PMA Executive Briefings explore workers' compensation challenges and solutions.
With this issue of PMA Executive Briefings, we’ll begin a focus on the important issue of effectively managing chronic pain in injured workers. We selected this topic because of the enormous impact chronic pain has on injured workers and their recovery, and subsequently, on workers’ compensation programs and costs.
The workers’ compensation industry has been making inroads in helping injured workers with chronic pain. Solutions continue to emerge, from physician intervention programs and advanced drug formulary strategies to the use of data analytics and new ways to integrate medical bill review and pharmacy benefit programs. A comprehensive and effective pain management program can make a significant difference in an injured worker’s recovery and help achieve optimum claims outcomes.
In this issue, we’ll examine chronic pain trends among injured workers, common treatment patterns and the impact of relying on prescription pain killers for relief of chronic pain rather than evidence-based treatments.
In subsequent issues, we’ll discuss best-practice strategies to prevent opioid abuse and long-term disability for those with chronic pain and solutions for helping injured workers who are dependent on opioids.
Chronic Pain Among Injured Workers
According to the American Chronic Pain Association (ACPA), chronic pain is ongoing or recurrent pain
that lasts beyond the usual healing time, more than three to six months, and adversely affects the individual’s well-being. The ACPA also defines it as “pain that continues when it should not,” thus recognizing the important role of psychology in the experience and treatment of pain.
It has been estimated that 100 million Americans suffer with chronic pain, and that chronic pain affects more Americans than diabetes, heart disease and cancer combined.1
Chronic pain is a significant issue for many parties involved in workers’ compensation. The recovery and well-being for many injured workers are impacted by ongoing painful conditions. Employer costs for claims with chronic pain diagnosis are substantial, ranging from prescription medications and treatments to delayed return to work and recovery.
Historically, lower back injuries have been the primary condition leading to chronic pain; however, in recent years, we have seen an increase in knee and shoulder injuries, especially rotator cuff and meniscus tears among older workers, that result in chronic pain.
The aging workforce is another factor. Older workers are expected to be the fastest growing segment of the workforce from 2012-2022.2 In this age group, cardio-respiratory and physical capacity gradually declines, as does visual and auditory functions. According to the National Council on Compensation Insurance (NCCI), older workers are not injured more frequently than their younger counterparts; however, injury severity increases
more than 50 percent for workers age 45 to 64 compared to workers age 20 to 34.3 Increased severity is more likely to lead to chronic pain.
Historically, lower back injuries have been the primary condition leading
to chronic pain; however, in recent years, we have seen an increase in knee
and shoulder injuries, especially rotator cuff and meniscus tears among
older workers, that result in chronic pain.
Treatment Patterns and Opioid Dependency
For 20 years, treatment for chronic pain has relied on a class of pain-relieving drugs called opioids (hydrocodone, oxycodone, etc.) that reduces the intensity of pain signals reaching the brain. These drugs have addictive characteristics similar to morphine and a debilitating impact on many injured workers who take them.
The opioid epidemic in both the workers’ compensation environment and throughout society has been well publicized.
Express Scripts found in a study of its payers that 50.9 percent of injured workers had an opioid prescription claim in 2016 and 25 percent of injured workers used opioids for 30 days or more in 2016.4
According to the Centers for Disease Control and Prevention, nearly half of all U.S. opioid deaths involve a prescription opioid, and in 2015, more than 15,000 people died from overdoses involving prescription opioids.5
Physician Treating First
Impact Opioid Usage
The prescribing patterns of the physician
who a patient sees first for treatment is an
important factor in future opioid use. This was
highlighted in a New York Times article.
The article cited a study that found patients
prescribed opioids by emergency room
doctors described as “high intensity”
prescribers (those who gave opioids to one in
four patients) are at greater risk of using the
drugs chronically than those who saw “low
intensity” emergency room doctors (those
who gave opioids to one in 14 patients).6
According to the Centers for Disease Control and Prevention, nearly half of all U.S. opioid deaths involve a prescription opioid, and in 2015, more than 15,000 people died from overdoses involving prescription opioids.6
The cause of this epidemic is multi-faceted and has been driven partly by Western medicine practices that place a heavy focus on finding the cause of pain and “fixing” it quickly with opioids rather than using alternative strategies for pain relief.
Adding Cost Without Relieving Pain
The reliance on opioids to relieve pain has proven to be flawed and costly. According to the National Safety Council’s report, The Proactive Role Employers Can Take: opioids in the workplace, opioids are no more effective in treating types of pain related to most common workplace injuries, including soft tissue and musculoskeletal problems, than non-opioid alternatives such as Tylenol and Advil or generic ibuprofen.7
Yet some physicians continue to prescribe opioids excessively, for reasons which may include failure
to adhere to evidence-based treatment guidelines and lack of training in pain management and injured workers’ psychosocial issues. These issues
include unrealistic expectations for recovery, activity avoidance, fear of pain, prior addiction, catastrophic thinking and poor opinions of an employer or supervisor. If treating physicians miss or ignore any of these issues, the patient is at higher risk of addiction and delayed recovery.
The NCCI reports that opioids and other controlled substances classified as Schedule II and III by the
Drug Enforcement Administration, (not physician-dispensed)continue to be a significant portion of workers’ compensation drug costs, 29 percent in
2014. The price of controlled substances has grown, with a 16 percent increase in 2014 alone.88
Over-prescribing opioids can also result in litigation. An injured worker may turn to the courts when the
extended course of prescription pain killers leads to long-term disability.
Insurance companies and third party administrators are leveraging three best practices to help injured workers with chronic pain in three primary ways. The first is working with medical providers to prevent opioid addiction and abuse among injured workers by focusing on holistic and evidence-based treatments for chronic pain. The second is teaming up with the medical community to help injured workers who have developed a dependency wean from opioids. The third is creating dynamic partnerships with pharmacy benefit managers that include formularies, and point-of-sale and retrospective strategies.
Upcoming Executive Briefings will describe these best practices in greater detail. We’ll focus on solutions that help ensure treatment for injured workers is based on evidence-based protocols for chronic pain that avoid opioid dependency.
1. American Academy of Pain Medicine, http://www.painmed.org/patientcenter/facts_on_pain.aspx#overview
2. Monthly Labor Review, December 2013, Bureau of Labor Statistics, https://www.bls.gov/opub/mlr/2013/article/
3. NCCI Research Brief, Workers Compensation and the Aging Workforce, December 2011
4. Express Scripts 2016 Drug Trend Report, Workers’ Compensation, http://lab.express-scripts.com/lab/drug-trend-report/
5. Centers for Disease Control and Prevention, https://www.cdc.gov/drugoverdose/data/overdose.html
6. Long-Term Opioid Use Could Depend on the Doctor Who First Prescribed It, Jan Hoffman, New York Times, February 15, 2017 https://www.nytimes.com/2017/02/15/health/long-term-opioid-use-doctors-prescriptions.html?_r=0
7. The Proactive Role Employers Can Take: Opioids in the Workplace, National Safety Council
8. Workers Compensation and Prescription Drugs: 2016 Update, NCCI Research Brief, https://www.ncci.com/Articles/