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Despite a decline in injured workers' use of narcotics and the workers compensation industry's increased vigilance about the risk of overutilization and addiction, the opioid epidemic is far from over.
Early intervention strategies, prescription drug monitoring databases and drug formularies have helped reduce the use of opioids to single-digit increases in the past several years, sources said.
“There's a sense now that we're starting to get our arms around the problem, but we've by no means solved it,” said Joseph Paduda, principal of Madison, Connecticut-based Health Strategy Associates L.L.C.
“It scares me that people will think, "We've got this fixed, let's move on ... and worry about something else,' “ such as compound drugs. “That's a huge mistake,” he said.
Compound drugs are pricy and rarely found to be medically necessary, but they account for only about 5% of drug spending, Mr. Paduda said.
Opioids, however, represent 29% of Sedgwick Claims Management Services Inc.'s drug spending, “which is huge,” said Dr. Teresa Bartlett, Troy, Michigan-based senior vice president and medical director of the third-party administrator. The percentage is consistent with pharmacy benefit managers' recent drug trend reports.
While utilization is declining, the cost of narcotics has increased due to a surge in the average wholesale price of medications, PBMs such as Helios, Express Scripts Holding Co. and Coventry Workers' Comp Services reported earlier this year.
Experts say physicians should screen injured workers prior to prescribing opioids, asking if they have a history of addiction or mental illness, among other questions, to see if they're at risk for delayed recovery or addiction.
Sedgwick asks every physician it works with to do this and report patients' levels of risk — based on their answers to the questions — back to the TPA, but the company is successful just 21% of the time, Dr. Bartlett said.
Several free risk assessment screening tools are available, but “physicians feel they understand their patients and know whether or not they're at risk for addiction or overdose,” Dr. Bartlett said.
Many physicians provide opioid agreements, which detail the risks and potential side effects of such drugs, to be signed by injured workers, said Dr. Robert Hall, Westerville, Ohio-based medical director at Helios.
“It sounds like a lot of those contracts have just been signed and not necessarily reviewed,” which is a missed opportunity, Dr. Hall said. Providers should walk injured workers through the pros and cons of opioids and alternative treatment options, he said.
Despite the risks, sometimes opioids are the right course of action, such as immediately after surgery, experts said.
“Opioids are a very necessary thing for dealing with acute pain,” Dr. Bartlett said. “What we talk about is really the chronic issue ... when it gets beyond a couple of weeks, you need to start worrying.”
When prescribed, injured workers also should be given a weaning schedule, and improvement in their pain levels “should be complemented by a reduction in opioids,” Dr. Hall said.
Overall, there's greater focus on education, said Michael Gavin, Duluth, Georgia-based president of medical cost management company PRIUM.
“We're entering an era of informed-choice health care delivery,” which Mr. Gavin described as “a nascent movement at this point.”
“If a physician tells a patient, "You need an MRI' or "You need this medication,' then (injured workers) truly be- lieve that they need it, and why wouldn't they?” Dr. Bartlett said. “Even though we might convince an injured worker, for the most part, we have to compel the doctor to change.”
For that reason, Sedgwick focuses primarily on working with treating physicians to ensure they use best practices, Dr. Bartlett said. PBMs, on the other hand focus more on patient education and training, she said.
Workers comp payers “don't want to manage pharmacy in a vacuum,” Mr. Paduda said. “There has to be a sharing of information and a sharing of data as well as a clear understanding of who's responsible for what.”
Mr. Paduda added that the most productive thing an employer can do is ask its PBM, “What should we be doing? What's that impact going to be? And what do I need to do to make that happen?”
The industry seems to have a handle on managing opioid use among new claims, but it's really the legacy claims, some of which are 20 years old, that drive about 75% of workers comp costs, Mr. Gavin said.
There needs to be a “holistic strategic focus on peer intervention, drug monitoring and tools like that to make sure care is being delivered appropriately,” he said. “The responsibilities that payers have ... in connection with opioids is changing.”
Several years ago, many employers and insurers would pay for opioids to avoid “noise from attorneys and doctors and injured workers who are upset about not getting their medications,” Mr. Gavin said.
“The risks of not paying and the risks of continued payment are being rebalanced,” he said. “Most medical directors are starting to say, "I cannot continue to authorize payment for drugs that I know are dangerous and could result in further injury or potential death to the injured worker.' ... The perception of risk is shifting.”
Third-party administrators are leveraging pharmacy and claims data to develop red flags used to alert adjusters when injured worker cases need more attention.