Monday, April 30, 2012

Louisiana Case: Correlation and Causation

Louisiana's First Circuit Court of Appeal has offered a ruling on a work comp case that (finally) highlights an example of how an employer might effectively deal with the compensability issues that arise from chronic opioid use.  The case is John Morgan vs. Barber Brothers Contracting Co., which began when Mr. Morgan suffered a legitimate, industrial-related neck injury in 1997.  Cervical fusion followed... then 14 years of prescription narcotics to deal with the pain.  Roberto Ceniceros offers a great overview on Business Insurance here.

Before we get into the specifics, let's discuss one of the great statistical misunderstandings of our time.  We're constantly bombarded with news stories about the latest, greatest "study" that says "product x causes cancer" or "playing video games makes us smarter" or some other eye-catching claim.  The first thought I have when I hear about one of these studies?  Is this correlation?  Or causation?  Are the two activities ("eating ice cream" and "being diagnosed with cancer") simply correlated?  Or does "eating ice cream" actually cause cancer?  (Let's hope not).  Get into the habit of asking yourself this question.  The answer is often unknown, which should cause us to look at these studies with a bit more skepticism than we often do. 

Back to Mr. Morgan.  After 14 years of using prescription narcotics, Mr. Morgan developed sleep issues, depression, lethargy, fatigue, and sexual dysfunction.  When asked to pay for sleep apnea testing and treatment for the sexual dysfunction, the employer refused. 

You see, the doctor had also ordered an inpatient treatment program to wean the narcotics (enlightened!).  This left a question for the employer: Was the sleep apnea and sexual dysfunction simply correlated with the opioid use?  Or were these conditions actually CAUSED by the opioid use? 

The answers here go to the core of the intransigent nature of the opioid over-utilization in work comp.  If someone gets hurt and ends up on chronic opioid therapy, has the payer automatically accepted the need to pay for all of the other (correlated?  or causal?) issues that arise from the use of these drugs over the long term? 

The First Circuit in Louisiana has done a potentially great service to the world of work comp.  Rather than declare the payer liable or not liable, they've essentially taken the position that the patient should go through detox first to better ascertain whether the sleep issues and sexual dysfunction are actually caused by the drugs themselves. 

Brilliant.  Now let's hope this catches on in other jurisdictions. 

On Twitter @PRIUM1

Thursday, April 26, 2012

Health Wonk Review (including Evidence Based!)

A new edition of Health Wonk Review is up... and I'm pleased that Evidence Based has made its first appearance. Thanks to Jennifer Salopek and Sarah Sonies at Wing of Zock for hosting. Michael

On Twitter @PRIUM1

Texas: Plan-Based Audit for Opioids

The state of Texas (Texas Department of Insurance, Division of Workers' Compensation) is currently accepting public comment on its proposed plan-based audit for pain management services in workers' compensation.  Since our comments will be made public anyway, I thought I'd throw them out here on the blog:

To: Donald Patrick, M.D., J.D., Medical Advisor
Date: Thursday, April 26, 2012

As a utilization management company focused on the application of the Official Disability Guidelines to prescription drug utilization in the State of Texas, we appreciate the opportunity to provide input and suggestions on the development of the new Plan-Based Audit for health care providers prescribing opioids.  We applaud the state of Texas for its efforts thus far in the area of narcotics control in workers' compensation and hope that this new Plan-Based Audit will further limit the inappropriate use of prescription narcotics.

Regarding Section III: Scope and Methodology - We understand the budgetary limitations associated with any undertaking such as this.  That said, we're concerned that a focus on early prescribing of an opioid (within 10 days of the date of injury and >30 days supply) is too narrow to capture the broad nature of the problem.  Often, injured workers only end up on grossly inappropriate drug regimens well after the initial injury, perhaps even years later.  Dose escalations, tolerance, dependence, and addiction develop months and years down the road.  While a focus on early prescribing behavior will alleviate a portion of the problem, our view is that the most intractable cases would not be identified with the criteria as currently proposed.

We suggest the Plan-Based Audit consider focusing on a measures much more likely to capture the most prevalent (and expensive) issue in the system - long term use of high dose narcotics.  We suggest the following:
- Health care providers who have prescribed opioids to injured employees where the morphine equivalent dosage (MED) exceeds 120 mg per day. 

Regarding Section IV: Selection Criteria - Again, we acknowledge budgetary constraints as a real issue in deploying a program such as the Plan-Based Audit.  However, selecting a mere 15 physicians may not be sufficient to change or influence overall system behavior.  The stated purposed of the Plan-Based Audit is to "focus attention on the issue of opioid utilization in the Texas workers' compensation system."  We fear that the relatively small scope of the current proposed plan will fail to garner sufficient attention to guide future clinical decision-making. 

Regarding Section V - Roles and Responsibilities - We suggest the following questions for the Medical Advisor's consideration as he develops guidance for the MQRP experts (these questions would be in addition to the already stated objecting of ensuring "that health care providers adhere to the Official Disability Guidelines and medically accepted standards of care for prescribing pain management services including opioids"):
1) Has the patient signed an opioid treatment agreement or narcotics contract?
2) Does the provider have the patient undergo regular urine drug monitoring?
3) Did the provider consult a prescription drug monitoring database prior to writing the prescription?
4) Has an opioid risk assessment been completed to evaluate likelihood of abuse issues?
5) What are the specific treatment goals for this patient in terms of functional improvement?

These questions represent several "best practices" in prescription drug utilization management and we believe these questions provide a potential road map for evaluating the treatment patterns of selected physicians. 

We appreciate of the opportunity to provide input and suggestions. 

Michael Gavin
Chief Marketing Officer

On Twitter @PRIUM1

Tuesday, April 24, 2012

H.R. 1063: What the Feds Can Do to Help Work Comp

I heard some discussion at RIMS around House Resolution 1063, titled "Strengthening Medicare And Repaying Taxpayers Act" (or the SMART Act, because all federal legislation must inevitably lead to a catchy acronym).  The bill is suprisingly brief (13 pages), relatively straightforward, and seems to create a much more efficient approach to protecting Medicare's interests in light of work comp settlements.

Whenever I'm with a client and we're discussing prescription drug over-utilization, I typically see a lot of nodding heads and sympathetic glances.  But when the issue of MSAs comes up (which, when discussing the onslaught of drugs in work comp, almost always comes up), claims executives' faces become contorted - total anguish.  The process is viewed as difficult, unreliable, unpredictable, and intractable.  I'm no expert on MSAs, but federal legislation to simplify the process seems to make sense (by the way, even though I'm not an expert, PRIUM has partnered with experts in the field - if you need one, let me know). 

The core of the bill appears to be found in Section II: "Not later than 65 days after the date of receipt of a request under subclause I, the Secretary shall respond to such request with a statement of reiumbursement amount, which shall constitute the conditional payment subject to clause (ii) related to such settlement, judgment, award or other payment."

So... assuming the claim is on a rational, evidence-based clinical path (big assumption, I know), this bill aims to create a more predictable timeline for CMS response and could lead to greater efficiencies in closing out claims.

A link to the entire bill is here.

What says the MSA community?  Helpful? 

On Twitter @PRIUM1

Friday, April 20, 2012

Express Script's WC Drug Trend Report: Something Missing

I'm working my way through all of the drug trend reports released within the last week.  I plan to provide a general overview of those within the next week or so (lots of data to sort through).  I just got through the highlights from ESI, though, and found the approach interesting - and troubling.

The overview I read starts with "2011 Highlights" on page 1.  And the overarching theme of the highlights is waste... $2.1 billion worth of waste in work comp.  They define waste as "any additional spend on pharmacy costs that provides no incremental gain in health outcomes."  Great definition. 

But the report goes on to emphasize three major areas where waste occurs:
1) Utilization of high-cost brand medications when lower-cost therapeutic alternatives are available;
2) Not enough use of mail order as a mode of drug delivery (retail is more expensive);
3) Processing of prescriptions through out-of-network pharmacies and third party billers.

Those of you that know PRIUM know that I'm a bit... let's just say "focused"... but what about utilization of prescription drugs that are not medically necessary according to clinical guidelines (guidelines which, in many states, are statutorily recognized)? 

Would ESI really have us believe that the way to limit inappropriate use of narcotics and other drugs can be summed up in "generics, mail order, and networks"? 

Later in the report, in much smaller font, there's a section on "Narcotics Abuse and Misuse" that at least acknowledges what the CDC has called an "epidemic," but ESI offers no direct solutions.  I think there's a simple reason for this: it's complicated to try to solve the problem of prescription drug abuse and misuse.

Across the thousands of reviews PRIUM has conducted over the last few years, we've found that approximately 73% of the drugs we've reviewed are not medically necessary.  Granted, there's selection bias here - PRIUM is often brought it when help is clearly needed on a claim.  But cut that number in half... or by two-thirds... that's still a big number.

I completely agree with ESI's definition of waste, but I think they've missed a core component of that waste.  When it comes to your PBM services, don't settle for reports.  Demand solutions.  Demand solutions that tackle head-on the issue of medical appropriateness, abuse, and misuse.   

On Twitter @PRIUM1

Thursday, April 19, 2012

KASPER: Doctors Slowing Progress

I've been tracking the progress of HB 4 (now HB 1 in the special session) in the Kentucky state legislature for a few weeks now.  The bill aims to strengthen Kentucky's ability to monitor prescription drugs and force pill mills out of business.  In a state where the prescription drug abuse epidemic is particularly bad, such a measure appears to make sense and should enjoy across-the-board support. 

Not so fast.

The Kentuck Medical Association has issued a "call to action" for its members to lobby for changes to the bill.  They claim the bill will lead to malicious prosecution of doctors and will interfere with a doctor's ability to practice medicine in a professional manner. 

So let's examine the core tenets of the bill:
- Physicians will be required to register in KASPER (only one-third of docs are registered today).
- Physicians running pain clinics would have to be on-site treating patients at least 50% of the time the clinic is open.
- Clinics will have to accept insurance vs. only cash payments.
- Physicians will be required to consult KASPER (Kentucky's PDMP - Kentucky All Schedule Prescription Electronic Reporting system) before prescribing schedule II and III drugs. 
- Doctors will be restricted from dispensing more than a 48-hour supply of schedule II and II drugs.
- Move management of the database from Health and Family Services to the Attorney General's office.
- Doctors might have to pay a $50 annual fee to support the administration of the KASPER database.

I'll grant that the $50 annual fee is a bit of an annoyance and I would suggest the state legislature find a different financing mechanism.  That being said, the requirement to consult the database and the restriction on physician dispensing are logical, high impact measures that will have virtually zero negative impact on the vast majority of doctors in the state of Kentucky.  Some doctors are concerned about the AG's office managing the database... but if you're a good doc doing the right thing, this shouldn't be a concern (particularly because hospice and emergency care are excluded).   

Governor Beshear has called a special session of the state legislature in which this bill will be addressed.  The House has already passed the bill (again).  Now it's up to the Senate where the bill failed during the general session mostly due to the efforts of the Kentucky Medical Association.

Other states are watching.  I hope Kentucky does the right thing. 
On Twitter @PRIUM1

Monday, April 16, 2012

RIMS 2012

Off to a great start here in Philadelphia. Exhibits open in an hour... and half our team is stuck in airports (with our marketing materials)... the shuttle never showed at the hotel, so I walked 8 blocks here... and our booth desperately needs a vacuum. Otherwise, we're all set!

We'll be pretty busy this week at RIMS, so posts on Evidence Based might be light. You can follow our thoughts and perspectives regarding the conference via Twitter @PRIUM1.
(Like this morning's commentary regarding the Texas DWC opioid audit: it's a start, but not enough to even make a dent.)

On Twitter @PRIUM1

Friday, April 13, 2012

Massachusetts: New Chronic Pain Guidelines

The new Massachusetts guidelines have been out for a while, but I finally had a chance to sit down (on an airplane, of course) and read through them in detail. A few quick comments:

Generally, I'm not a fan of state-specific sets of guidelines. While I've been accused in the past of acting as an agent of certain other sets of guidelines (no, I don't work for WLDI), I like the idea of evidence-based guidelines over consensus-based guidelines. Massachusetts chose to take Washington, Colorado, mix in a little ACOEM, and voila - new guidelines. I can understand the rationale (consensus does have a certain amount of value, albeit political value and not clinical value), but it calls into question the credibility of the guidelines from the outset. Who was on the committee? Who had influence? Who had the most lobbyists? In this case, the process appears to have been fairly inclusive, transparent, and thorough... it just creates another niche set of guidelines for all of us in work comp to have to get to know.

The section on medications in deceivingly simple. While it's roughly only a single printed page, it does contain the straightforward theme of valuing documented functional improvement above all else and does emphasize the need to incorporate the psycho-social component of care. The guidelines discuss the need to consult the Massachusetts Prescription Monitoring Program database, the need for a patient-physician agreement, and the need for ongoing drug screening. Perhaps most importantly, the guidelines strongly suggest that providers seek additional specialist-based consultation for any narcotic regimen exceeding 120 mg MED per day.

Alas, however, the guidelines in Massachusetts are only advisory in nature. They are to be considered by treating physicians, work comp judges, and utilization review agents, but none of these parties is bound by the guidelines.

A potential bright spot: Deborah Kohl, a member of the Massachusetts Academy of Trial Lawyers, commented on the new guidelines in a workcompcentral article, "On face value, I find them disturbing."

When the plaintiffs' attorneys find something disturbing, that's typically a good sign.

On Twitter @PRIUM1

Thursday, April 12, 2012

Texas: An Opportunity Revived?

In a post two weeks ago (TX: A Missed Opportunity), I wrote about what appeared to be an unfortunate decision on the part of the Division of Workers' Compensation in Texas to not include a performance-based measure for opioid prescribing on its 2013 provider report card.  This morning's workcompcentral brings news that DWC Commissioner Ron Bordelon has said, "Nothing is final until I sign off on it."  He is apparently willing to consider inclusion of a new measure for opioid prescribing (specifically, the level of narcotics prescribed either two months post-injury or two months post-surgery... definitely not the entire picture, but a start). 

Mr. Bordelon also rightly pointed out that the new closed formulary rules are a solid sign that Texas is doing something about the opioid epidemic in work comp.  Initial signs point to the potential success of the new rules.  PRIUM's analysis showed a nearly two-thirds drop in prescriptions for drugs labeled "N" by the Official Disability Guidelines.  PMSI just released their own analysis which appears to show about a 50% drop in "N" drug prescriptions as proportion of total prescriptions (Q4 2010 vs. Q4 2011).  Interestingly, for the entire fourth quarter of 2011, PMSI saw a total of 142 prescriptions for "N" drugs, 141 of which were blocked at the point of sale.  Only 1 script had a valid pre-authorization associated with it.

As he considers the opportunity, though, to include opioid prescribing behavior on the 2013 provider report card, I offer two management maxims that I personally live by:
1) You cannot manage what you do not measure.
2) Performance measured is performance improved.

I'll add my voice to the chorus of those calling for inclusion of the new measure. 

On Twitter @PRIUM1

Wednesday, April 11, 2012

From the National Rx Abuse Summit

Thanks to those of you who attended the session yesterday here in Orlando. And a special thanks to those of you who noted that you read Evidence Based.

The discussion in yesterday's session (Financial Impact to Employers) had a few highlights I wanted to share.

First, I had planned to show a short video clip from Physicians for Responsible Opioid Prescribing. While the audio worked well, the video didn't. Serendipitously, though, one of the doctors featured in the video was in the room and shared his thoughts on the topic live and in-person. Many thanks to Dr. Andrew Kolodny for being willing to fill in where the A/V system fell short. Dr. Kolodny's presence was also confirmation for many of us that this conference is the right place to be for those of us dedicated to eliminating inappropriate use of prescription narcotics in work comp.

Speaking of work comp, I began my presentation yesterday by noting that PRIUM is focused in the work comp space, but that I planned to broaden the discussion to other payers and stakeholders. But as I scanned the room, I saw lots of familiar faces... and as we moved to Q&A, it was confirmed for me that the room was filled with predominantly work comp folks.

Do we in work comp "get it"? Is the problem of prescription drug abuse more prevalent in comp than in the group or government payer sectors? Or did the work comp sector just do a better job of networking and creating awareness for the event?

Genuinely interested in your thoughts...

On Twitter @PRIUM1

Monday, April 9, 2012

Choosing Wisely: Evidence-Based Medicine Comes to the Masses

Last week, nine medical specialty societies (in concert with the ABIM Foundation) announced lists of tests and procedures that are frequently used, but show little clinical evidence of effectiveness.  Interestingly, each of the "lists" is titled: Five Things Physicians and Patients Should Question.

That's physicians... and PATIENTS.  I congratulate the Choosing Wisely initiative for involving the patient in the care decision, empowering the patient to participate in the decison-making process, and expecting that the patient can bear this responsibility. 

My personal favorite comes from the American College of Physicians:
Don’t obtain imaging studies in patients with non-specific low back pain.  In patients with back pain that cannot be attributed to a specific disease or spinal abnormality following a history and physical examination (e.g., non-specific low back pain), imaging with plain radiography, computed tomography (CT) scan, or magnetic resonance imaging (MRI) does not improve patient outcomes.

And similarly from the American Academy of Family Physicians:
Don’t do imaging for low back pain within the first six weeks, unless red flags are present.  Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs. Low back pain is the fifth most common reason for all physician visits.

The lists from all nine groups can be found here.

This is excellent work in that it is:
1) Data-driven
2) Consenus-backed
3) Patient-focused

For your reference, the nine participating groups were:
American Academy of Allergy, Asthma & Immunology
American Academy of Family Physicians
American College of Cardiology
American College of Physicians
American College of Radiology
American Gastroenterological Association
American Society of Clinical Oncology
American Society of Nephrology
American Society of Nuclear Cardiology

Now if we could only get the American Academy of Pain Management to participate...

On Twitter @PRIUM1

Thursday, April 5, 2012

The full cost of opioid over-utilization

Joe Paduda's blog today, "Is your hair on fire yet?", puts forth an excellent explanation as to the total cost of opioid over-utilization.  Beyond the costs to patients' health and payers' claims, a possible hidden cost to some payers is the lost time due to patients not being able to return to work, or not allowed back to work because of liability related to their ongoing drug use.  While that might seem to be obvious, in my discussions in the marketplace I completely concur with Joe that it is in large part not actively being addressed.

At this juncture, there is no lack of exposure to the problem (at this rate I'm anticipating a new 24/7 cable channel to deal exclusively with the U.S. prescription drug abuse issue).  And if you have read this blog, you know how passionate both Michael and I are on this subject.

So to Joe on behalf of Michael, myself and the PRIUM team, all I can say is ... Amen!

In this together – Mark

On Twitter @PRIUM1

Wednesday, April 4, 2012

Two steps forward, one standing still

My morning had a good start with my daily read of workcompcentral for activity on April 3:
  • Arizona Guidelines: The Senate passed an omnibus bill (HB 2368) that “requires the Industrial Commission (ICA) to develop and implement a process for the use of evidence based medical treatment guidelines, where appropriate, to treat injured workers no later than December 31, 2014.”  The ICA is to provide status updates each December 31 (starting in 2012), and if consensus cannot be reached by 2014 then at least a timetable will be established.  The floor amendment does not mandate what guidelines to create/select, or the criteria for selection, but at least sets the process into motion.  Obviously this isn’t law yet but this legislative consensus is a very good sign that a standard of care beyond the treating physician’s personal opinion is coming.  Feel free to go back in time and read my March 23 blog about Arizona.
  • Oklahoma Opt-Out: The compromise process in the legislature appears to be working as the Oklahoma Senate Judiciary Committee approved that employers with as few as one employee could choose to opt-out of the Work Comp system.  The original bill required fifty employees, which became a sticking point as the perception of bias towards larger employers.  Their substitute plan to offer medical and indemnity benefits would still be subject to Employee Retirement Income Security Act (ERISA) regulated by the federal government.  Not surprisingly, business and employer groups support this new option while insurers and insurance organizations oppose (they obviously have some skin in the game).  Several obstacles remain to this becoming law, including approval by the full Senate and then the House, but it certainly appears as though this is now much closer to happening. Feel free to go back in time and read my March 19 blog about this opt-out provision.
  • Mississippi Reform: Unfortunately, the good news stops here.  Mississippi appears to be at a standstill in regards to SB 2576 and HB 555 that would shift presumption in favor of employers in many cases, increase benefits for death and disfigurement, limit claimant’s attorneys’ fees, and allow employers to require drug tests of workers suspected of alcohol and drug contribution to work-related accidents.  As we all know, the “sausage making” process of legislating can be messy at times, and it is difficult to understand everything that happens outside of the spotlight and behind closed doors (“Gary Chism, R-Columbus, said that members were lobbied intensely over the weekend to pull back the measure”).  Obviously, there is more than meets the eye here as Mississippi tries to join the majority of states that at least give balance to the process of assessing medical appropriateness, but hopefully change will eventually come.
One state at a time ...

In this together – Mark

On Twitter @PRIUM1

Tuesday, April 3, 2012

Y doesn’t necessarily mean Yes

As readers of this blog know, I am keenly interested in the Texas Closed Formulary (TCF) and the effect those rules have on treatment and prescription behavior.  My January 2012 whitepaper documented a more than 50% reduction in the use of “N” drugs (as classified by ODG’s Work Comp Drug Formulary) for claims requiring preauthorization on dates of injury on or after 9/1/11.  Other sources subsequently documented similar or even greater reduction in the use of “N” drugs for new injuries.

Since February I have been seeking input as to what is happening with that 50% not using “N” drugs.  There is no consensus but many theories, including:
  1. Switching to more conservative therapy
  2. Switching to “Y” drugs
  3. Switching to interventional methods like injections or nerve blocks
  4. Cost shifting to the injured worker’s group health policy or Medicare/Medicaid
  5. Injured worker paying for the drugs themselves
  6. It was a statistical anomaly that will even out over time
After attending two conferences last week, I get the feeling that option 2 (switching to “Y” drugs) is largely misunderstood by non-clinical people in Work Comp.  I have even heard of physicians asking the DWC to tell them what “Y” drugs they can prescribe instead of the “N” drugs.  In this particular case, “Y’ does not equal “Yes”.

The ODG drug formulary applied a Status of “N” if the drug is not recommended as first-line treatment and preauthorization is recommended to assess their appropriateness and necessity.  A drug with a status of “Y” is a preferred drug for first-line therapy.

For example, all benzodiazepines (alprazolam, clonazepam, diazepam, lorazepam, temazepam, etc.) have an “N” status.  All non-prescription analgesics (acetaminophen, ibuprofen, naproxen) have a “Y” status.  For oxycodone opioids, OxyIR is a “Y” while Oxecta (recommended for patients with risk of abuse but not as first-line therapy for other patients) and OxyContin (second-line therapy due to issues of abuse and Black Box FDA warnings) are “N”.  But just because OxyIR is “Y” doesn’t mean it is medically appropriate as it still needs to meet the criteria of opioid treatment (conservative therapies and less potent analgesics were unsuccessful in controlling pain, risk management pre-screening has been completed for opioid use, etc.).

Other opioids that are “Y” include Suboxone (Buprenorphine), Codeine, Duragesic (Fentanyl) patches, Vicodin and Lortab (Hydrocodone/APAP), Dilaudid (Hydromorphone), Levo-Dromoran (Levorphanol), Morphine, Embeda (Morphine ER), Percocet (Oxycodone/APAP), Ultram (Tramadol), Ultracet (Tramadol/APAP).  If you have been involved in Work Comp, you probably recognize many of these drugs, and probably question their use in cases.  And that is my point.  Just because the drug is a “Y” in ODG, or not included in ODG’s formulary (i.e. non-FDA approved), does not mean they are automatically medically appropriate.

In this together – Mark

On Twitter @PRIUM1

Monday, April 2, 2012

Opioids Just the Start: The True Complexity of Drug Regimens

With our industry's intense focus on chronic opioid therapy, I thought it would be enlightening to point out that the opioid itself is generally the most expensive and prominent drug in the regimen, but typically leads to the use of a host of other medications, often used to treat the side effects of the opioid therapy.

Does this picture look familiar?

I'm consistently shocked at the content of the medical records we review here at PRIUM.  Often (though I acknowledge, not always), each of these conditions is treated as if it arose independent of the opioid therapy itself.  The treating physician documents the lack of good sleep hygiene, the muscle spasms, the depression, the weight gain, the sexual dysfunction, the constipation... all as if they arose as separate and distinct diagnoses.

The reality is that the physician is likely aware of the connection between the chronic opioid therapy and its side-effects, but I suspect documenting such is tricky.  To do so explicitly would lead to the logical conclusion that the opioid "trial" has failed and the drug(s) clearly need to be weaned and/or discontinued.  But this isn't what the patient wants - the patient wants his drugs.  He's in pain and that pain needs to be treated, even if that means the patient's medicine cabinet looks like a veritable retail pharmacy operation.  

Welcome to the reality of 21st century medicine: patient-directed care and a plethora of pills. 

All the more reason to STOP opioid therapy if it does not lead to clearly documented functional improvement.  There is no other valid clinical test.  If you're seeing opioid therapy on a claim without documented functional improvement, you're going to be paying for a lot of different drugs down the line (if you're not already doing so). 

On Twitter @PRIUM1