Wednesday, February 29, 2012

Sky Falling? Coventry’s View on Opioids.

Their answer?  Well, maybe. 
I commend Coventry for their seemingly thorough data analysis and for their very rational advice regarding solutions: “the soundest approach seems to use common sense.”  With that, I agree wholeheartedly.  They also do a decent job of providing guidance on how certain stakeholders should deal with opioids, from leveraging evidence-based guidelines to ensuring that PBMs and nurse case managers are properly focused on the issue.
I was surprised, however, by the results of some of the analysis and by the tone struck by the authors in some areas of the report.  For instance:
The authors state that “despite media headlines, it’s important to remember that just because a pain reliever is an opioid doesn’t automatically mean its use is inappropriate.  Increasing opioid use is part of an overall increase in prescription drug utilization in society.”  All true.  But is this the tone we want to strike in our industry when it comes to dealing with the issue? The authors quickly attempt to rebalance themselves by stating, “regardless, the issues are real, and clarity is needed.”  Well, glad we’re back on the same page.     
Later, the report states, “while not conclusive, the examination of diagnoses using bill review data and claim injury information does suggest that many of the claimants receiving Schedule II opioid drugs may be suffering from injuries that warrant at least some use of [opioid pain relievers].”  Suggesting that many of these claimants need these drugs flies in the face of the evidence-based guidelines quoted elsewhere in the report and provides for an incongruent and inconsistent message.  If it’s not conclusive, why suggest it?  Candidly, I’d love to see the data.  This is not what we’re seeing when we conduct triages of our customer’s claims.  Rather, we're seeing that about 75% of the opioids being prescribed are not medically necessary according to the guidelines.     
And their “drill down” on Fentanyl suggests that a “measurable number of claimants did have cancer diagnoses; therefore, Fentanyl use was more likely to be appropriate.”  I’m filled with questions on this one.  What constitutes a “measurable number”?  And are they suggesting that Fentanyl was more likely appropriate for just that “measurable number”?  And what kind of cancer diagnoses are we talking about?  Stage IV lymphoma?  Or Stage 1 prostate cancer (with which, I bet, a “measurable number” of middle aged males with bad backs have been diagnosed)?  If you’re going to talk about Fentanyl and even passingly suggest where/when it might be appropriate in work comp, you have to come with more than “a measurable number.”  (Though I'll give them credit for highlighting the obvious question of compensability). 
Perhaps I’ve seen too much of the dark side of opioid use.  It’s what we do here, day in and day out.  I commend Coventry for taking such a data-driven approach and for trying to present a balanced picture of the issue. 
I’m simply one who believes that if we’re going to make meaningful progress towards ridding work comp of medically unnecessary prescription narcotics, all of us must choose our words very, very carefully.
On Twitter @PRIUM1

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