A Healthesystems publication

Summer 2016

OPIOID EXIT PLAN B

FAST FOCUS: Defining a clear opioid treatment strategy that prevents prescription medication misuse should occur prior to initial prescribing. However, ongoing monitoring creates the opportunity to detect red flags at any stage of a patient’s treatment. Interventions deployed early in treatment can avoid more serious consequences such as opioid dependence or misuse. But for patients who are already facing dependence or addiction, there is still a significant opportunity for positive impact.

The prescribing of opioids, even conservatively, brings with it inherent risk. For some injured workers, prescription opioid use can be a slippery slope to dependence or even addiction. From a claims management perspective, these behaviors can extend the life of a claim (in some cases indefinitely) and delay or prohibit return to work, dramatically increasing both medical and indemnity costs. Opioid use doesn’t have to be long-term to delay recovery and extend the life of a workers’ compensation claim. A claim is 30% less likely to close within 90 days if an opioid is prescribed in the first 4 weeks.1

With overwhelming evidence that the negative impacts far outweigh their positive benefits, the first question we should be asking is: should opioids even be prescribed in the first place? The answer to this, in many cases, is a resounding no. However, when a prescriber does choose to utilize opioid therapy, ongoing monitoring and evaluation throughout the course of treatment can identify warning signs that warrant timely intervention. Earlier intervention is ideal, because it creates greater opportunity to impact the trajectory of a claim. In the majority of cases, identifying red flags within claims can initiate a conversation around the appropriateness of opioid therapy before any negative consequences can occur.

But national statistics tell us that many individuals are still slipping through the cracks. In a recent National Safety Council survey of 200 employers, 4 out of 5 reported observing some type of opioid-related issue in the workplace.2 And in 2014, nearly 19,000 drug overdose fatalities were tied to prescription opioids.3 While these numbers speak to a broader population, the same risks apply to the workers’ compensation industry – perhaps even more so due to the prevalence of injury and prescription drugs for pain management.

For injured workers who are struggling with dependence or addiction, there is still a significant opportunity to impact their claims – and their lives.

IDENTIFYING PATIENTS AT RISK

Identifying and treating opioid-related concerns, including addiction, provides a significant opportunity to change the course of a patient’s recovery for the better. Unfortunately, individuals with substance use disorders – including addiction to prescription pain medications – frequently do not receive the treatment they need for their disorder.4 In some instances, this may be due to patient motivation, or to limited access to treatment options. In other cases, it may be due to the opioid misuse going undetected.

Continually assessing therapy red flags that can identify individuals who may be misusing prescription pain medications creates an opportunity for a qualified professional to intervene with the prescriber, who can then determine whether opioid dependence or addiction is in play, and appropriate next steps, e.g., a detox program. Connecting the individual with the treatment they need plays a significant role in avoiding additional consequences of addiction and the resulting healthcare costs.

Payers, PBMs and employers all play a role in spotting red flags in therapy, which is the first step in identifying potential candidates for intervention. Workers’ compensation claims professionals and PBMs are especially well-positioned to flag the signs of potential opioid misuse within a claim – dose increases, irregular refill patterns, switching or using multiple prescribers or pharmacies, high-risk drug combinations, or escalating morphine equivalent dose (MED) levels. Healthesystems reported in-depth on this topic in the Fall 2013 issue of RxInformer (see “Red Flags in Opioid Therapy”). However, in a changing healthcare landscape, new opportunities for intervention need to be explored and tested.

For example, the introduction of opioid antidotes into workers’ comp claims provide a new decision point that didn’t previously exist. Evzio®, an auto-injection formulation of the opioid overdose reversal agent naloxone, has surfaced in workers’ comp claims over the past year. Narcan™, the first FDA-approved nasal spray formulation of naloxone, also launched earlier this year and may soon begin to surface in workers’ comp. Either of these products may be prescribed if the physician feels their patient is at risk of opioid overdose. However, a one-time prescription of either of these agents does not necessarily mean that the patient is struggling with addiction or misuse. Anecdotal reports show that some doctors are more likely to co-prescribe an opioid antidote as a precautionary measure. Regardless, the presence of Evzio or Narcan in a treatment warrants in-depth evaluation of the current opioid treatment plan. If a patient is at a risk level that necessitates the prescribing of an opioid antidote, the continued appropriateness of opioid therapy should be reconsidered. Frequently this does not happen. A Boston Medical Center study last year found that the large majority of chronic pain patients who were hospitalized for overdose continued to be prescribed opioids following the event – often because the original prescriber is unaware that the overdose occurred.5 This shocking statistic underscores the need for improved communication among stakeholders involved in the patient’s care.

INTERVENTION AT ANY STAGE CAN BE SUCCESSFUL

While prevention remains our best strategy in fighting the opioid epidemic, it is important to understand that individuals who are addicted to prescription opioids are not beyond hope. Intervention even at this later stage can have a positive impact.

Addiction is a complex and chronic disease comparable to cancer, HIV or diabetes, and it must be treated with the same level of persistence. Just as cancer treatments must be selected according to histology or patient characteristics, so must a drug addiction treatment plan take into account individual patient factors. And while addiction relapse rates can be disheartening, it’s important to keep in mind that they are similar to relapse rates in other chronic conditions such as diabetes, hypertension or asthma.6 These are obstacles that can be overcome, as they can be with most chronic diseases.

Addressing addiction can also be cost-effective. Though addiction treatment can be expensive, it can significantly reduce overall costs to the healthcare system and to society. Every dollar invested into an addiction treatment program yields $12 saved in drug-related crime, criminal justice costs, theft, and healthcare costs.6

Prescription Drug Misuse and the Workplace

Employers also have a stake in helping to identify and address prescription opioid misuse. Workplace costs associated with the misuse of prescription opioids are upwards of $25 billion per year.7 Individuals misusing prescription pain medications can pose an increased risk to themselves or other employees. They are also more likely to be tardy, absent, or impaired, resulting in reduced productivity.

Employers can play an active role in identifying employees who may benefit from addiction therapy through drug testing programs. Many employers who screen for illicit substances do not also screen for prescription opioids – in some cases because the additional testing represents a significant cost burden for them, or because the employer also believes it isn’t their place to monitor medications that employees have obtained legally from a physician. However, with the growing impact of opioid misuse in the workplace, the potential benefits of screening for prescription drugs may have to be reconsidered.

For employees who are recovering from addiction to prescription pain medications, Employee Assistance Programs (EAPs) can be an important part of staying on track with their sobriety. These programs can also decrease the need for inpatient addiction treatment services, reducing costs for these services. However, EAPs are not utilized as often as they can be. Employees may not be aware of the scope of services EAPs offer; in other instances, they may fear negative repercussions. Employers have a responsibility to make their workers aware of the benefits and confidentiality of these programs.

In some cases, employer education is also needed, as they are not necessarily aware of the prevalence of the problem or may not be equipped to manage it. The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that 9 percent of the full-time workforce are illicit drug users, including nonmedical use of prescription drugs.4 This number doesn’t even account for the portion of workers who are being prescribed pain medications for legitimate medical reasons, which still brings a degree of risk for dependence or misuse. Further education is needed on the direct and indirect risks posed by opioid misuse within the workplace, especially as they relate to the injured worker.

NEW DEVELOPMENTS IN TREATMENT

Healthesystems reported extensively on pharmacotherapy and behavioral therapy components of treating opioid addiction in the Fall 2014 issue of RxInformer (see the article “Getting Unhooked”), including traditional medication-assisted treatment with methadone or buprenorphine. Since then, there has been some development of new formulations that represent expanded or flexible treatment options that may meet the different needs of patients.

Bunavail® A buprenorphine/naloxone buccal film that adheres to the inside of the patient’s cheek was introduced to the market in late 2014.

 

Probuphine® In January of this year, the FDA Panel recommended approval of an implant that delivers six months of stable buprenorphine treatment to the patient. Probuphine was initially rejected by the FDA in 2013, but is now being reconsidered in light of additional study data provided by the manufacturer. If approved, this product may help improve the success of outpatient buprenorphine treatment by removing any patient behavioral factors that can impede adherence.

 

Detecting Opioid Red Flags

Dose increases

Dose increases may be medically necessary to adequately control pain over a period of time. However, high morphine equivalent dose (MED) levels resulting from dose increases are associated with an increased risk for opioid misuse and should be flagged. ACOEM Practice Guidelines, as well as the new CDC Guideline for Prescribing Opioids for Chronic Pain, recommend that MED should stay below levels of 50 mg/day.

Irregular refill patterns

A patient who refills their opioid prescription on time, but refills their neuropathic agent late or not at all, may be practicing what is known as selective adherence. This may be a sign that they are relying too heavily on opioids and not adhering to other aspects of their overall treatment.

Switching or using multiple physicians or pharmacies

Also known as “doctor shopping,” this may be a sign of a patient attempting to gain access to multiple opioid prescriptions. The physicians or pharmacies should be alerted to the behavior.

Lost prescriptions

Losing a prescription can happen, but a pattern of this behavior warrants giving the claim a closer look.

Overdose reversal medication prescribed

Evaluate whether opioid treatment continues to be appropriate in the patient, given the doctor’s decision to prescribe an opioid antidote.

Evidence of psychosocial factors

Opioid misuse often coincides with psychosocial or behavioral factors. Look for behaviors or language that may indicate disorders such as depression, anxiety, or catastrophizing.

Other behaviors

Sometimes there aren’t obvious red flags in a claim. Look for language that indicates drug-seeking behavior or a dependence on opioid medications during conversations with claimants.

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SOURCES

1 -Busse JW, Ebrahim S, Heels-Ansdell D, et al. Association of worker characteristics and early reimbursement for physical therapy, chiropractic and opioid prescriptions with workers’ compensation claim duration, for cases of acute low back pain: an observational cohort study. BMJ Open. 2015;5:e007836. doi:10.1136/bmjopen-2015- 007836.
2 -National Safety Council and the Indiana Attorney General Rx Drug Abuse Task Force. Results from a survey of Indiana employers. Available at http://www.nsc.org/NSCDocuments_Advocacy/FINAL%20Media%20briefing%20PPT.PDF
3 -Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, Mortality File. (2015). Number and Age-Adjusted Rates of Drug-poisoning Deaths Involving Opioid Analgesics and Heroin: United States, 2000–2014. Atlanta, GA: Centers for Disease Control and Prevention. Available at http://www.cdc.gov/nchs/data/health_policy/AADR_drug_poisoning_involving_OA_Heroin_US_2000-2014.pdf
4 -Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
5 -Larochelle MR, Liebschutz JM, Zhang F, et al. Opioid prescribing after nonfatal overdose and association with repeated overdose: a cohort study. Ann Intern Med. 2016;164(1):1-9.
6 -National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide, 3rd Edition. National Institutes of Health. Revised December 2012.
7 -Birnbaum HG, White AG, Schiller M, et al. Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Medicine. 2011;12:657-67.
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