OPIOID ABUSE
CRISIS: THE PLAGUE OF
WORKERS
COMPENSATION
KATHLEEN FRASER RN-BC, MSN, MHA, CCM, CRRN
PRESIDENT-ELECT NATIONAL CMSA
“Life is ten percent what happens
to you and ninety percent how
you respond to it.”
Lou Holtz
2
Deaths from prescription opioid
painkillers have reached
epidemic levels in the past
decade.
Opioid analgesics are now
responsible for more deaths than:
the number of deaths from suicide,
motor vehicle crashes, cocaine and
heroin overdoses combined!
4
Persons with pharmaceutical opioid-related
substance use disorders are disproportionally:
•
Caucasian
•
Female
•
Middle-age
•
Residents of rural communities
Yet more men than women die of overdoses from
prescription painkillers.
A disturbing trend has been caused by a whole host
of factors:
• A philosophical shift in physician attitudes toward
the treatment of pain.
• The Joint Commission on the Accreditation of
Healthcare Organizations core principles state
that “patients have a right to pain assessment
and management and a patient’s self-report is
the most reliable indicator of pain.”
6
While this attitudinal shift may be
positive for chronic pain sufferers,
regulatory systems must be designed
to effectively monitor these powerful
prescriptions.
7
Improving the way prescription painkillers
are prescribed can reduce the number of
people who misuse, abuse or overdose
from these powerful drugs, while making
sure patients have access to safe,
effective treatment.
8
Opioid analgesics, such as
oxycodone, hydrocodone, and
methadone, were involved in
approximately 75% of
pharmaceutical overdose deaths.
9
. According to the Center for Disease
Control, “Appropriate screening,
identification, and clinical management
by health care providers are essential
parts of both behavioral health and
chronic pain management.”
10
Some people obtain prescriptions
from multiple prescribers by "doctor
shopping." Pinning down just where
the problem lies is a task which is
arguably as tough as correcting the
problem of opioid abuse itself.
11
There needs to be better mechanisms
to hold prescribers accountable, enable
the use of drug monitoring and testing,
and monitor pain management clinics.
12
The most surprising thing is
that the payer community
has been consistently paying
for these drugs but has
shown little concern for
curbing the abuse. While the
responsibility doesn’t lie
with payers alone, it is now
critical that workers’
compensation stakeholders
come together to stop
these inappropriate
prescribing patterns.
13
Workers’ compensation stakeholders must
confront the inappropriate use of
narcotics in the system. Injured workers
are suffering and employers are paying
for the unintended consequences of
these drugs.
According to The New York Times, the cost of workers’
compensation claims sky rocket when injured
employees start using narcotics. The average lost time
workers’ compensation claim in the U.S. without the use
of opioids cost $13,000. When an employee is
prescribed a short-acting opioid like Percocet, the
average lost time claim cost triples to $39,000. When
an employee is prescribed a long-acting opioid like
oxycontin, the average lost time claim costs explodes to
$117,000, an increase of 900% over the average lost
time work comp claim without the use of any opioids.
15
Nonmedical use of prescription painkillers costs
health insurers up to $72.5 billion annually in
direct health care costs.
Over half a million emergency department visits in
2012 were due to people misusing or abusing
prescription painkillers.
Research indicates :
• Temporary Disability payments are 3.5 times more with opioid
prescriptions .
• There is a 322% greater likelihood for litigation.
• According to National Council on Compensation Insurance, Inc.
(NCCI), approximately 38% of pharmacy costs in Workers’
Compensation are for opioids and opioid combinations, amounting
to over $1.5 Billion.
• Contributing to over $100 Billion in lost productivity, medical costs
and disability payments.
17
“Alone we can do so little;
together we can do so
much.”
Helen Keller
Improved utilization of statewide databases that
track opioid prescriptions, ferreting out and
punishing overprescribing doctors, dealing with
the growing number of pain management clinics
and stricter controls in management of provider
networks are among the solutions a number of
states have adopted or are considering to tackle
this multifaceted problem
19
20
Opioids usually result in a change of motivation
within the injured employee. The employee’s
focus of recovery from the injury is replaced
with a focus on obtaining more of the opioid.
The long term use of opioids results in a subconscious (or sometimes even a conscious),
desire not to recover from the injury but to stay
off work to use the opioid.
NO STATES ARE IMMUNE TO THIS EPIDEMIC!
Louisiana and New York had the highest
utilization of opioids on a long term basis.
• In California, 3 percent of the state’s
doctors prescribe 55 percent of the
opioids.
•
Many states report problems with "pill mills"
where doctors prescribe large quantities
of painkillers to people who don’t need
them medically. They usually go to pill
mills so that they can obtain drugs and
resell them on the street.
22
Georgia just passed a “pill mill” bill that would license
and regulate pain management clinics and now
require the owner of such an establishment to be a
doctor.
States like Kentucky, Ohio, Tennessee, West Virginia,
Texas, Louisiana, Mississippi and Florida have
passed similar legislation.
.
In Ohio, pharmacists must record Opioid prescriptions in the
online Ohio Automated Rx Reporting System (OARRS). These
new guidelines encourage prescribers to use the data in
OARRS so that they will know how much pain medication a
patient already is receiving, perhaps from multiple prescribers.
The guidelines also strongly advise prescribers to talk with their
patients about managing their chronic pain, the risks of an
unintentional overdose from their prescription pain medication,
the potential for pain medication abuse, and secure storage of
their pain medications, to prevent misuse by others.
• In Approximately 20 states the doctor can both prescribe and sell the
drug to the injured employee, tripling the overall claim cost
• In Illinois a single Vicodin pill will cost an average of 53 cents at a
pharmacy, yet sold by the doctor prescribing , the Vicodin pill sold for
$1.44. Roughly a third of the prescriptions written in Illinois were for
drugs dispensed by the physicians.
• The spread was even greater in Connecticut, where the single Vicodin
pill sold by pharmacies averaged 37 cents, but $1.43 when sold by
the doctor prescribing the pill. This is not a best practice as it
bypasses the pharmacist oversight.
PRESCRIPTION DRUG MONITORING
PROGRAM
Maryland’s PDMP will make prescription
information available, upon authorized
request, to law enforcement agencies,
health professional licensing boards and
four units of DHMH5 to support
investigations into improper professional
practice, prescription fraud and illegal CDS
diversion.
COLLABORATION IN MARYLAND
The Advisory Board on Prescription Drug Monitoring; the Boards of
Physicians, Nursing and Pharmacy; the University of Maryland,
School of Pharmacy; the Governor’s Office of Crime Control &
Prevention (GOCCP); Chesapeake Regional Information System
for Our Patients (CRISP); and other DHMH agencies and
professional organizations, ADAA will provide PDMP training
and education on issues related to prescription drug abuse and
overdose to an array of stakeholders, including healthcare
providers, law enforcement, public health professionals and the
general public.
Maryland Medical Assistance (MA), in both the Fee-For-Service
Program (FFS) and Managed Care Organizations (MCO), currently
employs procedures to identify and remedy activities of both
recipients and providers that could contribute to the misuse of
pharmaceutical opioids. Although these programs have been
developed primarily for the purpose of quality assurance, cost
containment and fraud detection, they will be utilized as a
component of strategies to reduce opioid overdose. These
programs include a corrective care management program and
prospective drug utilization review.
Although heroin-related overdoses declined in
Maryland from 2007 to 2011, the state witnessed a
significant rise in overdoses related to
pharmaceutical opioid analgesics during this period.
Early data from 2012 suggests resurgence in
heroin-related overdoses concurrent with the first
reduction in pharmaceutical opioid-related
overdoses in years.
“Doctors
who have been convicted of behaving like street
drug dealers, or who lost their licenses due to similar
findings, will need to apply not just to the Board of
Medical Examiners, but also to the Director of
Consumer Affairs, if they want to practice again. They
will need to demonstrate that they can be trusted with
the responsibility they once abdicated.”
THE ROLE OF CASE MANAGEMENT?
The case management process is carried out
within the ethical and legal realm of a case
manager’s scope of practice, using critical
thinking and evidence-based knowledge. If we
want to preserve the ethical ethos of case
management, case managers must know the
ethical standards which they are held and
comply with them.
31
“The ethics of excellence are grounded in
action-what you actually do, rather than
what you say you believe. Talk, as the
saying goes, is cheap.”
Price Pritchett
32
STANDARDS OF PRACTICE
Empowering the client to problem-solve by exploring options of care,
when available, and alternative plans, when necessary, to achieve
desired outcomes.
Encouraging the appropriate use of health care services and strives to
improve quality of care and maintain cost effectiveness on a caseby-case basis.
Assisting the client in the safe transitioning of care to the next most
appropriate level.
Striving to promote client self-advocacy and self-determination.
Advocating for both the client, employer and the payer to facilitate
positive outcomes for the client, the health care team, and the
payer.
33
Prescription monitoring and nurse case
managers can combat the problem. If a nurse
case manager is not already assigned to a
lost time claim, the issuance of a prescription
to the injured employee for any narcotic
should be an automatic trigger to assign that
claim to the nurse case manager.
If a nurse case manager is already assigned to the
claim, the nurse should discuss with the treating
physician the use of short-acting opioids rather than
long-acting opioids. Careful monitoring of the opioid
use by both the pharmacy benefit management
company and the nurse case manager is essential to
holding down the cost of the claim and preventing
opioid addiction.
“Be the thermostat, not just
the thermometer”
Dr. Martin Luther King
WEBSITE RESOURCES
WorkCompWire, http://www.workcompwire.com
Centers for Disease Control and Prevention, http://www.cdc.gov
Managing Opioid Use in Workers’ Compensation, http://www.scripnet.com
Amaxx Risk Solutions, Inc, www.reduceyourworkerscomp.com.
Insurance Journal, http://www.insurancejournal.com
Workers Compensation Research Institute, http://www.wcri.com
adaa.dhmh.maryland.gov/
37
How do you keep your passion
for Case Management when our
patients, their families, bosses,
physicians, employers, adjusters,
etc, etc, etc….
can drain the passion
completely out of you?
38
“The pessimist may be right in
the long run, but the optimist
has a better time during the
trip.”
Anonymous
39
Hang in there!
Keep your sense of humor!
Be kind!
Have fun!
40
“We are all here for a spell; get
all the good laughs you can.”
Will Rogers