PMA Executive Briefings explore workers' compensation challenges and solutions.
In this PMA Executive Briefings series, we’re examining the challenge of managing chronic pain in injured workers. We began by exploring trends, treatment patterns and opioid usage, and then looked at evidence-based
treatment protocols to manage chronic pain. In this issue, we explore intervention strategies to help injured workers who have become dependent on opioids.
According to the National Institute on Drug Abuse, approximately 21 to 29 percent of chronic pain
patients who are prescribed opioids misuse them and 8 to 12 percent develop an opioid use disorder.1
Although best-practice insurance companies and
Third-Party Administrators (TPAs) have made
progress in partnering with medical providers to
prevent opioid dependency, the problem of addiction
still exists. To address this serious issue, the many
factors that contribute to addiction — and the signs
of dependency — should be understood.
Understanding and Identifying Addiction
Leading medical associations define addiction as a disease caused by a combination of behavioral,
environmental and biological factors. According to The National Center on Addiction and Substance Abuse, genetic factors account for about 50 to 75 percent of the risk that an individual will develop an addiction.2 Other risk factors include psychological issues such as stress, depression and anxiety, and environmental factors such as physical, sexual or emotional abuse or trauma, even distressing experiences that occurred years earlier.
When an individual takes opioids, chemicals associated with pleasure or reward are released
in the brain. Over time the person may need the substance — in increasing doses — to feel normal. If left untreated, the addiction can become more severe, and, in some cases, disabling and life threatening.
Before we discuss treating opioid dependency, it’s important to reiterate that opioid usage must
be carefully managed. Treating physicians should conduct a risk-benefit assessment before prescribing opioids and follow evidence-based protocols when prescribing opioids to injured workers. The CDC’s 2016 Guideline for Prescribing Opioids for Chronic Pain offers guidance to providers regarding when to prescribe opioids, opioid selection, dosage, duration, follow-up and discontinuation, and assessing risk and addressing the harms of opioid use.3
Identifying the early warning signs of opioid dependency is crucial. Insurance companies and
TPAs can set up automatic alerts to flag behavior such as requests for or the prescribing of higher doses of opioids without pain relief improvement, drug hoarding, early refill requests, acquiring pain medication from multiple providers and non-adherence to alternative pain therapies.
It can be a challenge for opioid-dependent individuals with chronic pain to adopt other strategies to manage their pain.
Peer-to-peer physician review and education can be keys to identifying the need to start a weaning
process. Physicians specializing in addiction treatment may be called upon by the insurance company/TPA to assess the treatment plans developed by the injured worker’s physician. Through the peer-to-peer review process, addiction specialist clinicians can engage the treating physician in discussions about alternative therapies to relieve their patient’s pain, restore function and reduce dependency. Often, the review results in changes in prescribing patterns by the treating physician.
If signs of addiction are identified, insurance companies/TPAs and medical providers should team up and intervene to help the injured worker. The most effective weaning approach is a holistic one that aligns with evidence-based best practices.
Managing Chronic Pain
The opioid epidemic continues to be one of the most troublesome issues plaguing workers’
compensation. To shed more light on this topic, PMA has focused three Executive Briefings on chronic pain and opioids. Here are key takeaways from the series:
- A fundamental change is occurring regarding how chronic pain is treated. The risks associated with using opioids are now understood. Best-practice insurance companies/TPAs are making progress in working with medical providers to help injured workers manage chronic pain and avoid opioid usage.
- Effective alternatives to opioids exist. Treatment plans for injured workers should recognize the differences between acute pain and chronic pain. Relying on opioids to relieve chronic pain has proven to be flawed and costly – opioids are no more effective in treating types of pain related to most common workplace injuries than non-opioid alternatives.4
- Treating physicians are key to solving the opioid problem. When managing chronic pain, it’s important to identify and select physicians who base treatment and prescribing patterns on holistic and evidence-based guidelines, and who have experience and skills in treating chronic pain patients.
- Insurance companies/TPAs should be leveraging three best practices for injured workers with chronic pain: proactively working with medical providers to prevent opioid abuse; using customized weaning strategies; and forming dynamic partnerships with pharmacy benefit managers to address opioid abuse.
- Proactive, ongoing opioid management is critical. If an injured worker is prescribed opioids, an insurance company/TPA should use advanced data analytics and a system of intervention alerts to proactively monitor opioid usage and triage a case throughout the injured worker’s recovery.
- Preventing and managing opioid usage requires integrated strategies, including pharmacy nurses, custom-designed formularies, morphine equivalent dosage (MED) point-of-sale programs, and fraud, waste, and abuse oversight.
- Restoring opioid dependent workers to health requires custom treatment plans and opioid intervention, enabling the individual to manage their pain outside the healthcare system.
A Holistic Approach to Opioid Withdrawal/Weaning
Weaning an injured worker from opioids is a complex and slow process. Their drug dependency
needs to be addressed, as does any chronic conditions, including the injured worker’s beliefs about pain, coping mechanisms and relevant psychosocial factors.
Weaning programs should be designed to accomplish the following:
- Reduce or eliminate the injured worker’s need for pain medications
- Restore optimum levels of function, which may include physical and/or occupational therapy
during the weaning process, and work conditioning
- Enable the individual to manage their pain outside the healthcare system
It can be a challenge for opioid-dependent individuals with chronic pain to adopt other strategies to manage their pain. Weaning strategies should be tailored to each individual based on their level of addiction, willingness to change and contributing psychosocial factors. They should also account for any co-morbidities impacting the injured worker’s health, such as obesity, diabetes, etc. Solutions may include medication to help control symptoms of withdrawal.
Admission to the most appropriate residential or
outpatient treatment facility that treats addictions
may also be considered. However, before a facility
is determined, there needs to be a comprehensive
review process to select the best treatment option
for each injured worker.
Helping injured workers with chronic pain overcome opioid dependency is a complex, difficult challenge that can require an array of customized services and support.
Also supporting the weaning program are
specialized services like drug testing, patient
medication agreements that outline an injured
worker’s responsibilities and help to create
accountability, pain intake surveys, as well as
pharmacy alerts that will trigger interventions if
an individual tries to fill a prescription.
Maintenance programs begin during or after the
weaning process to ensure that individuals not only stop or reduce their use of opioids, but can manage
pain through alternative therapies and improve their quality of life. As the injured worker may be dealing with chronic pain during withdrawal, activating the body’s natural pain management mechanics should be considered. These may include stimulating the release of neurotransmitters through activities such as exercise, acupuncture, meditation, massage and many other therapies.
Helping injured workers with chronic pain overcome
opioid dependency is a complex, difficult challenge
that can require an array of customized services
and support. To address these issues, the workers’
compensation industry continues to develop new
solutions to help injured workers regain their
health and deal with chronic pain. Of course, the
best strategy is to prevent opioid misuse and
dependency from occurring in the first place.
1. National Institute on Drug Abuse, https://www.drugabuse.gov/drugs-abuse/opioids/opioid-crisis#six
2. The National Center on Addiction and Substance Abuse, https://www.centeronaddiction.org/addiction/addiction-risk-factors
3. Centers for Disease Control (CDC), Guideline for Prescribing Opioids for Chronic Pain, https://www.cdc.gov/drugoverdose/prescribing/guideline.html
4. The Proactive Role Employers Can Take: Opioids in the Workplace, National Safety Council