10/15/2013

The Walking Meds

Strategies for preventing prescription pill zombies in workers’ compensation claims.

By Patrick Walsh , Jeffrey Austin White

There is an age-old debate: does life imitate art or does art imitate life? We suggest that when it comes to the use of narcotics in our society, there is a parallel between society and art that you probably haven’t considered.

According to www.ZombieZoneNews.com (“the most comprehensive zombie movie database”), there have been more than 400 zombie-based films made since 2000. This represents a 33 percent increase in zombie films since the turn of the century. Is it possible that the movie industry has somehow inadvertently caused the increase in narcotic utilization in workers’ comp? Is there even a relationship between zombies and opioids?

If we cannot blame the problem on moviemakers, why don’t we just go after video game makers? Nothing shapes the young adolescent mind better than a good old post-apocalyptic, flesh-eating, first-person shooter game. Scientific research from organizations like Iowa State University’s Center for the Study of Violence concludes that playing violent video games can lead to aggressive behavior and higher anxiety levels in teens. Now, if we can just prove that zombies take drugs, we might be on to something.

If these parallels don’t work for you, think about this. The film and gaming industries know what people want and what sells, as does the pharmaceutical industry. What sells in the workers’ compensation industry are potent, addictive, and extremely dangerous narcotics developed for end-stage cancer patients. Drugs like Hydrocodone, Oxycodone, Fentanyl, and Actyc come in all shapes, sizes, and compounds and, yes, even creams. Opioids are the number one prescribed drug by volume of scripts in the industry. According to a national vital statistics report, drug companies are now producing 698 milligrams of opioids per person in the U.S. per year—a 900 percent increase since the year 2000.

So why is the U.S. the world’s leading consumer of opioid pain medications? Why does a country that represents five percent of the world’s population consume more than 56 percent of the world’s pain pills? We argue that it is to improve our chances for becoming a pill-head zombie.

A Widening Scope

In an industry responsible for taking care of injured workers who often require chronic pain therapy, narcotics are the most available and profitable solution. There is little to no education or oversight on prescribing in workers’ comp claims, and carriers are required to pay for the drugs unless they want to battle it out in court.

Until state legislatures take a more active role in this epidemic, the workers’ compensation industry will continue to see an increase in the use of narcotics. Unfortunately, in the meantime, injured workers are finding themselves in a zombie-like state, unable to return to work and abandoned without a functional restoration plan. While we respect how some may think we are exaggerating and overreacting to the current media frenzy on the topic, let’s look at some of the evidence.

According to the Centers for Disease Control and Prevention, drug overdose death rates in the U.S. have more than tripled since 1990 and have never been higher. Overdose deaths involving opioid analgesics have shown a similar trend starting in 1999 with 4,030 deaths and increasing to 16,651 by 2010.

A Workers’ Compensation Research Institute (WCRI) study in 2011 revealed that 55 to 85 percent of injured workers across the country are now receiving narcotics for chronic pain. New research in the workers’ compensation industry released in 2012 indicates that certain classes of drugs and prescribing practices can dramatically impact medical outcomes, return-to-work times, and overall costs of claims. A recent study from Johns Hopkins University, published in the Journal of Occupational and Environmental Medicine, demonstrated a nine-fold increase in average claims cost in association with long-acting (or time-released) opioids in the absence of increased pharmacy spend.

Additionally, in February, the California Workers’ Compensation Institute (CWCI) published a research brief that demonstrates increased indemnity costs, medical costs, and return-to-work times in association with physician-dispensed opioids. With a renewed research focus on claims outcomes, as well as increased media coverage, the use of Schedule II narcotics to treat chronic pain in workers’ compensation claims has now been correlated to poor outcomes.

Finding the Source

In the face of all of this evidence, it’s clear that there is a problem. And like most of the films in the zombie genre, where solutions are ultimately developed to turn the tide, there are strategies to stem the tide of poor outcomes for injured workers on opioids. Before we review these strategies, let’s take a closer look at this problem and how increased utilization of opioids started from the perspective of the medical industry and the prescribing physician.

We believe there are six primary factors that led to increased utilization of narcotics in workers’ compensation claims, based upon medical consensus starting in the early 1990s. When you consider these, we suggest you also think about whether the current opioid epidemic can be attributed to the high availability of the drugs, lack of patient and physician education, the presence of financial incentives, or some combination of the above.

1    The belief that chronic pain was generally undertreated.

2    The belief that the use of opioids is safe and effective.

3    The belief that addiction would be rare in a clinical setting.

4    The belief that an established set of clinical guidelines would be widely accepted and utilized to help avoid serious problems. (American College of Occupational and Environmental Medicine  guidelines are not generally enforced.)

5    The belief that controlled-release or long-acting opioids would increase compliance and be less subject to abuse (even though there is no prevention of simultaneously using short-acting drugs).

6    The shift in societal perception towards the use of opioids, which no longer carries the stigma that was associated with their use 20 years ago. Further, aggressive marketing for the liberal use of opioids in virtually all painful conditions (led primarily by the pharmaceutical industry) has fueled the growth in prescription numbers and costs.

Correcting Course

As we become more knowledgeable about the impact of opioids on injured workers, we start to look for real solutions one belief at a time. So what can we do today to correct this problem and prevent an ecosystem that promotes the overutilization of opioids and an increased population of pill-head zombies?

First, ask the prescribing physician these simple questions:

1    Has the patient signed an opioid treatment agreement or narcotics contract?

2    Do you have the patient undergo regular urine drug monitoring?

3    Did you consult a prescription drug-monitoring database prior to writing the prescription?

4    Has an opioid risk assessment been completed to evaluate the likelihood of abuse issues?

5    What are the specific treatment goals for this patient in terms of functional improvement?

6    Have you reviewed the morphine equivalency of the prescription, and are you relatively certain that your treatment plan is consistent with the evidence-based medicine guidelines?

Carriers also can take a more active role in finding a solution by monitoring prescribing patterns for unwanted, aberrant, or fraudulent behaviors. The secret to success for improved claims outcomes, and keeping the injured worker safe, is contingent upon early intervention of these behaviors.

Detection of problematic behaviors can be accomplished with the implementation of a pharmacy benefit manager formulary or a custom-built early warning system. Below are the top five behaviors you might want to monitor to improve the safety and health of an injured worker using opioids for chronic pain:

1    Drug-Seeking Behavior – Obtaining drugs from multiple sources at the same time.

2    Drug-Diversion Behavior – Use of drugs for illegal or not medically authorized or necessary purposes.

3    Drug Addiction Behavior – Use of drugs for longer periods than necessary, which often results in physical or mental dependency.

4    Drug Overdose Behavior – Use of drugs over the recommended dosage or in combination with other drugs that may cause harm or death.

5    Drug Compliance Behavior – Are workers using the drugs as often as prescribed to ensure the best chances for functional improvement?

As an industry, we need to recognize that we have an issue, perform more research, continue to monitor behaviors, and develop new intervention strategies. It’s our obligation to ensure injured workers receive the appropriate care and treatment in order to make a productive and healthy return to work. We know that addressing these kinds of problems may require a unique and individual approach that is often expensive and time consuming. It is not an easy battle on the front lines—but neither is fighting zombies.   



Patrick Walsh is vice president and chief claims officer for Accident Fund Holdings Inc. He has been a CLM Fellow since 2012 and can be reached at www.afhi.com.

Jeffrey Austin White is director of medical management practices and strategy for Accident Fund Holdings Inc. He has been a CLM Fellow since 2012 and can be reached at www.afhi.com.

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