/hepatitis-c/.
  20. What is your take on nurse-monitored injection sites, and have they been found to decrease community outbreaks of disease? What have been some of the community concerns related to these sites? This is a trend I’ve read about, not only in the U.S. (Indiana’s response to the Hepatitis C outbreak because of heroin abuse is a needle exchange program via Senate Enrolled Act 461) but abroad (Canada, Portugal, Netherlands). The programs are often called “injection rooms” or “safe havens” or “needle exchanges,” sometimes even coming with outright legalization or decriminalization of drugs like heroin. Concerns are whether providing these options legitimizes use and therefore enables the addicts. Obviously, the preference would be to help people rid themselves of addiction and corresponding behavior. As far as results, studies in Portugal indicate decriminalization has not affected drug usage but has dramatically decreased drug-related pathologies like STD and Hep C and HIV. For more information about that, please read https://en.wikipedia.org/wiki/Drug_policy_of_Portugal.
  21. So what is the generally correct progression or step down in using an opioid after surgery? What would be a “pre-red flag”? Step therapy is going to be directly related to the level of pain associated with the effects of the surgery or injury. In some cases, that could be one to two days with a rapid de-escalation (e.g. Percocet to Tramadol to Ibuprofen). In other cases, where the trauma is significant or followed by painful physical therapy, step therapy could be two to three weeks or even months. Not only is the titration related to the severity of the pain, but so is the tolerance to pain or the side effects by the patient (e.g. the constipation is enough for the patient to want something different). Following are some “pre-red flags” that you might consider: Did the provider prescribe an unusually high days’ supply or quantity (e.g. a 30-day supply or 60 pills)? Did the patient run out of supply before the next office visit? Is there no evidence in the provider’s notes that a discussion occurred with the patient on the tapering process (i.e. articulating the exit strategy)? Was there a tapering attempted, but the patient did not respond well? Instead of tapering down (e.g. 20mg to 10mg, Percocet to Tramadol) is the potency increasing (Percocet to OxyContin)? Is it clear that the patient is not moving toward therapy and activity per expectations? In other words, “pre-red flags” are going to be gleaned from the provider’s notes during and post-surgery and prescribing patterns.
  22. Have you seen Suboxone prescribed as a painkiller vs. a manner by which to wean off heroin? What are your thoughts on Suboxone? The FDA is very clear in its labeling – “SUBOXONE sublingual film is a partial-opioid agonist indicated for treatment of opioid dependence.” Therefore, use of Suboxone for pain is considered off-label. Typically, the FDA approves uses (on-label) where the manufacturer can clearly document the benefits of use for a specific condition, so being considered off-label means the evidence was either not clear or not presented. There are many drugs prescribed off-label (the FDA allows off-label use, only restricting manufacturers from advertising or advocating off-label use), and Suboxone certainly qualifies. For all of the labeling details, go to http://www.accessdata.fda.gov/scripts/cder/drugsatfda. Interestingly, Butrans is another buprenorphine formulation that has been approved “for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.” There are some benefits to both in their built-in abuse deterrence mechanisms. While they’re not 100% airtight, they do put enough obstacles in place to make abuse more difficult (although Suboxone is highly abused in prisons). The concern I’ve heard from payers is that these drugs do not facilitate the tapering of opioids, so they are just added to the overall drug regimen, and they are much more expensive than many of the generic opioids, so reconciliation of therapeutic value vs. financial value is troublesome. Unfortunately, abuse deterrent mechanisms are not as widely available for generics as for name brands My personal opinion is there are less expensive treatment options than Suboxone, so it should be reserved for exceptions.
  23. Do you believe that legislation will be written in the near future that will penalize health providers if they exceed recommended narcotic treatment guidelines? Public policy is not only something based on evidence but also on politics. There certainly are enough treatment guidelines available from a variety of sources that indicate thresholds and areas of concern that would highlight abuse while protecting access to patients who receive benefits. Unfortunately, many of those guidelines don’t come with the necessary mandates or penalties for non-adherence. There are powerful lobbyists employed to maintain the status quo. At some point, I think the evidence of death and destruction from our prescription drug abuse epidemic will overwhelm the lobbyists and public policy will not only create mandates but also stronger enforcement mechanisms. The momentum is clearly on the side of more oversight. And it would not surprise me if personal injury lawyers start issuing more lawsuits and medical malpractice to rid the medical practice of the bad actors. Until then, it’s up to the DEA and state/local law enforcement to find and prosecute inappropriate prescribers, to provide help to substance abusers and to educate everybody of the dangers.

The ‘CURES’ for Work Comp Claims

When an injured worker submits a claim, it initiates processes aimed at returning the injured worker to gainful and sustainable work at the earliest possible time. In this journey, checkpoints and milestones are the best means to monitor progress. Checkpoints generally relate to visits with a medical practitioner where medical conditions are checked against expectations and, if necessary, treatments are adjusted. Milestones are associated with reaching a goal.

At the first medical appointment, the physician is required to prepare a report for the claims administrator based on a comprehensive medical examination of the injured person, including a review of the medical history. At the same time, the physician can access CURES (Controlled Substance Utilization Review and Evaluation System) to check whether the patient has received any scheduled controlled substances in the prior 12 months. Through this access, the physician can identify an at-risk patient and accordingly establish a treatment plan that considers both medications and adjunctive treatments. Also, if a patient is identified as an addict, he can be referred for rehabilitation and social re-integration. With subsequent medical appointments, the physician can again use CURES to check for any changes to the patient’s scheduled controlled substances usage since his last visit.

The importance of a physician using CURES to check a patient’s use of scheduled controlled substances cannot be overemphasized, especially in workers’ compensation, where a patient may not be forthcoming in sharing comorbidity information because of a lack of trust. Not knowing if a patient is currently taking scheduled controlled substances, the physician could jeopardize the patient by prescribing inappropriate medications.

In addition to the medical profession, CURES is available to Department of Justice investigators and law enforcement agencies to identify persons who visit a number of physicians to obtain supplies of scheduled controlled substances for abuse and diversion (i.e. physician shopping). Pharmacists and numerous regulatory boards from the medical board to the veterinary board also have access to CURES, providing them with the opportunity to monitor the medical profession for aberrant prescribing of scheduled controlled substances.

While states like Florida implemented a PDMP (prescription drug monitoring program) as late as 2011, California has monitored Schedule II controlled substances since 1940 and with the introduction of CURES in 1996 extended its monitoring to include Schedule III and IV controlled substances. Online access to CURES has also been available to the medical profession since 2009. Consequently, California has not experienced the abuse and diversion that Florida has with its “pill mills.”

Access to CURES by claims administrators or their representatives (i.e. third party payers) will not deliver improved quality of care or reduce prescription drug fraud and abuse and will add unnecessary costs through duplication of efforts already being performed by others using CURES. Close monitoring of checkpoints, however, by the claims administrator will provide benefits. Monitoring is accomplished through what is commonly referred to as “encounter data” and includes diagnoses, services performed and medications dispensed along with amounts charged and paid. Diagnoses, medical procedures and pharmaceuticals translated into coding systems such as ICD-10 (International Classification of Disease, 10th revision), HCPCS (HeathCare Common Procedure Coding System) and NDC (National Drug Code) provide excellent opportunities to automate the monitoring of encounter data.

Have claims administrators been able to implement technology solutions to automate the monitoring of encounter data and achieve outstanding results? Over the past two decades, many claims administrators have opted to outsource the management and control of critically important functions such as utilization review, medical bill review and pharmacy monitoring. Many of the outsource organizations only focus on that part of the encounter data that directly applies to their function — for example, pharmacy benefit managers only monitor the pharmacy. But using all the encounter data can promote a vibrant synergy very capable of achieving outstanding outcomes and results for the injured worker.

Losing control of encounter data eliminates the claims administrator’s ability to establish and monitor adherence to best evidence-based practices. When physicians have not adhered to their proposed treatment plans, opportunities to trigger yellow and red flags for investigation are lost.

Claims administrators who have automated the monitoring of their encounter data can assist states in reducing abuse and diversion by monitoring the quantities of medications being dispensed in a progressive or step therapy pain management plan, for example, and encouraging unused supplies to be returned to the physician at the next appointment. This can be achieved at no additional cost to the claims administrator and reduces the quantities of unused or unneeded prescription medications in circulation, which has been the focus of the DEA’s (U.S. Drug Enforcement Agency) “take back” initiatives. To date, the DEA has collected in excess of 1,400 tons of unused medications, which could otherwise have found their way into the illicit drug market.

For as long as the U.S. remains the biggest licit and illicit drug market in the world, claims administrators will remain challenged to deliver on their workers’ compensation claims handling obligations.

With a changing workforce, claims administrators will need to move more and more toward a biopsychosocial approach to managing medical conditions. They must provide quality care at the lowest possible cost, which can only be achieved through the fine analytics of consolidated encounter data.

Capturing encounter data through the claims administrator’s processes and fine analytics will consistently yield the best claims outcomes, from earlier return-to-work to lower costs associated with medical treatment through to automated overseeing of a claim, including provider performance monitoring and evaluation. All of these are the essence of superior workers’ compensation claims management.

Winning the War Against Opioid Addiction and Abuse

As we move forward with winning the war against opioid addiction, it can sometimes be challenging to read the daily headlines and stay positive, especially around the holidays. A December article titled “Drug Abusers May be Injuring Pets to Get Pain Killers” shared how police officers and community leaders informed the Ohio attorney general’s office that people have been abusing drugs rightfully prescribed to pets. The US News HealthDay story titled “Secure Your Prescription Drugs When Hosting Holiday Parties” warned readers about the importance of securing prescription drugs in a safe location before guests arrive. When stories deteriorate to addicts intentionally harming their dogs and to people worrying about holiday guests raiding medicine cabinets, rock bottom isn’t far away.

However, 2013 positioned us well for achieving improved results during 2014. Some of last year’s positive developments include:

1.   State law changes establishing clearer standards of care, reporting and tracking of controlled narcotics, bans on abused narcotics, etc.

2.   State and federal agencies aggressively prosecuting individuals who prescribe opioids illegally or  operate “pill mills,” revoking registrations of some pharmacies and compelling healthcare providers and pharmacies to surrender or forfeit their medical licenses to state medical/pharmacy boards

3.   Physician-led education efforts like the Physicians for Responsible Opioid Prescribing

4.   Medical boards actively addressing the inappropriate and illegal dispensing of drugs

5.   Heightened awareness of the neonatal abstinence syndrome crisis in the U.S.

6.   Workers’ compensation insurers leveraging advanced analytics, physician education efforts, evidence-based pain diagnoses and utilization reviews to reduce injured worker reliance on addictive prescription drugs

7.   The Food and Drug Administration’s Risk Evaluation and Mitigation Strategy

8.   The issuance of the October 2013 Trust for America’s Health report titled “Prescription Drug Abuse: Strategies to Stop the Epidemic”

9.   Continuing prosecution and sentencing of healthcare providers

10. Efforts by national medical organizations

The first eight developments were addressed in the authors’ first quarter 2013 Physician Insurer magazine article titled “The Opioid Abuse Epidemic, Turning the Tide” and our Dec. 2, 2013 Property Casualty 360 Claims Magazine article titled “10 Strategies to Combat the Rx Abuse Epidemic – An Insurers Perspective.”

This article will expand on the last two developments and share some thoughts on what may be in our future when it comes to winning the war on opioid addiction and abuse.

Prosecution and sentencing of healthcare providers

2013 was marked by the successful prosecution and sentencing of healthcare professionals involved in various forms of prescription drug diversion. Arguably the most notable of these was the 39-year prison sentence given to David Kwiatkowski, the former New Hampshire hospital technician who caused dozens of people to become infected with hepatitis C when he injected himself with pain killers using syringes that were then used on patients. Kwiatkowski admitted in August to stealing the drugs and leaving used syringes for hospital use for years, despite knowing he was infected with hepatitis C. His case drew national attention to the problem of prescription drug diversion among healthcare workers; caused a number of institutions to finally take a fresh look at their human resource policies and systems being used to detect diversion; and, has, we hope, sent a strong message of deterrence to all healthcare drug diverters — it is only a matter of time before you get caught!

Efforts by national medical organizations (NMOs)

On an extremely positive note, we are beginning to see NMOs join the fight to help stem the opioid epidemic. On Dec. 10, 2013, the American College of Physicians released a position paper titled “Prescription Drug Abuse: A Policy Position Paper From the American College of Physicians.” The goal of the paper was to provide physicians and policy-makers with 10 recommendations to address the significant human and financial costs related to prescription drug abuse. The recommendations include support for additional education, a national prescription drug monitoring program, establishment of evidence-based nonbinding guidelines regarding recommended maximum dosage and duration of therapy, consideration of patient-provider treatment agreements and the passage of legislation by all 50 states permitting electronic prescription for controlled substances.

In turn, in January 2014, the American Academy of Pediatrics (AAP) Committee on Drugs and Section on Anesthesiology and Pain Medicine issued a report titled “Recognition and Management of Iatrogenically Induced Opioid Dependence and Withdrawal in Children.” The clinical report recommended guidelines for prescribers to follow when weaning children from opioids. As noted by lead author Jeffrey Galinkin, MD, “[t]he key reason the AAP was keen to publish this paper and go forward with this guideline is that people are unaware that patients can get drug-specific withdrawal symptoms from opioids as early as five days to a week after having been on an opioid chronically.”

This recommendation was immediately followed by the Centers for Medicare and Medicaid Services (CMS) Jan. 10, 2014, Federal Register Volume 79, Number 7 publication of proposed rules revising the Medicare Advantage (MA) regulations and prescription drug benefit program (Part D) regulations to help combat fraud and abuse in these programs. The proposed rules include requiring prescribers of Part D drugs to enroll in Medicare, a feature that CMS believes will help ensure that Part D drugs are prescribed only by qualified individuals. As reported by Medscape Medical News, CMS is also seeking the authority to revoke a physician’s or eligible professional’s Medicare enrollment if:

• CMS determines that he or she has a pattern or practice of prescribing Part D drugs that is abusive and represents a threat to the health and safety of Medicare beneficiaries or otherwise fails to meet Medicare requirements; or

• His or her Drug Enforcement Administration certificate of registration is suspended or revoked; or

• The applicable licensing or administrative body for any state in which a physician or eligible professional practices has suspended or revoked the physician or eligible professional’s ability to prescribe drugs.

Furthermore, CMS proposes employing data analysis to identify prescribers and pharmacies that may be engaged in fraudulent or abusive activities. In Table 14 of Federal Register Volume 79, Number 7, CMS’ Office of the Actuary estimates the savings to the federal government from implementing its proposed provisions will be $83 million in calendar year 2015, $132 million in 2016, $171 million in 2017, $364 million in 2018 and $589 million in 2019.

Source: CMS

Innovation in our future

In addition to the above efforts, companies continue to innovate and research new ways to address historical challenges.

Vatex Explorations is building a real-time individual-dose monitoring system called Divert-X to reduce drug trafficking, misuse and addictions that result from routine medical care. Divert-X monitors a patient’s individual doses through the electronic transmission of data identifying the time of dose access, location and other measures. The analysis of the data in real time helps physicians and pharmacists identify drug-taking behaviors that fall outside of norms, allowing early intervention before misuse or addiction set in.

In 2012, the Food and Drug Administration approved an ingestible sensor that can be used to track real time data about your pill consumptions habits. The sensor, developed by Proteus Digital Health, was first approved for use in Europe before coming to the U.S. The ingestible sensor is part of the digital health feedback system, which includes a wearable sensor and secure app and is largely focused on serving the transplant population and patients with chronic illnesses. The authors could envision a day when the system could help in the battle against opioid addiction.

Insurance companies are doing a better job of leveraging advanced analytics to understand their opioid-exposed population and the prescribing habits of the physicians treating their injured workers. Through the review of medical bills (e.g., date and types of service and payment, ICD-9 diagnosis codes, CPT-4 procedure codes, etc.) and pharmacy data (e.g., bill frequency,  aggressive refills, NDC drug codes, quantity used, generic vs. brand, supply days, use of prescriber, pharmacy name, etc.), insurance companies can identify usage and treatment patterns that fall outside of expectations using cluster analyses, association rules, anomaly detection and network “link” analyses.

Law enforcement continues to push the envelope in finding innovative ways to combat drug diversion. Take, for example, the strategy developed in consultation with the National Association of Drug Diversion Investigators and Oklahoma Bureau of Narcotics to curb false reporting of the loss or theft of prescription drugs in Stillwater. According to a police spokesman, most physicians in Stillwater require patients to obtain a police report before they will write a replacement prescription for lost or stolen medications. This requirement resulted in an increase in the number of police reports filed, but a new problem emerged. How could anyone determine whether those police reports were legitimate? In response, the Stillwater police department created a database to record the names of any individual who reported the loss or theft of a prescription drug. The department now requires the individual to take a polygraph test before it will accept any subsequent report of a lost or stolen prescription drug. Fail that polygraph, and criminal prosecution may follow. Query: If this strategy were employed nationwide, would the medicine cabinet at home be guarded more closely?

Conclusion

There is no doubt we have come a long way in the battle against opioid addiction in a relatively short time. Although there is a lot of road left to travel, 2014 is well-positioned to carry forward the effective efforts from last year. Given the innovative spirit of the U.S. and passion of everyone involved in winning this fight, a better long-term solution could be just around the corner.

10 Strategies to Combat the Rx Abuse Epidemic – An Insurer's Perspective

The misuse and abuse of prescription drugs has taken a devastating toll on communities all across America. For insurance companies, the financial impact of rising opioid costs continues to cause concerns, as medical payments exceed indemnity payments.

In 1987, medical losses represented only 46 percent of the dollars spent on workers' compensation claims. Today, medical losses represent roughly 60 percent of the dollars spent on these claims.1 In the Winter edition of the NAMIC Mutual Insurance magazine, the article “Opioids: A Workers’ Compensation Epidemic” discussed the Accident Fund Insurance’s 60%/40% medical loss/indemnity loss split, in addition to calling opioids workers’ compensation’s current worst enemy.2

With approximately 20 percent of all medical spending going towards prescription drugs, workers' compensation, insurers have been working hard to mitigate these costs. Insurers have negotiated discounts with preferred providers, established comprehensive prescription drug networks, used advanced analytics to identify the most severe claims, promoted evidence-based pain diagnoses, leveraged utilization reviews, and invested in tort reform. All of these measures have been taken with the goal of reducing injured worker reliance on addictive prescriptions drugs and helping workers return to work sooner.

To address the opioid epidemic, a number of strategies have been developed at both the national and state levels in consultation with medical professionals, law enforcement, insurance companies, and public health and drug prevention experts. In October 2013, the Trust For America’s Health (TFAH) issued a report titled, “Prescription Drug Abuse: Strategies to Stop the Epidemic” identifying ten strategies being employed at the State level.3 In this article, we will provide a brief recap of the strategies and share our thoughts on some insurance company considerations.

Although no single strategy is a “silver bullet” that will alleviate the opioid epidemic, each strategy must be considered in the context of the unique circumstances that exist in each state. Ultimately, these efforts could play a role in helping insurance companies mitigate opioid related costs going forward.

A Recap of the 10 Strategies

1. Prescription Drug Monitoring Program: Does the state have an operational Prescription Drug Monitoring Program (PDMP)?

The TFAH report noted that 49 states have an active PDMP. These programs hold the promise of being able to quickly identify problem prescribers and individuals misusing and diverting drugs. The Prescription Drug Monitoring Program Center of Excellence at Brandeis University, the National Alliance for Model State Drug Laws, the Alliance of States with Prescription Monitoring Programs and other organizations have stressed the importance of PDMPs in fighting prescription drug abuse and misuse and improving patient safety. These organizations have also issued a variety of recommendations and leading practices for PDMPs including interstate operability, mandatory utilization, expanded access, real-time reporting, use of proactive alerts, and integration with electronic medical records.

On September 13, 2013, the American Society of Health-System Pharmacists web site discussed how PDMP programs are gaining steam.4  Specifically, they mentioned how New York became the first state to require that prescribers consult the State’s PDPM registry before prescribing Schedule II, III or IV controlled substances.   From an insurance company perspective, understanding how effective PDMP programs are with controlling physician prescriber behavior can help claim adjusters and actuaries gain a better understanding of medical costs going forward.

Of note, Missouri is currently the only state without a PDMP. From our perspective, this raises concerns that Missouri could be targeted by individuals looking to illegally sell/purchase prescription drugs and profit from their misuse and abuse. Without the tracking and monitoring of prescriptions, some patients may find it convenient to cross the border in order to fill their medications in Missouri. Not surprisingly, on November 21, 2013, KCTV News (Kansas City) published a story titled “Missouri a hot spot for 'doctor shopping' for Rx drugs” which seems to support this concern.5

2. Mandatory Use of PDMP: Does the State require mandatory use of PDMPs by providers? (i.e., any form of a mandatory use requirement).

The TFAH report found only 16 States require use of the PDMP by providers (and then only in certain situations) and of those States, only eight States require use of the PDMP before the initial dispensing of a controlled substance. From our perspective, it isn’t surprising that some professionals find the lack of enforcement troubling, especially given the recommendation from the Prescription Drug Monitoring Program Center of Excellence at Brandeis University that utilization of PDMPs be mandated for all prescribers.

Some providers have expressed genuine discontent with the mandatory use of the PDMP, since it increases their administrative burden and may reduce the time they can spend with patients.  However, this additional burden has to be weighed against the benefits of mandatory PDMP usage which can help prevent an addict from filling duplicate prescriptions, identify a stolen prescription pad, or highlight a provider who is obviously writing phony subscriptions. 

Ultimately, the majority of health-care providers rank patient health and safety as a priority, and given the undeniable prevalence of the prescription diversion and abuse, their goal can only be furthered by using the PDMP.  Lastly, from an actuarial perspective, the mandatory use of PDMP’s would increase the ability of States to measure the true value/effectiveness of PDMP efforts.

3. Doctor Shopping Law: Does the state have a doctor shopping statute?

Doctor shopping is the practice of seeing multiple physicians and pharmacies to acquire controlled substances — for a person’s own use and/or for reselling purposes. The TFAH report noted that all States have laws in place that either:

a) Make it a criminal offense to obtain drugs through fraud, deceit, misrepresentation, subterfuge, or concealment of material fact.

b) Make doctor shopping illegal.

c) Prohibit patients from withholding information that they have received either a controlled substance or prescription order from another practitioner, or the same controlled substance or one of similar therapeutic use within a specified time interval.

Doctor shopping laws are aimed at deterring individuals from one method of wrongfully obtaining prescription drugs. In Tennessee, the Office of the Inspector General has used these laws very effectively.

In the Long Island Newsday article “State’s new prescription pain pill system snags apparent doctor shoppers”, New York State’s online system discovered 200 instances of apparent doctor shopping in the first three days of use.6   With diversion and addiction on the rise, anything we can do to keep opioids out of the hands of those who shouldn’t access them is a move in the right direction. The more illegal pills taken out of circulation, the less likely an addicted injured worker will be able to further any bad habits.

4. Support for Substance Abuse Services: Has the state expanded Medicaid under the Affordable Care Act, thereby expanding coverage of substance abuse treatment?

The TFAH report noted that in 2011, 21.6 million Americans age 12 and older needed treatment for a substance abuse problem, but only 2.3 million received treatment at a substance abuse facility. This shortfall represents a “treatment gap” where treatment is not readily available for millions of Americans who are in need of assistance. The TFAH report found that 24 states and the District of Columbia have expanded Medicaid under the Patient Protection and Affordable Care Act (ACA), thereby expanding coverage of substance abuse treatment. However, it is unclear whether the remaining 26 States will expand their Medicaid coverage and substance abuse treatment efforts.

The authors have experienced firsthand the need for additional substance abuse treatment during the radio shows we host on Rx Drug abuse issues.  Several callers have expressed frustration over not being able to receive substance abuse treatment either for themselves or a loved one and want to know where they can go to find help.  Sadly, some Americans have resorted to committing a crime so they could receive free treatment while incarcerated.

Fortunately for some workers’ compensation claimants, a number of insurance companies have been proactively leveraging pain management programs to help wean injured workers off of addictive opioids.  This not only improves the quality of life of for the injured worker and his/her family, but benefits the employer through the employee’s return to work and the insurance company’s lower expenditure on medical.

5. Prescriber Education Requirement: Does the state require or recommend education for prescribers of pain medications?

The TFAH report noted it is important to educate providers about the risks of prescription drug misuse to prevent providers from prescribing incorrectly and/or to ensure they consider possible drug interactions when prescribing a new medication to a patient. The report also noted that most medical, dental, pharmacy, and other health professional schools currently do not provide in-depth training on substance abuse and students may only receive limited training on treating pain.

In July of 2012, the Food & Drug Administration (FDA) approved a Risk Evaluation and Mitigation Strategy (REMS) for extended release opioids that require manufacturers to fund voluntary painkiller training programs, at little to no cost, to all U.S. licensed prescribers. The FDA then issued a letter to prescribers, which was distributed by the American Medical Association (AMA), American Academy of Family Physicians (AAFP), the American Academy of Physician Assistants (AAPA), the American Academy of Pain Management (AAPM) and ASAM, which recommended that prescribers take advantage of those educational programs. However, the FDA did not make attendance by prescribers mandatory, a decision which drew criticism from some individuals that believed REMS should be mandatory.

How critical is the need for re-education regarding prescribing of opioids? In May of 2013, Dr. Thomas R. Frieden, the Director of the Centers for Disease Control and Prevention stated in a PBS interview: “When I went to medical school, the one thing I was told was completely wrong. The one thing I was told was if you give opioids to a patient who is in pain, they will not get addicted.  Completely wrong. Completely wrong. But a generation of doctors, a generation of us grew up being trained that these drugs aren’t risky.”7 If Dr. Frieden is correct, then the TFAH’s finding that only 22 States either require or recommend prescriber education for pain medication prescribers indicates that we have a long way to go in stemming the Rx Drug abuse problem. 

However, it is important to note that some insurance companies are doing their part in helping to educate prescribers. As noted on the Employers’ Insurance Company website, the company’s opioid program takes proactive measures to help control the flow of narcotics by involving the workers’ compensation insurance carrier, injured employees, workers’ compensation physicians and pharmacy benefit managers. The first prong of their program focuses on training physicians to recognize the signs of opioid abuse and encourages them to consider other effective pain management alternatives.8 It is insurance company efforts like this, in combination with FDA REMS, Physicians for Responsible Opioid Prescribing (PROP)9, and state and federal efforts that will help stem the Rx drug abuse problem.

6. Good Samaritan Law: Does the state have a law in place to provide a degree of immunity from criminal charges or mitigation of sentencing for an individual seeking help for themselves or others experiencing an overdose?

Per the TFAH report, 17 states and the District of Columbia have a law in place to either provide a degree of immunity from criminal charges or mitigation of sentencing for an individual seeking help for themselves or others experiencing an overdose. These laws are designed to encourage people to actually help those in danger of an overdose, as opposed to walking away or not even making the call to 911.

The TFAH report noted that a study conducted after passage of Washington’s 911 Good Samaritan Law found that 88 percent of prescription painkiller users indicated that once they were aware of the law, they would be more likely to call 911 during future overdoses. Thus, this strategy may well be critical in helping stem the toll of Rx Drug abuse until prescribing practices can be modified.

7. Support for Narcan Use: Does the state have a law in place to expand access to, and use of, Narcan (a/k/a, Naloxone) for overdosing individuals given by lay administrators?

Narcan is an FDA approved drug that can be used to counter the effects of prescription painkiller overdose. It is not a controlled substance; has no abuse potential; and, can be administered by minimally trained laypeople. The TFAH report found that 17 states and the District of Columbia have a law in place to expand access to, and the use of, Naloxone for overdosing individuals given by lay administrators. In addition, Washington and Rhode Island are currently implementing collaborative practice agreements where Narcan can be distributed by pharmacists.

As was noted in the article “Naloxone Expansion in California Will Enable Family, Friends To Save Lives At Home,” Californians are now able to reverse overdoses at home with a lifesaving injectable drug called Narcan, which can be administered through the nose or intravenously to a person suffering from an opiate overdose.10

8. Physical Exam Requirement: Does the State require a healthcare provider to either conduct a physical exam of the patient, a screening for signs of substance abuse or have a bona fide patient-physician relationship that includes a physician examination, prior to prescribing prescription medications?

Per the TFAH, 44 States and the District of Columbia have such a requirement. Unfortunately, the State laws vary regarding the circumstances under which an exam is required (for example, for all drugs or just specified prescriptions) and the consequences for prescribing without a required examination (i.e., whether there is criminal liability). While this is a promising strategy, wouldn’t unanimity between the States make this strategy even more effective?

The authors question whether “a physical exam requirement” is a better strategy than simply requiring a drug screen. While increased costs may be associated with such a strategy, a urine drug screen is the single most useful test to determine if someone is abusing controlled substances or diverting drugs they have been prescribed.

9. ID Requirement: Does the State have a law requiring or permitting a pharmacist to ask for identification prior to dispensing a controlled substance?

Pharmacists, as the dispensers of prescription drugs, play an important part in the distribution chain. Recognizing this role, the DEA took significant enforcement action in 2013 against national pharmacy chains for allegedly failing to recognize unusual sale volumes of controlled substances in several of their pharmacies.

The TFAH report found that 32 States have laws requiring or permitting a pharmacist to request an ID prior to dispensing a controlled substance. These laws vary in type from requiring presentation of an ID in all circumstances versus those where the purchasers are unknown to the pharmacist. In addition, some States require photo identification and others accept a broader range of government IDs.

The authors note that this “strategy” may represent one of the easier hurdles for drug seekers to circumvent given the ease of falsifying ID’s.  However, the battle against opioid addiction is a battle of inches, and the ID check represents one more step a possible abuser has to overcome to support their bad habit.

10. Pharmacy Lock-In Program:  Does the State’s Medicaid plan have a pharmacy lock-in program that requires individuals suspected of misusing controlled substances to use a single prescriber and pharmacy?

The TFAH report noted that in order to help healthcare providers monitor potential abuse or inappropriate utilization of controlled prescription drugs, some States have implemented programs requiring high users of certain drugs to use only one pharmacy and get prescriptions for controlled substances from only one medical office.  Lock-in programs are believed to help avoid doctor shopping while ensuring appropriate pain care for patients.

Forty-six states and the District of Columbia were noted to have a pharmacy lock-in program under the State’s Medicaid plan where individuals suspected of misusing controlled substances must use a single prescriber and pharmacy.  From discussions with pharmacists, it isn’t always easy for a pharmacist to question a treating physician about whether a prescription is valid.  From the authors’ experience, we have received a number of anecdotal reports of physicians treating pharmacists in a less than respectful manner when a pharmacist questioned whether a prescription was valid.  In these cases, the pharmacists are simply trying to do their best to help curb prescription drug diversion.  In our view, the Lock-In strategy helps strengthen the professional relationships between doctors and pharmacists.

How are the States Doing with Implementing the Strategies?

The TFAH report found that the States’ implementation of the 10 strategies vary widely. For example, 11 States have implemented at least 8 of the 10 strategies. 4 States have implement at least 9, and only New Mexico and Vermont have implemented all 10. Interestingly, in 2010 New Mexico ranked #2 in drug overdose mortality rate per 100,000 residents (which includes both prescription drug and illicit drug overdoses) while Vermont ranked 42nd. It will be interesting to see what advances, if any, New Mexico makes in the Rx drug abuse/misuse war during the next several years with all 10 strategies in place.

On the flip side, South Dakota is the only state with just 2 of the strategies in place.  However, it ranked 50th in drug overdose mortality rate per 100,000 residents in 2010, suggesting the State may not have a misuse/abuse problem of significance. However, two states, Missouri and Nebraska, have only three of the promising strategies in place. In 2010, Missouri ranked 7th in drug overdose mortality rate per 100,000 residents, while Nebraska ranked 49th. With no PDMP, it will be interesting to watch where Missouri ranks in future studies.

With over 60 percent of workers’ compensation payments going towards medical costs, it will be important for insurers to pay close attention to state specific efforts to combat prescription abuse. With the right amount of actuarial research and advanced analytics, workers’ compensation insurers can develop a better understanding of their opioid exposed population and the prescribing habits of the physicians treating their injured workers.  To the extent insurance companies can leverage the above strategies in combination with their own analytics, physician educational efforts, evidence-based pain diagnoses, utilization reviews, and tort reform efforts (e.g., In 2011, the 79th Texas Legislature adopted a closed formulary system which led to a 70 percent decrease in Schedule II narcotic costs11), we believe insurers can move the needle on reducing opioid abuse and addiction.

In the end, these opioid risk management strategies may not only generate dollar savings to workers compensation insurers as workers return to work sooner, but will help improve the quality of life for the injured worker and his/her family.

Footnotes

1 http://www.ncci.com/

2 http://www.namic.org/in/13winterpre.asp

3 http://healthyamericans.org/reports/drugabuse2013/TFAH2013RxDrugAbuseRpt12_no_embargo.pdf

4 http://www.ashp.org/menu/News/PharmacyNews/NewsArticle.aspx?id=3951

5 http://www.kctv5.com/story/24039604/missouri-a-hot-spot-for-doctor-shopping-for-rx-drugs

6 http://www.newsday.com/news/region-state/state-s-new-prescription-pain-pill-system-snags-apparent-doctor-shoppers-1.5995395

7 http://www.pbs.org/newshour/extra/daily_videos/prescription-drug-abuse-can-have-fatal-consequences/

8 http://www.employers.com/AGENTS/BLOG/post/2013/10/07/Opioid-Program-Shows-Results.aspx

9 http://www.supportprop.org/

10 http://www.huffingtonpost.com/2013/10/11/naloxone-expansion-california_n_4081044.html

11 http://www.riskandinsurance.com/story.jsp?storyId=533355286

Authors

Kevin Bingham collaborated with Alix C. Michel and David J. Ward in writing this article.

Alix C. Michel is an attorney at Michel & Ward, a firm based in Chattanooga, TN specializing in the defense of all types of healthcare professionals, hospitals, longterm care facilities, and educating society on the dangers of RX Drug Diversion and strategies to help in the fight against same.

David J. Ward is an attorney at Michel and Ward, a law firm based in Chattanooga, TN. Michel and Ward defends and advises physicians, healthcare providers, longterm care facilities, and others in professional malpractice litigation, professional licensing investigations, and healthcare practice issues.

This article first appeared on December 2, 2013 on PropertyCasualty360.com. © 2013 PropertyCasualty360, A Summit Professional Networks website.