I’m in DC for a couple of meetings focused on the use, abuse, and impact of narcotics in workers comp. To say this is starting to get major traction would be an understatement; payers, policymakers, employers, and pharma are all recognizing the issue for what it is – one of the biggest problems in comp today.
For now, here’s a few numbers to help put things in perspective.
– workers comp payers spent about $1.4 billion last year on narcotics. That’s ‘billion’ with a ‘B’.
– A study in Washington state determined that there between eight and twelve deaths were associated with workers comp claimants’ use of opioids each year from 1999 – 2002.
– over a third of claimants who start using narcotics are on them for more than a year.
– a fifth are on for more than two years.
– a seventh are on for more than three years.
– this despite well-recognized treatment guidelines that suggest narcotics should be used for a limited dime during the acute phase of an injury.
– in a Washington study, only 16% of the low back claimants taking opiates saw an improvement in functionality; only 30% saw a reduction in pain.
– the extended use of opiates doubles the risk of duration exceeding one year.
The elephant in the room is the issue of addiction. Many payers don’t want to hear about the likelihood that many of their long-term claimants are – in fact – addicted to or dependent on narcotics. For some reason, they appear content to ignore the issue; a couple claims people I’ve spoken with have said “we don’t want to ‘buy’ the addiction.”
Well, here’s a news flash; You already have.
Whether you choose to acknowledge this or not, claimants who have been getting opiates (and/or opioids, the synthetic version) for more than 90 days at a dosage exceeding 120 morphine equivalents per day are are at high risk for dependency/addiction.
And the ones who are addicted are ‘treating’ their addiction by consuming drugs which:
a) employers are paying for – directly or indirectly
b) are preventing return to work
c) increase total medical costs and require claimants to take other drugs to address the side effects of narcotics
d) may be sold, given away, or taken by family, friends, or other users.
What does this mean for you?
It’s time to get real, folks. Here are a few ways to get started.
Begin identifying the claimants at risk for addiction; develop a scientifically – and jurisdictionally – sound approach to addressing the risk; partner with your PBM on a comprehensive strategy; work with regulators to change rules where necessary and possible; task your medical director with developing – and implementing – a solution.
Washington State has what looks to be an excellent, well-researched approach.
Jun
29
Several other issues come to mind:
1. Drugging a patient is a lot easier than curing the patient (particularly where there are both patient and provider financial incentives by way of prolonged disabilty payments and physician dispensing);
2. Narcotic prescription increase seems to coincide with physician reimbursement and/or visit frequency decrease(a way to offset loss of profits);
3. Seldom does anyone actually test the patient to see if they’re using vs. selling the narcotics;
4. Narcotic reliant patients are an unscrupulous physician’s annuity.
Narcotic abuse by both prescribers and patients will continue because we do not monitor physician prescribing patterns (abuses), professional standards for medical necessity of narcotics are very loose, there is rampant off-label use,no price controls, and financial incentives to the providers to prescribe (both from drug companies and office dispensing).
The real “elephant in the room” is the profit motive for the doctors who prescribe and / or dispense narcotics.
If there was no profit for the doctors in prescribing and dispensing narcotics, there would be a much lower usage rate.
There are ways to stop the mischief, including an agressive use of evidence based Utilization Review. Payers have to stand up and work diligently to stop this abuse.
Friends: This is not so simple…poorly managed Chronic Pain ruins lives, causes indemnity losses far exceeding the costs of care, and kills people. I have some patients who are able to work only because of the miracle of narcotics.
That said, narcotics certainly do cause important problems, and getting folks onto lower doses and then off narcotics is our goal; our practice has recently inherited about 500 chronic WC cases from primary care MDs that are fleeing WC. Many of these patients are on narcotics- we are getting nearly all on lower doses, many slowly off, and some back to work. But, I am constantly begging carriers for non-narcotic care authorizations.
Carriers must use guidelines with great caution; allow ongoing coverage for non-narcotic measures to control chronic pain. Guidelines are largely developed from acute injury data, and so cannot be validly applied to chronic cases, but commonly are; some folks need maintenance chiropractic, massage, PT, mood meds, muscle relaxers, dietary supplements, various topical meds, heat pads, etc; when these are denied, there is little in the toolkit except narcotics.
No MD can effectively manage these complex cases and make money at the comp rates in NY. Insurers need to find the docs who get good outcomes and pay them what it is worth. If the insurer is not able to identify quality care and pay more for it, economic fundamentals will drive quality out of the system, increasing both suffering and cost.
Another key issue: a major cause of chronic pain is poorly done surgery, especially spine surgery; controlling our US epidemic of unnecessary spine surgery is a worthwhile goal for carriers. Use your data and get the folks who do need surgery to the surgeons with good outcomes.
Finally, the US overpays PHARMA egregiously for narcotics, and for pieces of plastic and metal to put into the spine; that should also be fixed.