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By Mark Noonan

For those of us who work in the Workers' Compensation arena, 2012 will no doubt be known as the year of the Opioid Tipping Point-a tipping point caused by the use, misuse, and abuse of pain relievers and the response to reign in their use for the sake of injured workers and the financial health of our workers' compensation system.

There is no debate that opioids are effective/potent analgesics widely viewed as helpful in managing moderate to severe acute pain. They were primarily developed and approved by the U.S. Food and Drug Administration for treating end-stage cancer pain. However, opioid overuse in managing the pain of injured workers and of the general population has reached epidemic proportions. To date, doctors, drug companies and patients agree that opioid painrelieving drugs are the answer for treating pain, but with the epidemic use of opioids and the resulting related problems of addiction and diversion, that paradigm needs to change.

An Opioid Primer

Reading a quick primer on pain medications would tell you that opioids are the synthetic versions of the naturally derived narcotics made from opium, which are called opiates. Opioids are partially or entirely synthetic and are commonly known by the drug names Oxycodone, Fentanyl, Morphine, Methadone, Hydromorphone, Oxymorphone, Levorphanol, Meperidine, and Codeine. The worst consequence of consuming opioids is that they can cause addiction and overdose, which can lead to permanent injury such as brain damage, or even lead to sudden death. Opioids are Central Nervous System (CNS) depressants. When depressed too far by CNS depressants, heart and lung functions can slow down and eventually stop. Despite the dire consequences of consuming opioids over a long time and in large quantities, opioid use has exploded over the last 10 years. Industry stakeholders who have tracked the opioid explosion have now grabbed the media attention and most importantly have convinced the industry that opioids are creating havoc not only in society but in our workers' compensation programs.

Ugly Opioid Statistics

There is no shortage of ugly statistics associated with opioid use, misuse, and abuse in the general population and in workers' compensation programs. Peter Rousmaniere's January 24th column in Risk & Insurance, "How Many Injured Workers Die from Opioids?", also contained many of these eye-opening statistics.

• Since 2003, more overdose deaths have involved opioid analgesics than heroin and cocaine. (CDC¹)
• 1.2 million emergency department visits were related to misuse or abuse of opioids; more than of all illegal drugs combined. (CDC¹)
• In 2010, enough opioids were prescribed to medicate every American adult with a typical dose of 5 mg of hydrocodone every 4 hours for 3 weeks. (CDC¹)
• 70% of nonmedical users report getting drugs that had been prescribed to someone else, and only 20% report that they acquired the drug from their own doctor. (DEA²)
• Employers and insurers will spend $1.4 billion on narcotics for workers' compensation this year; the vast majority of those dollars will pay for opioids. (ManagedCareMattersBlog³)
• Opioid abuse has been demonstrated in 9% to 41% of patients receiving chronic pain management. (NIH⁴)
• Nationwide, 3% of doctors account for 62% of prescribed opioids pain relievers. (CDC¹)
• Opioid painkiller OxyContin is the most prescribed drug in workers' compensation. (CDC¹)

CDC¹ http://www.cdc.gov/about/grand-rounds/archives/2011/pdfs/PHGRRx17Feb2011.pdf
DEA² http://www.justice.gov/dea/pubs/states/newsrel/2010/dallas071610.pdf
MCMBLOG³ http://www.joepaduda.com/archives/002144.html
NIH⁴ http://www.drugabuse.gov/news-events/news-releases/2011/04/analysis-opioidprescription- practices-finds-areas-concern

These ugly statistics were generated by our U.S. medical system-including our workers' compensations programs gone awry. Physicians believed that they were doing the right thing by prescribing effective pain relievers to patients. Rogue physicians learned that they could become very wealthy operating pain clinics and peddling opioids to addicted individuals.

Industry pain experts agree most of the challenge in reigning in the use and abuse of opioids is in prescriber and patient education. The challenge facing physicians is to understand the difference between acute pain (that pain resulting from injury/surgery Workers' Compensation Update: May 2012 3 Workers' Compensation Update May 2012 during the initial injury period) and chronic pain, which occurs after the healing process has substantially completed.

According to Gary Mills, PhD, of Pacifica Pain Management Services, not only are doctors struggling to distinguish acute from chronic pain and chronic pain from chronic pain syndrome, they are also struggling to differentiate biomedical from biopsychosocial treatments which are often key to healing workers' compensation injuries.

Acute stage pain from an injury lasts one to three months, sub-acute stage pain from three to six months, and chronic pain syndrome is seen at greater than six months. As pain science has evolved, experts like Mills have proven that during the acute stage, treatment should include appropriate medications, rest, and sometimes surgery.

Beyond the acute pain stage, a multidisciplinary biopsychosocial approach employing physical/cognitive rehabilitation, stress management, pain threshold alteration, perceptual changes, and even detox (if addicted to pain meds) is the best course to follow. Unfortunately, according to pain guru's like Mills, keeping workers' compensation and other injured patients on opioids through all three stages of pain, is actually detrimental to the body's natural healing process and simply causes addiction/dependence.

National Worker' Compensation and Disability Conference

Opioid use, misuse, and abuse took center stage during the National Workers' Compensation and Disability Conference® & Expo in Las Vegas in November 2011, and the topic is slated to headline additional conferences this year. Public health, prescribers, insurance companies, TPAs, and workers' compensation professionals at the conference were in agreement that a multi-pronged approach is needed. Most attendees left the conference with the opinion that thoughtful and sensible intervention directed by physicians and public health officials knowledgeable in the areas of pain management and appropriate use of these medications will play a large part of a successful national solution.

Effective State Responses

Washington and California are states leading the effort to reign in the use and abuse of opioids in their Medicaid and workers' compensation systems.

State of Washington Department of Labor and Industries, led by Medical Director Gary M. Franklin, MD, MPH, first introduced guidelines, and then proposed legislation to reign in the impact on employees and their families and the costs associated with the use, misuse, and abuse of opioids.

To Franklin, the connection was clear: Cut down the number and duration of prescriptions and provide pain management alternatives. State of Washington rules require doctors and Workers' Compensation Update: May 2012 4 Workers' Compensation Update May 2012 other prescribers to maintain and update detailed screening, history, and treatment-plan records for pain patients. A prescriber whose patient reaches a certain dosage level must consult a pain specialist. Washington's prescription management process has dramatically cut overdose deaths, emergency care, and costs.

Similarly, in California, abuse and workers' compensation program costs were driving factors in tackling the opioid problem. A multi-prong approach, led by Dr. Bernyce Peplowski, California State Fund Medical Director, has been curbing the use, misuse, and abuse of opioids. California developed a physician contract that outlined two week/60 day parameters, with requirement of utilization review approval beyond 60 days. Side effect warning letters are sent to physician and patient by the pharmacy benefits manager after first fill of narcotics and early utilization reviews by pain specialty matched peers are mandatory.

Both Washington and California provide education and support to physicians who are serving workers' compensation patients, but until more states get on board with legislation, national physician organizations will have to fill the void.

Florida Feels the Pain

Contrast the Washington and California successes with the State of Florida where physicians, pain clinics, drug repackagers, pharmacies, the state workers' compensation program, and many other stakeholders are embroiled in a battle about limiting opioid distribution. The hotly-debated HB 7095-the state's newest proposal regulating opioid distribution-bans doctor dispensing of drugs and subjects pharmacies to inspection of prescription records. A side effect of HB 7095 is that the state workers' compensation program will reap millions in savings if opioids are limited to pharmacy dispensing and avoid the physician and pain clinic repackaging mark-ups.

Previously, several other bills that limit the use of opioids in the state workers' compensation program and require additional physician reporting, have previously been stalled in budget committees.

Until the hotly contested bill is passed, Florida will keep the dubious distinction of leading the nation in the sale of Oxycodone with more than 400 million pills sold annually, plus the distinction of having 98 of the top 100 doctors dispensing Oxycodone nationally hailing from the state. The ripple effect of HB 7095 may be felt in other states since the Florida Attorney General's office reports that the state is the primary source of illegal prescription narcotic drugs for the eastern United States.

As mentioned above, both Washington and California provide education and support to physicians who are serving workers' compensation patients, but until more states get on board with guidelines and legislation, national physician organizations will have to fill the void.

Prescription Monitoring Programs

Many states have taken the first step in monitoring the use and curbing the abuse of opioids with prescription monitoring programs. In fact, 40 of 48 states now have prescription monitoring in place and most will use the information gleaned from the programs to take additional regulatory steps to start controlling opioids in the workers' compensation and general public populations. Medscape (provides specialists, primary care physicians, and other health professionals with medical information and educational tools) provides an overview of state opioid/class II prescribing policies on its web site.

Physicians Education and Cover

One resource physicians can turn to is the American College of Occupational and Environmental Medicine (ACOEM), the nation's largest organization representing physicians who practice occupational and environmental medicine.

In December, ACOEM submitted a draft document entitled "Blueprint for Prescriber Education for the Long-Acting/Extended-Release Opioid Class-Wide REMS" to the FDA. The Blueprint contains core messages intended for use by continuing education (CE) providers to develop educational materials to train prescribers of opioids.

ACOEM had already produced an updated "Guidelines for the Chronic Use of Opioids" earlier last year that provides an excellent set of checklists, screening/treatment guides, and even a patient Opioid Contract. The full 25-page guide is available free on the ACOEM web site. Guideline highlights include:

• Routine use of opioids for treatment of chronic non-malignant pain conditions is not recommended
• Screening patients prior to initiation of opioids for chronic pain
• Opioid Treatment Agreement ("Opioid Contract") for patients with chronic pain
• Urine drug screening for patients prescribed opioids for chronic pain

Other Stakeholders Must Get on Board

With national physician organizations, state workers' compensation systems, and individual practitioners buying into controls that will ultimately reduce the use, misuse, and abuse of opioids, the industry has reached its tipping point. Other industry stakeholders- pharmaceutical companies, insurance carriers, TPAs, and companies that self-insure-will need to follow suit. Opioid use, misuse, and abuse is one of the most pressing challenge facing the workers' compensation system in 2012 and no doubt, we will continue to see study after study about the increasing costs in terms of lives, families, and worker productivity. The societal and personal costs, not to mention the organizational costs associated with opioid use, will bury us if we do not join forces to push forward and conquer this threat.

For More Information

At Integro, we aspire to be a client's broker of choice by consistently exceeding expectations and building intimate trust. If you need assistance or more information on any of the workers' compensation issues discussed, please contact Mark Noonan, mark.noonan@integrogroup.com, (617) 531-6855 or Jim Bacon, jim.bacon@integrogroup.com, (415) 365-4230.