A Healthesystems publication

Spring 2014

Preventing Chronic Opioid Abuse

Chronic opioid therapy is preventable in many, but not all cases. To minimize opioid use, payers can work with their PBMs to develop pain management strategies that advocate for use of conservative therapies based on evidence-based guidelines. 

If a prescriber does not write an opioid prescription, the patient cannot develop an opioid dependence. It is a simple concept, but opioids are too often prescribed in workers’ compensation when non-opioid conservative therapies are indicated by evidence-based guidelines. Inappropriate prescribing can lead to chronic opioid therapy defined as opioid use beyond 90 days post injury.1 Opioids have not been proven safe or effective for treating chronic pain.2 Long-term opioid therapy is associated with extended disability, less successful outcomes and higher utilization of medical resources.3,4,5,6

Opioids are rarely indicated for many common injuries seen in workers’ compensation such non-severe knee, leg, ankle, shoulder and some low back injuries that do not involve fractures or require surgery.7

Evidence-Based Treatment Guidelines

The case scenario on page 27 is typical of a workers’ compensation drug regimen. Evidence-based opioid guidelines, such as those developed by the American College of Occupational and Environmental Medicine (ACOEM), ODG and others— recommend a holistic approach to pain management and limited and appropriate use of opioids, especially in the non-acute phase of injury. The guidelines place the focus of treatment on the injury, not the patient’s pain. The treatment goal is to restore as much function as possible so the patient can return to activities of daily living and work. Pain relief is a tool that enables the patient to participate in treatment and recover.

Effective conservative treatment can eliminate or minimize pain and help the patient return to work in a timely manner. Payers can partner with PBMs to develop strategies to reduce reliance on opioid therapy and prevent chronic opioid therapy. PBMs can conduct educational outreach with prescribers on evidence-based treatment guidelines. Informed prescribers are more likely to implement a course of conservative treatment and utilize alternative therapies when indicated by the guidelines.

Coping With Pain

Research shows that several factors can influence chronic pain:

Prescribers should set realistic expectations with patients regarding pain relief and consider use of cognitive behavior therapy, physical and occupational therapy, massage, acupuncture, yoga, chiropractic care and other alternative therapies to help patients cope with the presence of some pain long-term.

Good Communication Can Keep Therapies on Track

Claims professionals should question the use of chronic opioid therapy in all non-cancer claims. They can open a dialog with prescribers to gain a better understanding of the goals and progress of prescribed therapies. Questions can include:

The Benefits of a Conservative Approach

A conservative approach to the neck and shoulder strain experienced by Patient X in the case scenario on page 27 would look very different and foster recovery instead of disability and opioid dependence.
The conservative regimen presented follows evidence-based guidelines and offers real potential for the patient to recover without opioid therapy.

Cost Considerations

While the initial cost of treatment using a conservative approach might be higher than opioid therapy, payers can consider that the duration of these therapies is likely to be finite and result in the patient returning to work. A significant savings in overall claims costs can be realized and disability can be averted.

 

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SOURCES

1 -Denniston PL, ODG Treatment in Workers’ Comp 2013, Eleventh Edition. Work Loss Data Institute, Encinitas, CA.
2 -Ballantyne JC, Shin NS. Efficacy of opioids for chronic pain: a review of the evidence. Clin J Pain. 2008;24(6):469-478.
3 -Franklin GM, Stover BD, Turner JA, et al; Disability Risk Identification Study Cohort. Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort. Spine (Phila Pa 1976) 2008;33(2):199-204.
4 -Webster BS, Verma SK, Gatchel RJ. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery, and late opioid use. Spine (Phila Pa 1976) 2007; 32:2127-2132.
5 -Kidner CL, Mayer TG, Gatchel RJ. Higher opioid doses predict poorer functional outcome in patients with chronic disabling occupational musculoskeletal disorders. J Bone Joint Surg Am. 2009;91(4):919-27.
6 -Leider HL, Dhaliwal J, Davis EJ, et al. Healthcare costs and nonadherence among chronic opioid users. Am J Manag Care. 2011;17(1):32-40.
7 -Reed Group Disability Guidelines™, 2014, developed by the American College of Occupational and Environmental Medicine, www.mdguidelines.com/ and Denniston PL, ODG Treatment in Workers’ Comp 2013, Eleventh Edition. Work Loss Data Institute, Encinitas, CA.
8 -Livengood JM. Psychologic and Psychosocial Factors Contributing to Chronic Pain. Current Review of Pain. 1999;3(1):pp 1-9
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