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, common treatment patterns, and opioid usage. In this issue, we on addressing chronic pain with treatments based on evidence-based protocols that avoid opioid dependency.

There is a fundamental change underway in how chronic pain is treated, both in workers’ compensation and healthcare in general. In 2016, these trends coalesced in a notice from the U.S. Surgeon General to medical providers, in which providers were asked to stem the tide of the opioid epidemic. According to the notice, opioid overdose deaths have quadrupled since 1999 and opioid prescriptions have increased markedly. Today, nearly two million Americans have a prescription opioid-use disorder, contributing to increased heroin use and its related problems.¹

In 2016, the Centers for Disease Control (CDC) published new guidelines for treating chronic pain, specifically stating the risks associated with prescribing opioids and the benefits of other therapeutic treatments (see p. 2). Increasingly, scientific research is questioning whether opioids are effective for those with chronic pain. In the workers’ compensation environment, best-practice insurance companies/Third Party Administrators (TPAs) are making progress in helping injured workers manage chronic pain and
avoid opioid dependency. This Executive Briefing will explore those strategies, focusing on physician
selection and use of evidence-based medicine, analytics and intervention, pharmacy management
strategies, and clinical management/expertise.

Physician Selection/Evidence-based Medicine

Simply put, evidence-based medicine is treating patients according to clinical guidelines that have proven to achieve optimal results. Using evidence-based medicine can enhance a physician’s ability to make better care decisions.
When managing chronic pain, it’s important to identify and select physicians who base treatment and prescribing patterns on evidence-based guidelines and have experience and skills in treating chronic pain patients. Treatment according to these guidelines is more likely to consider the specific needs and preferences of each patient and therapeutic alternatives to opioids, thus improving pain relief and avoiding drug dependency. Treatment plans for injured workers should recognize the differences between acute pain and chronic pain and its treatment:

• Acute pain is a protective response to tissue injury. Opioid drugs, which were originally developed for late-stage cancer patients, have been prescribed to address acute pain. However, it has been found that Tylenol, Advil, and other non-opioid alternatives are just as effective in treating pain related to most
  common workplace injuries.
• Chronic pain is unique to each individual and requires a broader, multipronged treatment approach. Injured workers with chronic pain get the best results with a combination of therapies that address the physical, functional, emotional, and spiritual aspects of pain.

Complimentary therapies for chronic pain that help avoid the use of opioids, including cognitive therapy, yoga, mindfulness-based stress reduction, biofeedback, and acupuncture, have all shown promise. In addition, psychological treatments for anxiety may help injured workers reduce chronic pain.

Outreach to physicians by insurance companies/TPAs can help raise awareness of opioid abuse
and encourage:

• treatment options outside of opioids
• the use of new tools and technology for smarter prescribing patterns
• consultations with pain management specialists

Analytics and Intervention

An insurance company/TPA’s managed care department is invaluable in achieving the best possible outcomes for injured workers.

Optimally, an opioid management process identifies injured workers who are at risk for chronic pain at the early stages of their injury. For example, an injury affecting multiple body parts, such as neck pain radiating down to the shoulder and arm, may signal chronic pain risk. When this risk is identified, quick intervention is needed. In this example, the injured worker’s care may be directed to an orthopedic specialist to improve the initial diagnosis and create a treatment plan.

Today, nearly two million Americans have a prescription opioid-use disorder, contributing to increased heroin use and its related problems.¹

Before starting opioid therapy, a thorough patient assessment addressing a wide range of factors (injury type, complicating health and psychosocial issues) should be conducted.

If an injured worker is prescribed opioids, proactive management of their usage is vital. Goals and benchmarks need to be set, including an exit strategy. This will help prevent relying on dosage increases of opioids to address pain, potentially leading to opioid dependency.

Using advanced data analytics and a system of
intervention alerts, an insurance company/TPA can
play a key role in monitoring opioid usage and triage
a case throughout the injured worker’s recovery.
Alerts that trigger intervention can begin as soon as
an opioid is prescribed. Once alerted, the insurance
company/TPA’s managed care staff can take action.
That may mean a point-of-sale (at the pharmacy)
intervention to determine if the prescription is
appropriate and if intervention with the physician,
pharmacy or worker is needed. Intervention may
occur at the pharmacy before a prescription is filled,
or to prevent a second prescription from being filled.

Optimally, an opioid management process identifies injured workers who are at risk for chronic pain at the early stages of their injury.

When opioids are prescribed, pharmacy nurse
specialists (who have specialized clinical skills and
expertise) focus on the following:

• conducting drugs reviews
• identifying and addressing over-utilization and inappropriate use
• initiating intervention strategies to prevent or remedy drug dependency problems
• drug counter-indications and side effects

Pharmacy Management Strategies

An insurance company/TPA, working with a pharmacy benefit manager (PBM), can maximize the following strategies to manage opioid usage (and other drugs related to chronic pain):

Custom Designed Formularies (approved list of
medications developed by insurance companies/
TPAs). The use—and effectiveness—of formularies varies widely among insurance companies/TPAs. The best strategy is to develop formularies for specific injuries, and other conditions. A chronic pain formulary is imperative and should be based on CDC guidelines for opioids, and address muscle relaxers, tranquilizers, compounds, and
other drugs often prescribed with opioids. (Such drug combinations can heighten the addictive and debilitating effects of opioids.) Formulary usage must be in compliance with jurisdictional regulations.

Morphine Equivalent Dosage (MED) point-of-sale
programs. An MED point-of-sale program uses a real-time comparison tool to assess the clinical appropriateness and safety of an injured worker’s opioid usage. At the point of sale, the MED tool
calculates the amount of opioids (cumulative MED) the injured worker has been prescribed from all their
treating physicians. This is especially important, as injured workers may be treated by multiple
physicians, who have an incomplete picture of an injured worker’s care and prescriptions. An MED
above a recommended threshold indicates the injured worker is at risk, and they may be prevented
from obtaining prescriptions that could be unsafe and harmful.

Fraud, Waste, and Abuse Oversight. Monitoring fraud, waste, and abuse should be a crucial part of any pharmacy management program. Opioids are extremely addictive and have a high resale value on the street. Injured workers may use multiple physicians and hospitals to attain multiple prescriptions to resell, or combine with other medications for “feeling good” rather than pain relief. An insurance company/TPA’s managed care team, in conjunction with the PBM, should monitor not only opioids but all medications the injured worker is prescribed for safety and clinical appropriateness. In addition, an insurance company/TPA’s drug monitoring strategy needs to have a comprehensive view of all prescription drug distribution channels for injured workers. These can include physician-dispensed, retail pharmacies, mail order, third-party dispensing, and self-pay. All panel physicians should be required to utilize Prescription Drug Monitoring Program (PDMP) databases, where available. Evaluating the total scope of drugs
from all sources results in more effective intervention strategies.

Clinical Management/Expertise. Treating chronic pain using prescription drugs and other strategies is
very complex. Best-practice insurance companies/TPAs capitalize on an array of intervention strategies, including physician outreach, drug testing, pain score assessments, and peer-to-peer review, all of which should be incorporated into the claims process. Pharmacy nurses help injured workers utilize appropriate prescription drug regimens and avoid drug dependency.

Ongoing Oversight

The treatment plans and opioid interventions described above are not one-size-fits-all approaches. Insurance companies/TPAs should develop strategies based on factors including injury type as well as comorbidities and psychosocial factors affecting recovery or opioid use. A managed care team can develop indicators to signal when treatment is not working and alternative therapies are required.

Best-practice insurance companies/TPAs expertly manage chronic pain throughout the life of the claim, ensuring treatment is appropriate, focused on recovery/return to work, and avoids opioid dependency. For employers, this adds up to quality care for injured workers, faster recovery and return to work, and lower claims costs.

When injured workers are relying on opioids for chronic pain relief, insurance companies/TPAs and the medical community need to team up and intervene. In the next PMA Executive Briefing, we’ll focus on strategies to help wean injured workers off opioids and find therapeutic alternatives, including inpatient versus outpatient alternatives, weaning support, work conditioning, and the impact of comorbidity factors.

Footnotes