The national crisis of the misuse of and addiction to opioids echoes in the workplace every day. A National Safety Council (NSC) poll, estimates that over one-quarter of the U.S. workforce is using opioids. The costs to employers are well documented – increased absenteeism, lower productivity, higher health care costs, more occupational injuries, fewer skilled workers who can pass drug tests, and increased workers’ compensation costs. A recent study by the Kaiser Family Foundation found that large employers experienced a sharp increase in costs for treating opioid addiction and overdoses among their workers, rising from $646 million in 2004 to $2.6 billion in 2016.
While the workers’ comp industry has made significant progress in limiting opioid prescriptions for acute pain, much work remains to be done. According to a new workers’ compensation drug trend report from Optum, forty-nine percent of injured workers receiving a prescription drug were taking an opioid in 2017, a figure that was about four percentage points lower than in 2016.
Although each workplace has its own challenges, an assessment of a company’s efforts to combat the opioid problem should focus on three areas:
- Reducing or eliminating initial opioid usage for recently injured workers
- Helping injured workers who have become long-term users wean off of opioids
- Prevention – preinjury support
Reducing or eliminating initial opioid usage for recently injured workers
While efforts to curb opioids in workers’ comp vary significantly by state, customized formularies, utilization management and clinical programs, legislative action including limits on initial opioid prescriptions for acute pain, and claims professional education, have collectively worked to reduce opioid prescriptions for pain. Some states are requiring alternative approaches. In Ohio, for example, residents with work-related back injuries are now required by law to try remedies such as rest, physical therapy or chiropractic care before surgery or opioids.
Employers, too, play a powerful role in preventing the development of opioid addiction. Educating workers about the dangers of opioids may prompt injured workers to forego opioids altogether rather than accepting an initial short-term prescription. Monitoring opioids prescriptions by receiving alerts when they are prescribed and setting limits can ensure that guidelines are followed. Intervening early and ensuring that injured workers have a clear path for getting back to work helps control the fear of pain, which leads to avoidance behavior.
Physicians, who can clearly explain the advantages of alternative treatments and the dangers of addiction, as well as gain the workers’ trust, will be effective in facilitating a return to work without reliance on pain meds. Utilizing nurse case managers can provide valuable interaction with physicians and can help injured workers manage their pain, recover, and avoid opioid dependency.
Training supervisors and managers to identify workers who struggle with pain or are at greater risk for dependence will trigger a need for early intervention and behavioral programs that focus on pain management through employee engagement and resilience. Unsupportive supervisors who intimidate workers by insisting they work through the pain or ignore the problem may disrupt the recovery.
The process takes planning and must be geared to the individual. Effective change comes when workers understand the benefits of non-drug pain therapies and buy into the solution. There are some workers who will want immediate relief, the hallmark of pain meds. Others may not want to exert the effort or time involved in physical therapy, acupuncture, exercise, or yoga, and others may be skeptical of mindful therapies. It’s the employer’s role to foster trust, provide support, and help motivate the employee.
Helping injured workers who have become long-term users wean off of opioids
While averting opioid dependency in a new workers’ comp claim is no easy task it’s tenfold more difficult in legacy claims tied to long-term opioid prescriptions. There are many barriers to successfully resolving long-term claims that involve chronic opioid usage:
- The treating physician doesn’t buy into alternatives and won’t suggest them to a patient
- There aren’t enough physicians who have adequate training on pain management and opioid prescribing
- There’s attorney involvement
- The worker is in a vicious cycle of drugs trying to manage the pain – the worker hasn’t slept, has anxiety, depression or nausea, and takes other pills alongside their Vicodin or OxyContin to repress those side effects
- The prospects of returning to work seem slim and the worker has psychosocial factors such as depression, hopelessness, and hostility
- The worker is focused on pain and unwilling to quit or reduce their pain medications
- Medicare set-asides allows comp claims to close with cash set aside to pay for future drugs – often strong doses – with little oversight
Although these barriers are daunting, there is promise in a recent report released by California’s Workers’ Compensation Insurance Rating Bureau. The report, Study of Chronic Opioid Use and Weaning in California Workers’ Compensation, showed nearly half of the study claims with employees demonstrating chronic opioid usage (11 months from the date of injury) weaned off of opioids completely within 24 months from the date of injury. The weaning process typically involved a gradual decrease in opioid prescriptions combined with a mix of alternative non-drug treatments and non-narcotic drugs.
Vital to success is the adjuster who must remain involved throughout the process. It begins with knowing how to look at the data, not only to identify claims where opioid usage costs are high, but to identify trends. What types of injuries are involved? Do they occur in the same department or under the same manager? Can they be linked to certain physicians? Chronic use of opioids extends disability, and data analysis is critical to building a plan.
The adjuster must be familiar with and open to evidence-based innovative treatment options and understand how best to work with the injured worker. The program’s success also relied upon peer-to-peer conversations with the prescribing physicians and developing a program specifically aimed at helping workers cope with significant chronic pain. It demonstrates that a well-designed, carefully managed program with the focus on the individual can work.
The increased awareness around the epidemic has improved the possibilities of success with legal action, as indicated by a recent decision of the West Virginia Supreme Court. In Grinnan v. West Virginia Office of Insurance Commissioner, the court ruled unanimously that a carpenter was not entitled to continued treatment with OxyContin for a 26-year old back injury. However, legal action should be viewed as a last resort because of the time, money, and hostility involved.
Prevention – preinjury support
In the past, opioids were often prescribed for musculoskeletal injuries, effectively masking the pain but doing nothing to treat the injury. Ensuring good ergonomics in work place design and processes and ensuring that workers can handle the physical demands of their job is a good first step. Listening to workers who have minor pain and providing the support to minimize it, will help prevent costly claims.
Drug policies should be reevaluated to identify the situations where testing makes the most sense as well as what tests should be used. Screening for prescription drug use, illicit drug use, and adherence to legitimate opioid medications is a sound approach to mitigate risk. Working with legal counsel, the employer should decide what testing is warranted for pre-employment screening, pre-duty, periodic, at random, post-incident, reasonable suspicion, return-to-duty, or follow-up situations.
Legitimate claims from workers who already are using opioids are among the most difficult to resolve. A recent article on lexisnexis.com by Thomas Robinson notes that a study to be published by the Journal of Occupational and Environmental Medicine supports the widely-held notion that pre-injury opioid and benzodiazepine use may increase the risk and cost of disability after a work-related injury.
Prevalence of compensable claims was higher among cases with pre-injury opioid use compared to cases without such pre-injury use (28.6 percent vs. 19.5 percent) and prevalence of post-injury opioid use was higher among claims with pre-injury opioid use compared to cases without such pre-injury use (67.2 percent vs. 22.8 percent). Train supervisors and managers how to identify the signs of drug abuse, the steps to take if abuse is suspected, and the legal issues involved. It is in the best interest of the employer to provide support and confidential access to treatment.
Proactive employers are also altering health plans to restrict the use of prescription opioids. The Surgeon General urges employers to ensure that health providers are following the Centers for Disease Control and Prevention (CDC) guidelines, “Use your levers on the health care delivery side.” He notes that dental prescriptions for opioids is the first step for many toward addiction. “If you tell your employees and their families that you’re not going to pay for more than 10 pills if they go to the dentist, that will have a quicker impact than anything I can do as surgeon general to educate the prescribers in the community.”
While the path to finding effective treatment of choice can be long, difficult, and expensive, doing nothing can be costlier to the employer and devastating for the worker.
Note: NCCI is doing a series exploring three viewpoints on issues surrounding opioid use and workers’ compensation: those of doctors, insurers, and workers compensation regulators.
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