Tapering the opioid crisis: Best practices for claims professionals

It’s no secret that the opioid crisis in the United States has reached epidemic status.

In the claims business, we see trends in workers’ compensation claims that begin with an opioid. Suddenly we notice additional prescription drugs being added to the patient’s profile to combat the side effects. This can ultimately cause the claim to go in the wrong direction. (Credit: Iryna Imago/Shutterstock)

It’s no secret that the opioid crisis in the United States has reached epidemic status. We hear about the impact it’s having everywhere from our hometowns to Hollywood — raising attention from agencies such as the Centers for Disease Control and Prevention to the White House. Sadly, over 134 people in the U.S. lose their lives due to an opioid overdose every single day. Since 2000, the rate of opioid overdose deaths has more than quadrupled.

As insurance professionals, we have seen firsthand how claimants are being affected by the overprescribing of these medications. While opioid prescribing is trending in a better direction than it was three or four years ago, excessive opioid utilization and opioid use disorder as a result of pain management strategies continue to be critical challenges facing the industry today.

Opioid dependence is often an unintended consequence for an injured worker — raising obstacles for them, their family members and their employers.

A spiraling effect

Opioids such as morphine, oxycodone and hydrocodone are commonly prescribed for pain management. When a patient is injured, doctors will often recommend a short-term dosage of an opioid to help ease the pain. For an injured worker, even a prescription intended for short-term pain management can lead to physical dependence and eventually opioid use disorder.

As we know, injured workers are often dealing with a range of underlying issues beyond physical pain. Many times, an injured worker will experience fear or depression — concerns about losing their jobs, their finances or anxiety caused by those concerns and their sudden health problems. In fact, all these psychosocial inputs can work to make the pain more severe. Opioids may numb the physical pain of injury, but also elicit a feeling of euphoria that will mask other issues. It is this reward of euphoria that may lead to overuse. A patient will see the medication as a coping mechanism and over time will build both a physical dependence and a tolerance to the drug. They will require a higher dosage to feel the same effect while their body begins to rely on the medication. Unfortunately, opioid-related deaths often occur when one goes without the drug for a number of days, which decreases their tolerance. A sudden relapse to the same high dosage they took when their tolerance was higher can cause respiratory issues that may lead to death.

For employers, drug dependency is a costly problem. Historically, opioid use is proven to delay an employee’s return to work and lead to an increase in other health and prescription drug costs. Studies show that when a workers’ compensation claim involves an opioid, it is not only more expensive but is also more likely to have a longer duration.

These drugs can cause other side effects, such as drowsiness, constipation, depression and hormonal changes, such as a decrease in testosterone. As a result, patients will seek care for these other health issues and doctors will often prescribe additional medications. In the claims business, we see trends in workers’ compensation claims that begin with an opioid. Suddenly we notice additional prescription drugs being added to the patient’s profile to combat the side effects. This can ultimately cause the claim to go in the wrong direction.

Managing the problem, one claim at a time

For certain injuries in the acute setting, opioids may be effective and should be prescribed for a short duration (three days supply). Many states already have or are adopting new regulations to help curb the opioid prescription abuse crisis. For example, California has a drug formulary in place and many other states have mandates on fills.

Working together, industry professionals are making strides to address this crisis by developing pharmacy utilization review programs to prevent abuse. Clinicians, pharmacists and claims professionals can leverage their knowledge and experience to identify potential red flags before prescription drug problems escalate. One critical area to monitor is the Morphine Equivalent Dosage (MED) of the opioids prescribed. When there is an MED increase in someone’s prescription profile, program advisors may begin to put steps in place to proactively manage the situation. A collaborative team can strengthen the claims process by validating each prescription drug during the life of a claim. Providing targeted training and education about the proper use and administration of opioids remains critical to achieving the best outcomes.

What can employers and claims professionals do to help manage this crisis? Together they can put together a program that includes collaboration with pharmacists, nurses and doctors. Holding clinical roundtables to discuss what the team is seeing in the industry and about changes in compliance can be very valuable.

While this is a complex issue, there are many things that can be put in place to help manage this crisis:

For employers, it is in their best interest to help injured workers by providing the resources, support and education needed to manage opioid use disorder. By taking a solutions-focused approach, employers will save money, help workers get back to work, speed recovery and reduce the potential for secondary claims.

There is no easy solution to this growing problem. However, insurers and other claim professionals must invest in and leverage the latest pain management interventions, technologies, training programs and continue to push for tighter controls on the prescribing of opioids to guarantee the best outcomes.

Related:

Paul Peak (paul.peak@sedgwick.com) is AVP clinical pharmacy at Sedgwick Claims Management Services Inc. The views expressed here are the author’s own. 

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