Thursday, March 17, 2016

What the New CDC Opioid Guidelines Will Mean to Work Comp

Not much, I fear.  Allow me to explain...

What the CDC has done here is critically important to addressing the public health crisis that is opioid misuse and abuse.  While the CDC's process came under scrutiny (from, among others, me), the resulting guidelines are evidence-based, well-written, and carry the imprimatur of the preeminent public health agency in this country.  That's groundbreaking.  But I'm not sure we're going to see a significant impact in workers' compensation for three reasons.

Before we dive in, here's a link to the guidelines.
Here's a link to Dr. Tom Frieden's (CDC Director) letter regarding the guidelines in NEJM.
And here's perhaps the most practically valuable thing the CDC published earlier this week - a checklist for primary care physicians who prescribe opioids (this is excellent).

Reason #1 we're unlikely to see a significant impact in work comp: It takes a long time for new medical evidence to penetrate actual physician practice.  The guidelines have received a lot of press coverage over the last few days, but busy primary care physicians may not be immediately responsive to new medical evidence even if they see it on the front page of the local newspaper. First, not all physicians have the same faith in an agency of the federal government that I possess.  In fact, for some, the notion that the federal government published these guidelines may be the primary source of skepticism.  Second, there will armies of pharma reps to gently, diplomatically, but firmly push back, find holes, work arounds, etc. to increase the likelihood that current prescribing practices remain intact.  Third, there are obviously no enforcement mechanisms in connection with these guidelines.  A primary care doc who chooses not to follow them will face no immediate consequences (though, we should be clear, the long term consequences to the patients of such a doctor could be catastrophic).

Reason #2: Our primary cost drivers in work comp are long term, chronic pain cases.  The new guidelines offer precious little guidance for these types of cases.  Most of the guidelines focus on opioid initiation and to the extent chronic opioid therapy is addressed, the guidelines suggest avoiding it.  Well... what if we have an injured worker who has been on opioids for that past 10 years?  Whose dose has escalated regularly and dangerously over that period?  The guidelines suggest those opioids should be weaned.  Right.  Telling a primary care doc to simply wean a patient off of opioids in the midst of a long term, complicated, polypharmacy drug regimen is perhaps expecting too much.  I would have liked to have seen more detailed guidance on how to deal with such complex patients.  So why didn't the CDC go there?  Because it's really complicated, that's why.

Reason #3: Primary care docs, by and large, didn't create most of our pain management issues in work comp.  Granted, I'm dealing with a very skewed subset of cases here at PRIUM.  I recognize we suffer from adverse selection, so this might not be accurate for the entirety of the work comp universe.  But what we see is that surgeons and pain management specialists tend to initiate complex pain management drug regimens (after the profitable procedural work is done) and then, in perhaps the most unkindest cut of all, the patient is discharged back to the primary care doc... who is now overwhelmed by a monster of a drug regimen that he did not create.  Yes, primary care docs write almost 10 times more opioid scripts per year (28 million) than pain management and interventional pain management doctors combined (3 million), but will these new guidelines - aimed at primary care docs - help them much if they're not the ones making the initial prescribing decision?

I'm thrilled the CDC published these guidelines.  I think they represent useful, cogent, and practical thinking.  And I hope I'm wrong that we won't see a material impact in work comp.

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