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Restricting painkillers for injured workers can result in unintended costs

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While concerns about opioid use and dependence have raised alarms in workers compensation claims, medical experts say insurers and payers also should be wary of not providing enough treatment to injured workers suffering chronic pain.

And while the dangers of opioids are well-documented, experts say the workers comp industry could do more to provide alternative treatments, such as physical therapy.

“It's a major expense for the insurance companies, utilizing the emergency room as a chronic pain center,” said Dr. Steven Feinberg, chief medical officer at Feinberg Medical Group in Palo Alto, California, and an adjunct clinical professor in the anesthesia/pain management department at the Stanford University School of Medicine.

“We're probably not doing enough of the nonpharmacological alternatives,” said Dr. Gary Franklin, a neurologist and medical director of the Washington State Department of Labor and Industries, the state's monopoly workers comp insurer.

Sources say workers comp insurers and payers need to evaluate injured workers case by case to determine appropriate treatments to help claimants manage their pain, including occupational, physical and cognitive behavioral therapy.

“The way we should be approaching this is literally individually by every injured worker and looking at what's the best thing to help them get better,” Dr. Feinberg said.

The Federation of State Medical Boards revised its policy on using opioids to treat chronic pain in 2013. Though most of the policy addresses the risks of using opioids and medical practices that can prevent addiction, it also says “undertreatment of pain is recognized as a serious public health problem that compromises patients' functional status and quality of life.”

Lisa Robin, the federation's Washington-based chief advocacy officer, said that while the organization recognizes the dangers of opioids — including potential addiction or overdose deaths — the group also wanted to acknowledge that deciding whether to treat patients in acute pain with opioids should be done individually.

“The patient has to be carefully evaluated,” Ms. Robin said. That includes “a thorough evaluation not only of their physical being, but of any sort of history of substance use as well as their home situation, their family, their support (system) and also (if they have) any other conditions.”

Dr. Franklin said there is no amount of opioid treatment that he believes is completely safe for injured workers with chronic pain.

“The evidence of efficacy is very low, but the evidence on potential risk is very high,” Dr. Franklin said.

Still, he says the workers comp industry historically has not been willing to pay for alternative therapies to avoid narcotics. That includes physical therapy or occupational therapy to improve physical function, and cognitive behavioral therapy to help patients cope psychologically with their pain.

“I think insurance companies and others really have not done a very good job of covering services that might actually help instead of opioids,” said Dr. Franklin, who said the Washington state agency has developed a program to provide more physical therapy and cognitive behavioral therapy to workers comp patients.

Dr. Feinberg agrees that some have been driven to opioids because of a lack of alternative treatments available under their comp coverage.

Some doctors say some insurers “won't approve psychological care. They won't approve what's called functional restoration programs, meaning a combination of psychological and pain management. They won't approve physical therapy. So there's nothing left but to drug the patient, so to speak,” Dr. Feinberg said.

While Dr. Feinberg said opioids are “dangerous drugs,” he also said fears about the drugs have prompted states such as California to approve legislation that allows workers comp insurers to abruptly stop opioid treatment for patients who did not appear at risk of addiction.

And abruptly cutting injured workers off from opioids, rather than weaning them slowly, can result in withdrawal symptoms and encourage claimants to seek costly treatment in emergency rooms, sources say.

Dr. Feinberg cites a California workers comp case in which he was asked to weigh a comp insurer's decision to end opioid treatment for an older injured worker who had been taking a “moderate” level of opioids for an extended time. The worker's son told Dr. Feinberg in a face-to-face meeting that cutting off the medication left his father more disabled than when he was taking the drugs.

“He described to me how his dad had gone from doing light chores on the farm and being relatively happy to basically being in bed 24/7, off his medicines; and to me, that's not a good outcome,” Dr. Feinberg said.

Dr. Dwight Robertson, Glendale, California-based national medical director at Employers Holdings Inc., said the workers comp insurer uses a multidisciplinary approach to wean workers comp patients off opioids and provide alternative treatments, including physical therapy. The insurer also conducts peer-to-peer consultations between its medical experts and treating physicians to help them create less risky treatment plans.

“When you consider the fact that there are (nonsteroidal anti-inflammatory medications), aspirin, Tylenol — other medications for pain besides opioids — those are probably not used as much as they should be,” he said.

Austin, Texas-based workers comp insurer Texas Mutual Insurance Co. also emphasizes using alternatives to opioid medication, such as inpatient or outpatient rehabilitation programs for patients and psychological support systems, said Dr. Nicholas Tsourmas, the insurer's medical director, in a statement to Business Insurance.

While some patients who are cut off from opioids may experience side effects such as abdominal pain and diarrhea, Dr. Tsourmas said the potentially fatal risks of opioid treatment outweigh the risks of withdrawal.

“Presently, no one dies of opioid withdrawal,” he said in a statement. “They do develop an illness which sometimes requires medical attention for support, but opioid withdrawal is not life-threatening. High-dose opioids used injudiciously are life threatening.”

Experts recommend using questionnaires that also are available online to measure whether a patient might be at risk of opioid dependence, as well as contracts that require injured workers to give informed consent to long-term narcotic prescriptions and warn them of the potential risks.