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.

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.

Summary

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.

Footnotes