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With a record number of opioid-related deaths nationwide despite a drop in utilization, overprescribing of the pain medications is an ongoing issue in workers compensation, and some argue that drug overdose kits should be provided to anyone taking prescription opioids.
“The opioid overdose epidemic is worsening,” the U.S. Centers for Disease Control and Prevention said in a January report. “There is a need for continued action to prevent opioid abuse, dependence and death.”
Of more than 47,000 drug-related deaths in 2014, which the CDC said is a record, 61% involved some type of opioid, including heroin.
In its latest drug trend analysis, released in April 2015, Express Scripts Holding Co. reported a decline in utilization of opioids but an increase in the number of days supply that workers were prescribed. And while opioid utilization decreased 10.9%, the narcotics still accounted for 36.0% of the 25 most commonly dispensed comp medications in 2014.
“There is a lot of media around it. However, in work comp, the overdose potential (is) very high because they are utilizing a lot of the pain meds,” said Nikki Wilson, Omaha, Nebraska-based director of pharmacy product development at Coventry Workers' Comp Services. “We are seeing a lot of the opioids within our industry, but fortunately if you go back and look at each one of the trend reports we put out in the last five or so years, you can see that each year there has been a reduction.”
Dannielle Foroozandeh, Irvine, California-based director of pharmacy product development at Coventry Workers' Comp Services, said clinical management programs may be responsible for the overall reduction the in utilization of narcotics. “Over the last five or so years, we have actually seen a decline in narcotic utilization,” Ms. Foroozandeh said.
“There is a happy theory to lower use and a dark theory,” Peter Rousmaniere, co-author of “Workers' Compensation Opt-out: Can Privatization Work?” and a risk management consultant in Woodstock, Vermont, said in an email. “The happy theory, to which I in effect subscribe ... is that prescribing doctors became more careful and a host of controls, such as prescription monitoring systems and such, began to kick in,” he said, citing Texas' earlier formulary efforts.
“The dark theory is that nothing by the docs or others made much of a difference — use went down because patients abusing the drugs were no longer able to do it thanks to drug redesign, and simply (stopped) asking for it,” he said.
But while utilization may be down, overprescribing remains a problem in workers comp, and health care professionals should consider alternatives to opioids, said Dr. Gary Franklin, medical director of the Washington State Department of Labor and Industries, the state's monopoly workers comp insurer.
“The problem is that sometimes workers comp insurers don't pay for … cognitive behavioral therapy, integrated exercise,” Dr. Franklin said. “You want to prevent inappropriate opioid use in the first place. Even during an acute pain episode, you don't want to use opioids for things that aren't very severe.”
Aside from the potential of addiction, overdosing and death, injured employees prescribed opioids early in their workers comp claim tend to have “lower recovery time and more delay to return to work and higher medical costs,” Dr. Melissa Cheng, Salt Lake City-based assistant professor at the University of Utah's Rocky Mountain Center for Occupational and Environmental Health, said in an email.
To fight opioid overdoses and deaths in general, the World Health Organization recommended increasing access to naloxone, which is used to revive people who overdoes on heroin and other opioids, as well as training family and friends to use overdose kits.
The CDC this month also recommended increasing access to naloxone.
“It's unclear how many lives you can save doing that, but it's a good idea to give high-risk patients (naloxone) kits to keep at home and their families. So anyone on high doses of opioids, over 100 milligrams a day, should be given a kit,” said Dr. Franklin.
Students at John Hopkins University, Baltimore, have taken another approach: building a tamper-resistant pill dispenser prototype to help fight drug overdoses that can be opened only with the prescribed individual's fingerprint.
“The ideal end game would be that when patients are prescribed opioids, they have the opportunity to have them delivered in a device that only they can get into at the time and in the dose that they need so that it protects them and everyone in their environment from accessing these things,” said Andrea C. Gielen, a professor and director of the Johns Hopkins Center for Injury Research and Policy.
Taking into account the link between chronic pain and insomnia, the workers compensation industry is educating health care providers and injured workers about sleeping pill alternatives to improve patient safety.