This summer, the U.S. Surgeon General Vivek H. Murthy sent a letter to every physician in the country asking them to help “turn the tide” on the opioid crisis.

Related: This drug could end America's painkiller epidemic

“It is important to recognize that we arrived at this place on a path paved with good intentions,” Dr. Murthy wrote. “Nearly two decades ago, we were encouraged to be more aggressive about treating pain, often without enough training and support to do so safely. This coincided with heavy marketing of opioids to doctors. Many of us were even taught — incorrectly — that opioids are not addictive when prescribed for legitimate pain. The results have been devastating.”

Indeed, the epidemic has forced the healthcare industry to take a critical look at opioid prescriptions and seek alternatives to pain management. In March, the Obama administration announced the federal government's first coordinated plan for reducing the burden of chronic pain to address the epidemic.

But healthcare workers aren't the only ones who can solve this crisis. Patients, employers and insurers all play a role in the problem…and must be part of the solution.

Here's what they all need to know…

Opioids can help ease pain in the short-term, but physicians must carefully monitor their use long-term. (Photo: iStock)

Physicians

It might be easy to simply write a prescription for oxycodone or some other opioid when a patient comes in suffering from chronic pain. In fact, many patients dealing with long-term pain have come to expect that they'll leave the doctor's office with that prescription in hand.

In the short-term, opioids certainly can help ease the sometimes debilitating effects of pain, especially acute pain experienced after trauma or surgery. In these scenarios, it's vital for providers to map out the next steps for pain control and break the cycle because, in the long-term, these drugs can cause more harm than good.

And some physicians, for too long, have relied on the drugs as the only answer — sometimes even prescribing opioids when there is no real medical purpose to simply turn a profit. State and federal officials, especially in Florida, a hotbed for abuse, have cracked down on “pill mills” where doctors have made millions by essentially passing out prescriptions.

Opioids are not the answer for all kinds of chronic pain and some provide huge risks with uncertain benefits. (Photo: iStock)

Many physicians and health care providers, however, are focused on combatting the epidemic. Before prescribing opioids, physicians should:

• Stop using opioids as a regular course of action. Instead, prescribe therapies that don't include opioids, such as exercise and cognitive behavioral therapy or anti-inflammatories for chronic pain. When they are used, the CDC recommends combining non-pharmacological or non-opioid pharmacologic therapies.
• Plan how to deal with acute and protracted pain complaints.
• Strictly limit the number of pills and refills per prescription.
• Be aware that opioids aren't the solution for all kinds of chronic pain. For instance, Harvard Medical School says that opiates for chronic lower back pain carry “big risks with uncertain benefits.”
• Ask the patient if any other doctor or clinic has prescribed a pain medication and seek a toxicology screening to ensure there isn't already an addiction problem. Be sure to follow up with additional screenings.
• Sign a pain management contract with the patient – and enforce it.
• Check your state's prescription drug management program database to identify patients who are obtaining the drugs from multiple providers. New research from Weill Cornell Medicine found that there was a more than 30 percent drop in the rate of prescribing the most addictive class of painkillers – Schedule II opioids – in two dozen states through these databases.
• Always prescribe the lowest effective dosage and begin with immediate-release opioids, not extended-release or long-acting opioids, according to the CDC. Never provide more than needed.
• Continue to monitor patients who are using opioids and be sure to wean them off the drugs as soon as possible.

Related: 10 factors influencing the treatment of chronic pain

It's critical for doctors to educate patients about the use and possible side effects of opioid medications. (Photo: iStock)

Patients

Opioids can be an effective form of treatment, but they also can turn a life upside down. According to the CDC, as many as one in four patients who take prescription opioids in a primary care setting struggle with addiction. Use of these prescription pain medications can also lead to abuse of illegal drugs such as heroin, which is an opioid.

Some opioid addicts turn to the illegal drug because it's cheaper and easier to get than prescription medication. According to the National Institute on Drug Abuse, about half of young people abused prescription opioids before they injected heroin for the first time.

Education is key. Some patients believe they can't become addicted to narcotics because it was prescribed legally. But the body does not know or care how the opioids were introduced. It just knows that it is used to having them onboard.

Other options for pain management include physical therapy, behavioral therapy and accupuncture. (Photo: Shutterstock)

If you're suffering from chronic pain, patients should:

• Ask their doctors about alternative treatments such as cognitive behavioral therapy, exercise, acupuncture, physical therapy and other medications, including acetaminophen and ibuprofen.
• Tell your physician whether you've had difficulties with opioids in the past so that alternative therapies can be pursued.
• Always take the medications as directed by your doctor and ask about other drugs, including alcohol, to avoid while on the prescription.
• Take the lowest dose that covers your pain. Understand that being pain free is likely impossible. Accept the situation as much as possible and use the minimum amount of narcotic possible.
• Be careful to keep the drugs where others can't access them. If there are any pills left over after you no longer need them, look for drug drop off programs to ensure they aren't stolen or abused.
• Expect regular follow-ups with your doctor, who will want to monitor your pain level and side effects and track any problems.

Employers must work closely with healthcare providers to ensure employees are receiving the necessary care for injuries and understand how that care will impact their ability to work. (Photo: iStock)

Employers

For employers, the economic costs of opioid abuse is huge. According to one study, the financial burden totals more than $50 billion a year, mostly thanks to lost productivity and crime.

But the bottom line isn't the only thing at risk when workers use opioids — even those who take a regular dose. According to the National Safety Council, opioids may make some workers too impaired to work, a concern especially for those who operate heavy machinery or must remain alert at all times.

And it's hard to pin down the “stereotypical” opioid user. The safety council says that nearly a quarter of the U.S. workforce has used prescription drugs for non-medical reasons.

What's more, employers may think they are catching problem employees through drug screenings, but not all drug-testing panels cover prescribed medications.

Read on for employer recommendations…

Not all drug screens will identify prescribed medications. (Photo: iStock)

For safer and healthier workplaces, employers must:

• Seek out an expanded drug testing panel, which looks for drug compounds not found in a five-panel test — benzodiazepines and opioid pain medications, according to the safety council.
• Know the physicians who are prescribing the narcotics and be on the lookout for those who prescribe more opioids than others. Having reputable providers who are open and transparent with injured workers is critical to a foundation of good care.
• Ask insurers and providers to look out for warning signs that may signal abuse such as lost prescriptions or unorthodox refills.
• Rely on case managers — filed or telephonic — to regularly follow up with your employees during their medication and treatment.
• Document. Document. Document. If an injured worker has been out on a serious injury, have policies in place to monitor drug usage.
• Regularly educate yourself and employees about the dangers of opioid use and its insidious nature.
• Create a safe zone policy that allows for employees or injured workers to come and discuss possible addiction issues.

Opioids are an inexpensive treatment intially, but in the longrun the costs for use can quickly add up for insurers. (Photo: iStock)

Insurers

Insurers have long considered opioids an inexpensive way to treat chronic pain. But, according to one report by the Foundation for Ethics in Pain Care and PRA Health Sciences, private and public insurers' moves to make methadone a first-line drug for chronic pain is one of many reasons behind the country's current opioid crisis.

In reality, while the individual pills may be inexpensive, treatment of the long-term effects of the drugs add up quickly. Consider these statistics from FAIR Health: In 2015, the average cost for private payors for a patient diagnosed with opioid abuse or dependence was more than 550 percent higher — nearly $16,000 more per patient — than the average cost for all patients' claims.

RXInformer found that prescription opioid abuse also can lengthen the life of a claim. Claims are 30 percent less likely to close within three months if a patient starts taking an opioid within the first four weeks, according to the clinical journal's report.

There are several actions insurers can take to help reduce opioid use and the resulting costs. (Photo: Shutterstock)

To help cut down on opioid use and abuse, insurers can:

• Ensure case managers follow patients throughout treatment and their use of any opioids.
• Develop red flags, such as specific diagnoses, procedures, injuries and lost time thresholds that could indicate the need or use of chronic pain medications. These alarms should signal the need for early assignment of the case to case managers.
• Insist on periodic, random drug screenings, which look for drug compounds not found in a five-panel test — benzodiazepines and opioid pain medications, as recommended by the National Safety Council.
• Look out for warning signs, including doctors who prescribe a high number of opioids and patients who use several pharmacies or seek regular increases to the dosage.
• Cover alternative pain treatments and monitor new treatment developments, which may be more cost effective than traditional opioids in the long run.

Understanding the risks associated with the use of opioids and collaborating with insurers, employers and medical providers can generate a better long-term outcome for workers dealing with chronic pain and severe injuries, creating a best-case scenario for all.

Kari Williamson, BS, RN, LNCC, CCM ([email protected]) is the president of MKC Medical Management and works with attorneys, insurance examiners and others within the medical-legal-insurance space to better manage and understand claim issues.