Anyone who manages workers compensation claims knows a routine claim can easily become a complex claim. The reasons are varied, but today one driving factor is the use of narcotics in the treatment of chronic pain in injured workers. Deborah Gleason, clinical resources manager at ESIS Inc., discusses this growing problem and how to counter the trend.

Chronic pain affects about 100 million Americans, more than the number affected by heart disease, diabetes and cancer combined, according to a June 2011 report from the Institute of Medicine's “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.”

The prevalence of chronic pain is growing and is likely to continue to do so, according to the IOM report. As the rate of reported chronic pain increases, it has been accompanied by a rise in the rate of adults reporting the use of prescription drugs for pain, including opioids such as OxyContin, Percocet and oxycodone products.

Only 3.2% of Americans reported using opioids for pain during the seven-year period from 1988-1994, according to data from the National Health and Nutrition Examination Survey, which was cited in the IOM report. But by the four-year period from 2005-2008, that increased to 5.7% of the population.

Workers compensation

In workers compensation cases, spending on narcotic opioids far outpaces the spending in the group health market.

Narcotic analgesics comprise almost 34% of the total drug spend for workers comp payers as opposed to about 3% in the group health market, according to the IMS Institute for Healthcare Informatics, cited in the PMSI Annual Drug Trends Report for 2012.

Of the total medical expense for workers compensation claims, the cost of prescription medications accounts for 19%, according to the National Council on Compensation Insurance.

The impact on the cost of claims is also significant. When a workers compensation claim involved a narcotic, the claim cost averaged nearly $20,000 more than claims without opioids, according to a report in the 2009 Journal of the International Assn. for the Study of Pain, which was cited in the PMSI report.

The use of narcotics also affected time lost from work. Odds of chronic work loss were six times greater when opioids were used, according to the Journal.

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Counter the trend

With the help of their third-party administrators, companies can play an important role in promoting the appropriate use of narcotics. This can mean early and appropriate returns to work to prevent an otherwise simple claim from converting into a legacy claim.

Companies should look for a TPA that can offer several critical capabilities. These include:

•Early intervention: The first few hours after an employee is injured are critical. This is when initial decisions about treatment are made, including what to prescribe for pain. Look for a TPA with a clinical resource hot line to access nurses that can help assess injuries and direct employees to urgent care or an appropriate network doctor who are positioned to best handle the treatment of injured workers and have a proven track record of successful outcomes.

•Applied insight: At specific junctures throughout the life of a claim, the use of narcotics should be evaluated. When narcotics are prescribed, there should be notations in the claim file and a mechanism in place to monitor the types of drugs and duration of use. Use of pharmacy benefit management with aggressive utilization review is critical. Because the treatment of chronic pain can be protracted, doctors and injured workers need to be supported over time. Decision points should be established to prompt reviews by a clinical pharmacist who will review the case and provide an opinion on whether the continued use of narcotics is appropriate. If narcotics are deemed no longer appropriate, then the TPA's pain management specialist can work with the treating physician to determine appropriate next steps.

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•Predictive analytics: Strong partnerships between companies and their TPAs are the result of ongoing and meaningful interaction. A TPA that uses predictive analytics can extract value from a company's claim experiences. This can help pinpoint problems and spur collaborative approaches to develop plausible solutions. Monitoring claims that involve the use of opioids can help identify claims trends and patterns that companies may want to address immediately or in the future.

•Return-to-work programs: Any time an injured worker loses time from work, there is a risk that the individual will never return. When narcotics are involved, the odds of chronic work loss are significantly higher. Aggressive return-to-work programs, therefore, are critical. Employers should look for ways to provide employees with modified job duty whenever possible to get them back on the job.

Today, there is no such thing as a routine claim. With narcotic use and abuse on the rise, workers compensation claims must be carefully managed.

Employers should partner with a TPA that can provide tools and resources specifically designed to monitor narcotic use throughout the life of a workers compensation claim. Perhaps more important, employers should be armed with information so they can access programs and services that provide better outcomes while promoting optimal pain management, early return to work, and improved quality of life for injured workers.

Deborah M. Gleason is the Philadelphia-based Clinical Resources Manager for ESIS Medical Impact, part of ESIS Inc. She can be reached at 215-640-5232 or Deborah.gleason@esis.com.