Monday, March 23, 2015

Data Suggests We Still Have a Long Way To Go

A quick scan of this morning's news shows we have a long way to go in the fight against prescription opioid misuse and abuse.

From a survey conducted by the National Safety Council we learned that:

  • Nine in 10 opioid painkiller users are not concerned about addiction as a side effect, though 60 percent of users have at least one addiction risk factor 
  • 69 percent of opioid painkiller users feel opioids are the most effective medications to treat pain, though research shows this is not true
  • Americans mistakenly believe gun violence, severe weather and commercial airline travel are more significant threats to their safety than opioid painkillers
  • Many Americans do not realize they have taken opioids

  • 42.9% of the 1,285 patients on long term opioid therapy had signed a treatment agreement
  • 62.8% of those patients had been subject to a urine drug test within the last year. 
  • The study's lead author, Laila Khalid, told workcompcentral, "It should be 100% adherence."  

So once more unto the breach, dear friends, once more.  Another week in the battle against prescription drug abuse.  Lots of work to do.  


Monday, March 2, 2015

Inconsistent Standards of Care, Judicially Mandated

Very little good has ever come from judges attempting to interpret legislative intent in the face of disputed medical treatment.

Barbara Shepard injured her back, neck, and left shoulder in 2005 while employed with the Oklahoma Department of corrections.  The OK Work Comp Court ordered that the carrier pay for treatment, inclusive of office visits and (you guessed it) pain management medications.  "This provision," stated the order, "shall be reviewed by the Court upon application of either party for good cause shown."  

Turns out evolving contemporary medical evidence and the risks of opioid medications do not amount to "good cause."  

Despite Oklahoma's adoption of the Official Disability Guidelines as of March 1, 2012, the Court found that those guidelines do not retrospectively apply to Shepard's case.  Simply because of the date on which she was injured, Shepard is subject to a different (and, frankly, inferior) standard of care.   While physicians on both sides of the dispute agree that the guidelines indicate she should not receive the pain management medications she has been taking, the Court instead relied on a purely legal framework to make its decision.  Thus, not only has the Court failed to contemplate the growing body of medical knowledge from which the patient could benefit, but it has also created two standards of medical care for Oklahoma work comp patients that depends entirely on one's date of injury.   

Let's consider an admittedly controversial analogy: Instead of being injured in 2005, let's pretend for a moment that Shepard was hurt in 1917.  And instead of an injured back, she had a work-induced cough.  During this time, she might have been prescribed a popular cough suppressant manufactured and sold by Bayer pharmaceuticals.  The chemical compound was diacetylmorphine, but it was marketed under its trade name: heroin.      

Seven years later, in 1924, in the face of a public health crisis and mounting evidence of heroin's harmful properties, Congress passed the Heroin Act, which outlawed the sale, importation, and even the manufacture of heroin.  

According to the Oklahoma Supreme Court, however, Shepard should still get heroin for her cough... despite the evolving medical evidence and the statutory support for recognizing that medical evidence, Shepard should still get her heroin, simply because she developed her cough seven years before we knew that heroin was more likely to harm her than help her.

Opioids, thankfully, are not illegal.  There are many patients, particularly the terminally ill, that benefit greatly from these medications.  But it's also true that we didn't know in 2005 everything we now know about opioids in the treatment of chronic, non-cancer pain.  For instance, in 2005, the National Safety Council had yet to publish this informative graphic:

We cannot create a sustainable system of medical care for injured workers that does not allow for the incorporation of the best available medical evidence.  

On Twitter @PRIUM1

Wednesday, February 25, 2015

The Research is Catching Up to our Experience

I see a theme among recent posts: pointing to new research that confirms things we already knew because we see them in claims every day.  This is good news.  The science is catching up to our practical experiences with opioids, addiction, and chronic pain.

The latest confirmation comes from the Cleveland Clinic.  In an article published in the Journal of Pain late last year, researchers assessed the likelihood of opioid abuse based on past history of non-opioid substance abuse.  For those of us close to complex chronic pain cases, we know that a history of, say, alcohol abuse, is correlated with opioid abuse.  But until now, we didn't have compelling data from peer reviewed literature to back our intuition.  Granted, cross-substance abuse is a well known research area... but this study focused specifically on opioids among patients with chronic, non-cancer pain.  

Among other important conclusions, here's what I thought was most important: In a pain rehab program, participants with a history of a nonopioid substance use disorder had 28 times the odds of having an addiction to prescribed medications.   

What does this mean for you?  
  1. Every injured worker, every claim, every doctor... must have an opioid risk assessment performed prior to any potentially addictive prescriptions are written.  
  2. Doctors must be educated on how to interpret the opioid risk assessment and use it to tailor treatment to the individual needs (and risks) of the injured worker.  

Failure to complete these two steps will invite tragedy.  

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Monday, February 23, 2015

Opt Out: A Tale of Two Tweets

[A guest post from Ben Roberts, PRIUM's General Counsel]

When I checked my twitter feed one morning last week, two tweets caught my attention:

1. ARAWC: Tennessee Legislators Introduce Workers’ Comp Option Legislation 
2. Supreme Court Asked to Review Constitutionality of Opt-Out Process. Full story at: 

I find the juxtaposition interesting: Tennessee legislators are trying to create an opt-out process in their state; meanwhile, attorneys in Oklahoma are trying to undo their opt-out process by challenging its constitutionality.  

Oklahoma’s opt-out provision was created by the passage of SB 1062 in 2013 and, at the time, several constitutional challenges were made.  But now a group of attorneys is again taking the constitutional challenge directly to the Oklahoma Supreme Court, hoping to have the opt-out provision struck down. 

The Tennessee legislation, SB 721, requires employers who choose to opt-out of the system to set up their own plans meeting certain requirements.  This is similar to the opt-out provision in Oklahoma, and while we haven’t heard any constitutional objections from Tennessee, I am sure they will follow.

It appears as though OK and TN are trying to replicate the results of Texas -- the only other state that permits “opting-out”.  The Texas non-subscriber provision has been in place for nearly 100 years, and many companies have seen significant cost savings and better claim outcomes in that state.

The goals associated with providing employers with the option of opting out are well outlined by the Association for Responsible Alternatives to Workers’ Compensation (ARAWC):
• An Option can reduce the overall costs of treating employee injuries and support local job growth and economic development.
• An Option can deliver better medical outcomes and higher satisfaction for injured workers.
• Employers in Option states see significant savings and improved medical outcomes.

But, these changes aren’t made overnight.  

I often equate making changes to the workers’ compensation system to changing a tire on a moving vehicle.  The solution has to fit an ever-changing system.  It’s not something that can be done easily, and in order to be successful, it must be well thought out, well planned, and well executed.

Ben Roberts
Ben is PRIUM's General Counsel.  You can follow him on Twitter @WC_Compliance
As always, you can follow PRIUM @PRIUM1

Thursday, February 19, 2015

The Right Target in Chronic Pain Cases: The Brain

Need convincing that the key to chronic pain management lies in behavioral health?  NPR has a great piece today on the human brain's ability to deal with pain signals and what this might mean for chronic pain management.

"The brain also determines the emotion we attach to each painful experience, Linden says. That's possible, he explains, because the brain uses two different systems to process pain information coming from our nerve endings.
One system determines the pain's location, intensity and characteristics: stabbing, aching, burning, etc.
"And then," Linden says, "there is a completely separate system for the emotional aspect of pain — the part that makes us go, 'Ow! This is terrible.' "
Linden says positive emotions — like feeling calm and safe and connected to others — can minimize pain. But negative emotions tend to have the opposite effect." 

The article also references a study published in 2011 that found 8 weeks of "mindfulness" practice appeared to enhance a subject's ability to manage pain.

These articles and studies add to a growing body of evidence that suggests that when workers' compensation payers ignore the link between behavioral health and chronic pain, they do so at their own peril.  We must begin to routinely incorporate these modalities into chronic pain care, at every stage of the claim.  We have to stop being scared of psych diagnoses and begin addressing the route causes of chronic pain.

If you're focused on relief of non-specific low back pain and ignoring what's going on in the injured worker's brain (including the injured worker's emotional state), you're shooting at the wrong target.

On Twitter @PRIUM1

Thursday, February 12, 2015

Naloxone, Fences, and Ambulances

[The following is a guest post from PRIUM's General Counsel, Ben Roberts]

Every day we are hearing more news and reporting on the “anti-overdose” drug Naloxone. Just looking at my Google feed this morning I see articles from Maine, West Virginia, Pennsylvania, and Virginia discussing legislation and it widespread use.

Last year, New Jersey passed the Overdose Prevention Act which permits broader access to naloxone and provided criminal and civil protections for those who administer it.

The Governor of West Virginia is about to sign SB 335  which allows medical responders and law enforcement to carry naloxone as well as allows physicians to prescribe the drug to those at risk of an overdoes as wells as their family and friends.

Many more state have passed and proposed similar legislation.

I think that these efforts should be applauded.  Given the state of the prescription drug epidemic, overdose prevention is something that should be on every legislative agenda this year.  But when I see these reactive approaches to public health issues I can’t help but be reminded of a poem from my childhood. 

In Joseph Malines “The Fence or the Ambulance” a great debate arises in a community about their own “public health” issue:

Twas a dangerous cliff, as they freely confessed
though to walk near its crest was so pleasant
But over its terrible edge there had slipped a duke and many a peasant
So the people said something would have to be done
But their projects did not at all tally
Some said, "Put a fence around the edge of the cliff"
Some, "An ambulance down in the valley.”

The poem continues with the community making the choice of the ambulance over the fence.

'For the cliff is all right if you are careful,' they said,
"And if folks even slip or are dropping
it isn't the slipping that hurts them so much
as the shock down below when they're stopping."

Then an old man remarked: "It's a marvel to me
that people give far more attention
to repairing results than to stopping the cause
when they'd much better aim at prevention

if the cliff we will fence, we might also dispense
with the ambulance down in the valley.

Overdose prevention, like abuse deterrent formulations of opioids is a positive step, but legislators need to be focusing on proactive steps to help avoid this problem and stem this epidemic.

Ben Roberts
Ben is PRIUM's General Counsel.  You can follow him on Twitter @WC_Compliance
As always, you can follow PRIUM @PRIUM1

Wednesday, February 11, 2015

Non-medical Use and Addiction: Distinctions in the Opioid Crisis

A new study coming out soon in the Annual Review of Public Health attempts to reframe our discussion regarding the opioid crisis.  Often, we focus attention on nonmedical use of opioids.  Those of us in the insurance world know that while nonmedical use is a serious societal issue, it's only one part of the opioid problem.

From the study (among the authors of which is Andrew Kolodny, one of the most well known and recognized voices of reason in the public dialogue around the opioid crisis):
"Policy makers and the media often characterize the opioid crisis as a problem of nonmedical opioid pain reliever abuse by adolescents and young adults.  However, several lines of evidence suggest that addiction occurring in both medical and nonmedical users, rather than abuse per se, is the key driver of opioid-related morbidity and mortality in medical and nonmedical opioid pain reliever users."  

This distinction is critical because it focuses our attention, our resources, and our solutions in a different direction (or, at least, in more directions) than if we were to simply assume that opioid overdose deaths are driven by diversion, misuse, and abuse among young people.

The reality is that there are likely as many as 5 million people in this country addicted to prescription opioids and as many as half of them are receiving legitimate prescriptions from legitimate doctors for legitimate pain.  Not all chronic pain patients on long term opioid therapy will exhibit drug seeking or otherwise aberrant behavior.

Another important insight from the paper is the analogy that Dr. Kolodny and his colleagues draw between the methods of combating other public health crises and the approach we should consider taking toward the opioid crisis:
"... our purposes is to demonstrate that prevention strategies employed in epidemiologic responses to communicable and noncommunicable disease epidemics apply equally well when the disease in question is opioid addiction.  Interventions should focus on preventing new cases of opioid addiction (primary prevention), identifying early cases of opioid addiction (secondary prevention), and ensuring access to effective addiction treatment (tertiary prevention)."  

We have a long way to go in all three categories, but papers like this push our collective thinking in the right direction.  Worth a read.

On Twitter @PRIUM1