Opioid misuse and abuse is an all too familiar story for many, including within the workers’ compensation industry. Sprains, strains, burns, lacerations, and punctures commonly require treatment of pain in addition to the wound itself. While many of these types of injuries resolve in less than 90 days, the longer the claim remains open, the greater the likelihood that opioids will be used to treat long-term pain. This often adds complexity and cost to the claim, and may influence return to work, functional restoration, and recovery.And, this isn’t for just one or two claims, but likely hundreds of claims at a time, all of which is time-sensitive and requires the same amount of attention and oversight.
The industry, however, is making positive progress.
Many states have passed regulation/legislation aimed at curbing the misuse and abuse of opioids, both globally and specifically within workers’ compensation. Florida, for example, now requires pain clinics to register with the state and, along with Kentucky, Oklahoma, and Tennessee, strongly limits the dispensing of Schedule II and/or Schedule III medications from a doctor’s office. Numerous states, including California, Florida, Kentucky, and New York, passed legislation to better fund their prescription drug monitoring programs (PDMPs), and enhance reporting times and reporting requirements by prescribers and dispensers. Ohio, Washington, and Wyoming have enacted state-based workers’ compensation formularies, which require pre-authorization prior to dispense of certain opioids. Oklahoma and Texas have adopted a closed formulary, and other states, such as Delaware and New York, have implemented a preferred drug list (PDL) or treatment guidelines to further limit usage of opioids as first-line medication therapy.
The pharmaceutical industry is also making positive changes with the introduction of abuse-deterrent formulations of opioids. Crush-resistant formulations have a harder shell, making it more difficult to crush the pill into a fine powder that can be liquified and injected.
Physicians have greater awareness of and experience with the use of opioid analgesics as part of an injured person’s medication therapy. Physicians are paying closer attention to signs of potential misuse or abuse such as patients who say they are “allergic” to everything except that one, specific opioid; those who have all the right answers to pain threshold questions; patients who insist on paying in cash; those traveling long distances to see them; and those who bring in a family member who directs their choice of medications. They are also implementing Medication Agreements and urine drug testing, checking PDMP databases, and gaining insight from Risk Evaluation and Mitigation Strategy (REMS) and medical guidelines, which are evolving at both the state and national level.
Payers and employers are enhancing their programs to help injured workers. They are putting stronger emphasis on prevention programs and developing programs to aid in communication between physician and injured worker. Working with their pharmacy benefit managers (PBMs), they are able to offer resources to the injured worker to help him or her better manage pain. Plus, they are taking a proactive look at pharmacy data for indicators that an injured worker’s claim could be heading down the wrong path, and engaging their PBM to help with clinical programs.
Advanced analytics programs with predictive models and clinical interactions allow a PBM to assess risk, focus resources, and optimize therapy. As an important liaison between the injured worker, physician, and payer, the PBM can improve outcomes. For example, in our 2014 Drug Trend Report, we reported significant reductions not just in number of prescriptions dispensed but also lower dosages utilized in our book of business. In 2013, there was a 5% reduction in the utilization of opioid analgesics and the prescription cost per claim decreased by 6%. Most impressively, those who used opioid analgesics used lower doses than the previously reported year. Morphine Equivalent Dose (MED) decreased by 9.6% — a significant year-over-year reduction in MED per claim.
This type of collaboration among stakeholders, shared expertise, aligned objectives, and proactive management at every stage of the claim effectively bends the curve away from high-cost misuse and abuse situations and toward brighter outcomes. Join Helios as we light the way forward to ensure safe and appropriate use of opioids through our global utilization management strategies.