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A lasting legacy of pain

Workers comp sector struggles with weaning injured workers off opioids

A lasting legacy of pain

An industry whose hallmark is pain management is now grappling with its own ailment for which there is no easy cure: legacy claims tied to long-term opioid prescriptions.

Even as regulations, formularies and intervention programs set up by pharmacy benefits managers, insurers and others are established to crack down on opioid prescribing, the question of what to do with injured workers who were prescribed strong pain medications as part of their treatment years ago is a complicated one, experts say.

“Legacy claims are interesting because the education about opioids didn’t really come out until 2010, and the (U.S. Centers for Disease Control and Prevention) didn’t come out until recently to say, ‘Hey, this is bad,’” said Debra Doby, a New Yorkbased partner at Goldberg Segalla L.L.P., referring to the CDC’s 2015 release of guidelines that found opioids ineffective in managing chronic pain — guidelines now working their way into the industry and into state capitol buildings.

Numerous studies show that opioid prescribing is on the downturn in workers compensation and opioid early intervention programs have become an industry mainstay, with a cadre of nurse case managers, review boards and others aiming to ensure a person does not become dependent on drugs never intended for long-term use whose side effects run a troublesome gamut that includes death.

“The focus is on the front end (of the claim), but it doesn’t deal with what we are left with,” said Deborah Gleason, who works as a clinical resources manager in the Philadelphia office of ESIS Inc., the third-party administrator subsidiary of Chubb Ltd.

“It is messy, it is complex, and it is highly individualized,” said Mark Pew, senior vice president at Prium, a Duluth, Georgia-based medical cost management firm, who uses “#cleanupthemess” on social media when blogging about the quagmire that has the industry rethinking its approaches.

“We are starting to understand as an industry that injured workers are people, too,” he said. “From there, what do you do?”

Inside the mess

Few disagree over what started the problem: among the culprits named are widespread marketing of pain medications, pain being considered a vital sign along with pulse and blood pressure and a culture that craves instant gratification.

Dr. David Deitz, a managed care consultant who runs his own consulting firm David Deitz & Associates L.L.C., out of Westport, Massachusetts, said he lived through the “decade of pain,” when in the 1990s a doctor’s quality assessment included this question: Are you in pain?

“There was an encouragement to send them away with a treatment for pain,” said Dr. Deitz. “That was one of the drivers of the opioid epidemic. Physicians were not willing to be dinged in an assessment because someone was still in pain.” And now — decades later under the cloud of a staggering opioid death toll — there’s a disconnect in the workers comp industry on what to do and what’s being done for long-time claimants who need to reduce or step away from opioids.

Those who work with drug weaning and addiction programs say insurers have historically been slow or outright unwilling to pay for alternatives such as cognitive behavioral therapy, which aims to teach a person with chronic pain how to mentally manage their pain; physical therapy and massage, which can provide relief but are limited; and drug treatment programs.

“This needs to shift,” said Dr. Mel Pohl, chief medical officer at the Las Vegas Recovery Center, whose business is estimated to be 30% related to workers comp. “Almost all of these claims are legacy. They’ve been on (opioids) a long time; they are high-cost disabled (people) utilizing a lot of opioids and don’t have a way out. I don’t know that there has been an appetite (for insurers to pay for treatment). Insurance companies are in the business of not paying if they can. But chances are more and more insurance companies will get on the bandwagon.”

“I do see that tension,” said Steven Ryan, an attorney and workers compensation specialist with Frommer D’Amico Anderson L.L.C. in Harrisburg, Pennsylvania. “There is this issue of trying to address legitimate concerns and balancing that with getting an insurance company to pay for it.”

Meanwhile, those who manage workers comp insurance claims admit the past isn’t pretty, and some note a paradigm shift.

“It’s been great to see how everybody is recognizing it now,” said Peter MacDonald, Hartford, Connecticut-based vice president of workers compensation claims for Hartford Financial Services Group Inc. “Opioids, by and large, do not help people get better and that’s what our mission is … we’re finding these claims and we continue to work on them.”

Liberty Mutual Insurance Co. is also digging into its data to find the older claims. “We’ve gotten better at it and the tools have gotten better,” said Frank Radack, the insurer’s vice president and manager of managed care in Boston. “One of the solutions we have is interdisciplinary pain management programs; we work with some of the centers of excellence.”

“I think payers are getting the message and they are more willing to pay for (treatment),” said Dr. Deitz. “There’s evidence that payers have dragged their feet in paying for this, but that’s less of a problem now than it used to be.”

State regulators are also starting to tackle the problem.

Among the most powerful changes facing the comp industry are the formularies that call for weaning injured workers off opioids. For example, Texas in 2011 gave doctors two years to wean such claimants or to create plans to tackle the older claims. California, with its formulary set to be enforced Jan. 1, 2018, is giving doctors three months to come up with a plan to wean or reduce opioids for long-time patients in the comp system.

“My concern is that with these legacy cases, even though everything that is being done makes sense … it’s going to be a mess,” said Dr. Steven Feinberg, a pain expert and founder of the Palo Alto, California-based Feinberg Medical Group, which helps injured workers manage pain using integrated methods. He said he hasn’t seen widespread education for treating physicians on how to wean or an expansion of adequate programs to help injured workers reduce their medications.

Michael Coupland, West Palm Beach, Florida-based psychologist and network medical director for IMCS Group Inc., a national network of clinicians that helps wean injured workers off opioids, said he’s also apprehensive about the future. “There’s this better catching of those (dependent on) opioids, but when you catch them, how do you treat them?”

Both experts call for additional education for providers and payers and say they can start by better understanding the patients themselves.

An average Joe

This category of injured workers are usually people with musculoskeletal pain, whose pain remains stagnant and might be, ironically, caused by a physical dependence on an opioid, a condition known as hyperalgesia, a term now finding its way into workers compensation circles. They are people whose pain, discomfort and side effects make return to work impossible — an injured worker who hasn’t slept, who has anxiety, depression or nausea, and takes other pills alongside their Vicodin or OxyContin to quell those side effects.

An injured worker like Joe in 2013.

Joe, who didn’t want his last name printed because of the “stigma” of having been dependent on opioids, fell 12 feet off scaffolding while working as a carpenter in Dartmouth, Massachusetts, in 2006, suffering a back injury. He was in his late 20s and thought he’d heal quickly, he said. “No puncture wounds,” he recalled, thinking he was lucky at the time, because in construction “you see it all.”

The first doctor he saw put him on Percocet, a commonly prescribed opioid. The second — a pain management specialist — upped his dose after long visits that gauged range of motion and other metrics for measuring recovery.

For several years, his employer’s insurer sent him to see a specialist every six months, and in time the visits with the doctor became shorter and he always left with a new prescription for pain medication. The pain never went away. He wasn’t sleeping. He missed his construction career: cracking jokes, picking on the new guy because that’s what you do, he said in a Boston accent.

Joe said he wasn’t living. And that he had never heard of “opioids,” and yet took them every day. In 2013, frustrated with where his life was, he Googled his prescriptions.

“I started reading all these horror stories and I started thinking, there’s gotta be something else,” he said. “I didn’t want to be on that stuff.”

At about that time, Joe was referred to work with Mike Pringle, the director of specialty services at Windham Group, a Manchester, New Hampshire-based workers compensation case management company that specializes in opioid weaning, among other offerings.

Mr. Pringle calls Joe one of his success stories: He’s back to work now and lives pain-free.

But there aren’t that many Joes, Mr. Pringle said, calling the problem facing the industry the most challenging, either because payers were historically unwilling to fund treatment or the injured workers themselves were unwilling to quit or reduce their pain medications.

Joe weaned himself in about three weeks; taking smaller and smaller doses until he was off the pain medications completely. But that likely won’t work for everybody, Mr. Pringle said, adding that interventions and therapies need to be varied and combined. He used an analogy redolent of getting somewhere.

“Each intervention is like a spoke in a wheel on a bicycle,” said Mr. Pringle. “A bicycle wheel with two spokes doesn’t work too well.”

“Now that the (opioid) problem has been unveiled to the public, we have to do something about it — the legacy cases of people who got injured 10 to 15 years ago and have been on narcotics since,” Mr. Pringle said. “Those are the cases that are a real challenge because so much of the groundwork where you could have had a positive impact, those days are long gone. It’s almost like building a building and realizing you have to change wiring after it’s built … None of this is easy.”

Time and money

“You can wean anybody by stopping the drug, but if we are trying to do something to help the injured worker get back to their life, it will take more,” said Dr. Feinberg. “It’s expensive to help people have a better life.”

“You have to have every tool at your disposal,” said Mr. Pew. “You have to be willing to pay for treatment, to pay for yoga, to pay for (cognitive behavioral therapy).”

Dr. Pohl’s treatment facility in Las Vegas will be going to 80 beds from 40 in a few months because he’s anticipating more patients as regulation and politics leads more people into treatment.

While costs vary by payer, $1,000 a day is a good estimate for daily treatment for a person in opioid weaning — a complicated process that could result in numerous adverse events, Dr. Pohl said.

Among the worst early side effects of weaning, and why it isn’t always successful, is the anxiety associated with what can happen, said Mr. Coupland. Nausea, headaches, and rapid heartrate are associated with weaning off opioids. And some might not be able to go through it if they suffer a heart condition, he said.

Once stabilized, there’s the life-goal approach and the management of pain that comes next.

“They have to want to feel better and be more socially active,” said Mr. Coupland. “They have to want to play with their grandkids or have a better quality of life. A life on opioids is isolated; most people just stay at home and have very little social life; they get separated from family activities and involvement and focus very much on what they can’t do instead of what they can do. The brain wants to justify having the drugs so they can focus on the pain.”

Insurers have historically avoided paying for therapy that targets a person’s thinking — cognitive behavioral therapy — for fear of creating a “psych claim,” said Mr. Coupland.

Other experts expressed similar concerns.

“Cognitive behavior therapy raises a red flag for insurers because it opens the doors for a psych claim,” said Ms. Doby. “I think we get back down to education. Typically, you find with the legacy claims, you have to educate the claimant; they have to understand how to cope with their pain.They have to understand how to move differently, and that requires therapy. That results in a successful person coping with their pain.”



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