Turning the tide in employee opioid abuse

Each day across the United States, more than 130 people die after an opioid overdose. In 2018, an estimated 1.7 million people suffered from prescription opioid abuse disorders. For many of them, their addiction began with a prescribed opioid like hydrocodone or oxycodone following an injury at work.

Opioids can be a helpful treatment option in managing pain that occurs after certain surgeries and types of cancer. But, studies indicate that many healthcare providers overprescribe opioids and many patients misuse the drugs, resulting in what innumerable news reports, academic studies and televised documentaries aptly described as the “opioid epidemic.” The financial toll of this epidemic — the costs of healthcare, lost worker productivity, addiction treatment, and law enforcement — is estimated at $78.5 billion a year.

Fortunately, headway is now being made in reducing opioid abuse in cases involving injured workers, thanks to the combined efforts of workers’ compensation insurance brokers, third-party administrators, insurers and pharmacy benefit managers partnering to attack the problem. Altogether, the number of claims with a prescription that included an opioid fell from 55% in 2013 to 40% in 2017, according to the 2019 State of the Line Guide published annually by the National Council on Compensation Insurance, a workers’ compensation insurance rating and data collection bureau.

In their work, the partners are leveraging real-time pharmacy transaction history, data analytics, and clinical dashboard tools to flag potentially inappropriate opioid prescribing, other unsafe prescribing habits, and high-risk providers. By monitoring opioid prescriptions for potential misuse, the partners help ensure injured workers receive superior healthcare, optimal pain management and return to work faster.

This collaboration is helping to combat opioid abuse.

Too much of a good thing

Treating severe and chronic pain has long been a key aim of healthcare professionals. In this regard, the development of opioids like morphine, codeine, fentanyl, and hydrocodone, among others, is an important healthcare milestone. Many physicians ask patients to rate the level of pain they are feeling. The challenge is that pain is subjective; each person is able to endure different levels of pain; moreover, various factors beyond the injury itself can influence the level of pain experienced.

In 2012, physicians wrote a record 255 million opioid prescriptions, a prescription rate of 81.3 per 100 people. Many patients also were taking the pain medications for longer periods of time. For example, 15% of injured workers prescribed opioid medications were still taking the drugs six years after the injury occurred, according to a 2018 study of workers’ compensation claim data by the National Institute for Occupational Safety and Health (NIOSH). Thirty percent of injured workers were taking the drugs two to six years after their injuries and 55% for up to two years.

The longer an opioid prescription remains in place, the greater the risk the injured worker will remain temporarily disabled, NIOSH stated. The federal agency cited a study of lower back injury claims indicating that employees still using the pain medications took three times longer to return to work, compared to those with similar back injuries who did not receive any opioid prescriptions.

The pain medications also are linked to soaring absenteeism rates. Workers with an opioid use disorder miss an average of 29 days of work per year, in contrast with the average 10.5 days for all employees, the Bureau of Labor Statistics reported.

Added up, the staggering economic and emotional toll of opioid abuse has become a national public health crisis. To assist corporate clients in their goal of returning injured employees to work as soon as possible, workers’ compensation insurers and brokers have aligned with pharmacy benefit managers (PBMs) to identify addictive behaviors early enough in the pain treatment process to reduce the risk of drug abuse.

What we’re doing

This is our objective at QBE North America and Sedgwick, in working with industry-leading PBM partner Optum. Our collective goal is to effectively and efficiently manage opioid use on behalf of workers’ compensation policyholders. Like other parties engaged in workers’ compensation, we realize that historical and real-time claims data is crucial in addressing adverse outcomes. Sedgwick’s pharmacy program, which is staffed with pharmacists, nurses, and physicians, works with Optum to access real-time pharmacy data. Using customized clinical tools to analyze Sedgwick’s vast storehouse of claims data and Optum’s real-time point-of-sale pharmacy data, we can identify potential pharmacy issues early in the life of the claim.

Once flagged, we trigger a high-risk alert. A standard trigger is an injured worker who receives six weeks of an opioid or a morphine equivalent dose of 80mg per day or more. Once triggered, a Sedgwick nurse will work in collaboration with the claims examiner to address the issue with the prescriber. Other alerts trigger when specific high-risk drug combinations occur and ensure that outreach is made to the prescriber(s) to advocate for better, safer prescribing.

During the claims review process, evidence of potential prescription abuse like early and/or consistent drug refills are flagged, as are inconsistent urine drug screens and overuse of PRN opioids (PRN is a Latin term, pro re nata, meaning “as the thing is needed”). Such medications essentially are taken for intermittent pain but can lead to overuse and abuse.

We have also developed customized drug formularies with our PBM partner that align with each type of workplace injury and related phases of pain, such as an injury with acute pain that can last for up to six weeks. We further require prior authorization for medications generally considered inappropriate in a workers’ compensation context. For example, if an injured worker submits a diabetes prescription request through the workers’ compensation pharmacy benefit, our point-of-sale prior authorization process reviews the prescription to ensure it is related to the claim before the medication is dispensed. When possible instances of prescription abuse are identified, the prescriber is contacted to discuss the clinical issues, including the expanded potential for an opioid use disorder.

If a claim is flagged for intervention with an injured worker for drug rehabilitation purposes, the claims examiner is contacted to evaluate if the use of a treatment facility is appropriate. This patient-centered approach to opioid use disorders also encourages such non-pharmacologic interventions as cognitive behavioral therapy, meditation, yoga and stress and anxiety counseling.

Lastly, the clinical dashboard’s comprehensive view of all data concerning client workers’ compensation claims serves another purpose, flagging physicians who prescribe opioid pain medications more than other healthcare providers.

Although every workers’ compensation claim is different, this partnering approach to opioid abuse is making a difference. In many cases, we have succeeded in helping to wean injured employees off pain medications before this use turned into an obdurate addiction. We’ve also intervened with physicians to reduce prescriptions of opioids for consistent pain management, encouraging the use of other medications like ibuprofen and non-pharmacologic pain management therapies.

As gatekeepers in the medical care of injured employees, our role in addressing this public health crisis is a very serious matter. We believe we are striking a delicate balance between much-needed pain relief for injured workers and averting adverse health outcomes from opioid abuse. As a nation, we are not yet out of the woods, but there is a reason for hope.

Related:

• The opioid epidemic cost the U.S. $631B over the past 4 years
• 8 strategies for combating opioid addiction
• Multiple companies had hand in opioid crisis

Julie Hespe (julie.hespe@us.qbe.com) is senior vice president of core commercial & workers’ compensation programs at QBE North America. Paul Peak (paul.peak@sedgwick.com) is AVP clinical pharmacy at Sedgwick Claims Management Services Inc. The views expressed here are the authors’ own.