As agents and brokers prepare to counsel clients on ways to minimize the risk of opioid abuse and addiction in workers’ compensation programs, they should be aware of the principles of pharmacovigilance.
This is a practice that has long been used in the pharmaceutical industry to ensure safety around prescription drug use. It involves various stakeholders participating in the monitoring and reporting of adverse drug reactions that could be dangerous — as well as promoting their safe, prescribed usage.
As the term implies, comprehensive and ongoing surveillance of prescribing and usage patterns is the key to safety, and this spirit of vigilance is urgently needed in workers’ comp around opioid use.
Excessive use and addiction
Addiction to prescription painkillers is a growing problem in the United States. Physicians feel compelled to write a prescription at each patient visit, and patients equally desire a quick fix for health issues, particularly pain. As a result, opioid prescription sales have increased 300 percent since 1999. Another consequence is that drug overdoses, predominantly from opioid painkillers such as OxyContin and Percocet, now exceed car crashes as the leading cause of unintentional death.
By its nature, the workers’ comp industry experiences a disproportionately high incidence of opioid use due to the type of accidents and injuries that occur. For claimants with chronic pain issues, opioid abuse can occur in up to 41 percent of cases.
Claimants prescribed an opioid painkiller can develop a tolerance to the drug, require increased dosages and become highly reliant. These claimants may require extensive time away from work, lose the motivation to return and become negatively affected in a number of other ways.
Vigilance at the macro and micro level
At the macro level, regulators can strengthen pharmacovigilance. Norwalk, Connecticut-based Shatterproof, an organization that strives to end addiction, supports legislation that would require physicians and pharmacies to engage with state-run prescription drug monitoring programs to help identify and address prescription drug abuse.
Mandating a closed formulary backed by evidence-based medical guidelines is another macro-level change that would promote alternative pain therapies and use of opioids only when medically necessary.
At the micro level, nurse case managers serve as the central architects for “pharmacovigilance.” Their monitoring helps detect situations that require further review and proactive intervention. For example, they may find prescription costs are rising faster than overall medical costs on a particular claim, without a subsequent improvement in the injured worker’s functional status. They may detect other signs of abuse, such as opioid prescriptions from three or more providers or a significant increase in dosage — all of which can be addressed to avoid the spiral into addiction.
Related: Tackling the opioid epidemic
Some physicians prescribe opioids outside of evidence-based guidelines. A clinical management program can ensure that opioid usage is consistent with medical recommendations. (Photo: iStock)
An integrated approach
Agents and brokers will find that clients are aware of the opioid epidemic, but many think they have sufficient programs in place, such as pharmacy benefit management.
Although pharmacy benefit management programs play a critical role, their efforts must be integrated with those from claims, medical management and bill review in order to effectively monitor and detect issues early enough to impact the course of a claim. For example, as treating physicians send invoices and treatment plans, bill review and medical management teams can unearth early signs of misuse.
A key obstacle to this multifaceted pharmacovigilance approach has been a lack of integration. With disconnected silos, the industry is missing opportunities for greater oversight and coordination that could lead to improved safety and outcomes. Clinical and bill review programs should have infrastructure in place to ally with pharmacy benefit management programs for a concerted and comprehensive pharmacy review program.
Another key component is outreach and education with treating physicians, who may not realize their prescribing patterns fall outside of evidence-based guidelines. A clinical management program should offer a specialized team of physicians for peer-to-peer review and consulting. This team typically has enhanced pharmaceutical knowledge to ensure usage consistent with guidelines, help facilitate tapering procedures when needed and aid in transitioning to a more holistic treatment a plan. For example, non-pharmacological options could include physical medicine, heat and cold therapy, electrotherapy and cognitive behavioral therapy.
Technology and analytics also play a crucial role. Dashboards help organizations monitor overall program performance, as well as zero in on outliers. Clients can observe patterns in spending and return-to-work results on opioid-related cases. They can set up alerts for common issues, such as prolonged opioid use, which can be addressed by the medical management team. Algorithms can look at certain types of claims, such as shoulder injuries, to see whether opioid use on these cases lines up with industry benchmarks, and if not, manage the cases more closely.
Drivers toward change
A predominant driver for change is cost — and the cost of this problem has reached a critical mark that can no longer be ignored. Use of narcotics in workers’ comp tallied more than $1 billion for employers and insurers in 2012, the bulk of which was spent on opioids. Financial controls help detect and manage the issue, but it’s only part of the overall mindset shift that’s required to affect change. Upping the ante on this issue are recent court decisions that have found employers and workers’ comp insurers financially responsible when injured workers have fatally overdosed on prescribed painkillers.
Agents and brokers will find that employers are concerned about the well-being of their employees. They want injured workers to return to work to maintain productivity, but they also want to do the right thing to ensure their safety.
A shift in mindset must occur among all workers’ comp stakeholders in order to achieve the coordinated vigilance that’s required for prescription safety. After all, if an organization experiences one overdose, it’s one too many.
Managing claims in a new way can be difficult to implement, but in the long run, organizations that have put these safeguards in place will see a positive financial impact and peace of mind in knowing they’ve put employee safety first.
Ron Skrocki is senior vice president for product management and development at Wayne, Pennsylvania-based managed care services provider Genex Services.
Related: When painkillers turn to pain