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Opioids create dilemma for doctors, insurers

Opioids create dilemma for doctors, insurers

The steady march away from opioid prescribing in workers compensation will continue into 2017, according to industry experts who call this ongoing shift in treating pain for injured workers a necessary, but complicated journey for all parties involved.

Doctors have mixed feelings about more state regulations guiding opioid prescribing.

And for comp insurers, it means covering alternative pain therapies, which some have been reluctant to pay for in the past.

“We have to realign ourselves on how we treat pain … instead of sending everybody out the door with an opioid,” said Dr. Robert Goldberg, San Francisco-based chief medical officer and senior vice president for pharmacy benefit management firm Healthesystems L.L.C.

Injured workers who may think every ache deserves a pill will need to look elsewhere for relief in some cases, experts say.

“What the patient wants may not be what they need,” said Dr. Dan Hunt, Lansing, Michigan-based medical director for workers comp insurer AF Group. “You can actually make the injured worker upset with you (by not prescribing painkillers). That alone brings up growing pains.” 

Several states have placed opioid prescribing restrictions, guidance, and monitoring in place to limit the amount of narcotics in the hands of patients, with more changes expected this year.

For instance, California is set to implement a workers comp prescription drug formulary on July 1 that will drastically limit opioid prescriptions without a medical review. New York and Florida are considering similar drug formularies for workers comp, according to reports.

Meanwhile, Maine revised its prescription drug monitoring program in January, requiring prescribing physicians to check the state’s database to see whether a patient has already received a prescription for opioids or other controlled substances. Pennsylvania and Ohio both strengthened their monitoring programs in 2016, and experts say others will follow suit.

Such regulations seem to have had an effect on workers comp. A study released in September by the Cambridge, Massachusetts-based Workers Compensation Research Institute showed a 20% to 31% reduction in opioid prescribing for six of the 25 states it studied, including Texas and New Jersey. The report observed that the decreases coincided with various state reforms aimed at curbing opioid abuse.

Medical experts tend to agree with formularies and tracking, but not without reservations.

Phil Walls, Tampa, Florida-based chief clinical officer for pharmacy benefit manager Matrix Healthcare Services Inc., which does business as myMatrixx, said physicians ought to be “self-regulating,” but that the new regulations are “necessary.” 

Dr. Steven Feinberg, founder of the Palo Alto, California-based Feinberg Medical Group, said most doctors are pressed for time. He worries that workers comp prescribing regulations could stall treatment for a worker who may need more pain medicine than a few days’ supply. “When I am seeing 25 patients a day, I don’t have time to say, ‘Mother may I?’”

During a December webinar hosted by the Western Occupational and Environmental Medical Association in San Francisco, Dr. Goldberg said that the opioid prescription review process under California’s new workers comp formulary could take as long as five days.

Dr. Stephen Martin, a Barre, Massachusettsbased family doctor and a University of Massachusetts Medical School professor, said such a review process could prove detrimental for a worker in serious pain from a crushing injury, for example.

“In an acute pain situation… I would wonder about a person’s state of mind when they get to day eight and don’t have access to pain relief and they will have to contend with a system that doesn’t have the same timeline for resolution as they have, which is to not be in pain,” he said.

Greg McKenna, Chicago-based senior vice president of external affairs for Gallagher Bassett Services Inc., said litigation could arise in such situations based on an injured worker’s “perceived deprivation of rights.”

Experts are looking for ways to manage injured workers’ pain without relying on opioids. For some, that means physical therapy, massage therapy, chiropractic sessions, cognitive behavioral therapy, or encouraging claimants to practice mindfulness.

“I think the treatment angle is headed toward a holistic approach,” said Paul Peak, Memphis, Tennessee-based director of clinical pharmacy for Sedgwick Claims Management Services Inc. “We are addressing the whole person.” Dr. Goldberg said individuals need to be treated on a “case-by-case” basis, and noted that alternative pain treatment could be more cost effective in the long run.

“If you look at the pharmacy costs being accrued (with opioids), those are in the hundreds of thousands of dollars,” Dr. Goldberg said. “Whereas you look at 10 sessions of physical therapy at $100 a session, it’s $1,000.”


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