It’s the nightmare of every health care provider and workers compensation insurer: An injured worker is over-prescribed opioids, develops an addiction, begins using heroin and eventually overdoses. What was meant to be a helpful aid in the healing process becomes a life-destroying addiction.
New research suggests opioids can sometimes actually worsen pain, and every state except Missouri now has legislation for prescription monitoring programs, which seek to aid in the detection of doctor shopping—when a patient attempts to fill prescriptions from multiple doctors—and duplicate opioid prescriptions.
Workplace injuries often have a pain component that call for an opioid prescription, necessitating careful management. Most workers compensation insurers use a third-party pharmacy benefit manager (PBM) to manage multiple scripts for potential drug interactions and appropriateness. Since 75% of patients in heroin addiction treatment report starting their opioid use with prescription medication, employers that wish to avoid these nightmare scenarios should question their insurers about their third-party relationships, as well as other important aspects of their prescription drug program.
One obvious and important measure of an effective prescription drug program is the “pharmacy spend,” which is the percent of the medical cost of claims an insurer spends on pharmaceuticals. The industry spends an average of 10-15%. An exceptional carrier can have a pharmacy spend of about half this amount.
Agents and employers should ask their carriers whom they assign internally to monitor their PBM in order to spot holes in the PBM process. If a medical provider doesn’t think an insurer is too involved with its patient’s care and treatment plan, that insurer most likely isn’t involved enough.
PBMs can provide a lot of information to insurers, but insurers need to request and use this information for a better outcome. For injured workers who receive opioid prescriptions that last longer than two weeks, MEMIC often recommends that the treating physician requires the patient to sign an opioid contract. This allows for periodic drug screening to ensure proper usage and to avoid any negative interaction with other drugs.
Most medical providers appreciate insurers taking an active role because it alerts them to possible red flags from patients who may be doctor shopping. Insurers can also provide employers with first-fill prescription cards in order to monitor care from the beginning and prevent out-of-pocket expense for the injured worker. In this process, the insurer can choose to approve only a 30-day opioid prescription in order to avoid excessive use and the potential for unused pills ending up in the wrong hands.
In January 2013, MaineCare, Maine’s version of Medicaid, began limiting opioid painkiller dosage strength and duration. By the end of 2013, MaineCare recorded a 30% drop from 2011 levels in the number of recipients receiving prescriptions for opiate medications.
The purpose of the policy wasn’t just to limit opioids. It also required chronic pain patients to try alternative therapies, so the opioid decrease corresponded with an uptick in the number of visits to physical and occupational therapists, cognitive behavioral therapists, chiropractors and other alternative pain treatment providers.
The goal of an effective workers compensation insurer is to improve a worker’s health so they can return to work, but the side effects of opioids can actually prevent people from returning to a productive life. Although opioids have become the default remedy whenever pain is present, scientific evidence suggests alternative therapies can be not only safer for the patient, but also more effective from both a treatment and cost standpoint. For example, Kevin Flanigan, MaineCare’s medical director in 2014, says Maine saved $1.3 million on prescriptions while it spent $750,000 on alternative pain management practices.
What alternatives to opioids will insurers pay for? Serious carriers closely monitor the outcomes and research supporting all forms of treatment. Beyond simply masking pain, effective treatment should accelerate healing and increase function.
Physical and occupational therapy, along with chiropractic treatment, may be key to the future, while numerous alternatives to opioids have the potential to be more effective and less addictive, whether on their own or acting in concert. These include antidepressants, anticonvulsants, topicals, nerve blockers and even the cannabidiol in medical marijuana. Insurers and employers will undoubtedly face questions about the efficacy of medical marijuana and how it might interact with employer drug policies, not to mention legal discrepancies between federal and state laws.
Once touted as a miracle drug, opioids may still have their place in managing pain. But the tide is turning against the knee-jerk prescribing practices of recent years.
Matthew H. Harmon, senior vice president for claims for The MEMIC Group, has worked in the workers compensation field for 22 years.