Opioid use falls, but issues remain

When the pandemic hit two years ago a years-long strategy in the workers compensation industry was controlling opioid prescriptions — a goal that has continued despite interruptions stemming from COVID-19 claims and disruptions. 

Experts say opioids in new injured worker claims are continuing to trend downward, as state-mandated formularies, monitoring programs and other protocols appear to be working to curb the long-term use of addictive pain medications. Yet emerging, adjusted federal guidelines, along with opioids in older claims, will be challenging. (See related story).

“Pain isn’t going away,” said Silvia Sacalis, vice president of clinical services for pharmacy benefit management company Healthesystems LLC in Tampa, Florida. “We are headed in the right direction in terms of continuing to focus on it … and ongoing vigilance is going to be important.”

Workers comp opioid spending has declined more than 62% since 2016, according to data collected in 2021 by Maggie Valley, North Carolina-based consulting company CompPharma LLC, which also found that total workers comp pharmacy costs have decreased by 38% over the past decade.

“All the policies that have gone into effect over the past few years have contributed to reducing opioids in our industry,” said Reema Hammoud, Southfield, Michigan-based assistant vice president of clinical pharmacy for Sedgwick Claims Management Services Inc. “In general, everybody is doing what they are supposed to do.” 

Preliminary data released by the Cambridge, Massachusetts-based Workers Compensation Research Institute at its annual conference in March showed that formularies — lists of prescription drugs approved for use by workers with injuries, which are now in place in 17 states — have been particularly effective, as most require multi-step utilization reviews for most opioid prescriptions. 

In California, where a workers comp formulary went into effect in 2018, per-claim drug utilization and payments fell “immediately” after implementation, according to WCRI. For opioids alone, there was a 38% reduction in prescriptions for injured workers between the fourth quarter of 2017 and the second quarter of 2018. 

Another study by WCRI, released last year, found that other state policies had a hand in reducing opioids for injured workers. Prescription drug monitoring programs — put in place in the past five years — reduced the amount of opioids prescribed by 12% in the first year of implementation, and regulations limiting the duration of initial opioid prescriptions resulted in a 19% decrease in the amount of opioids in workers compensation claims. 

Yet “opioids remain the No. 1 as far as the most utilized therapeutic class for injured workers,” said Nikki Wilson, Omaha, Nebraska-based director of clinical products for Mitchell Pharmacy Solutions, adding that “proactive intervention is still there” despite issues brought on by the pandemic. 

One such issue was regular access to providers, which Ms. Wilson and others said was bridged with the emergence of telehealth. 

“We learned things from the pandemic on how to reach people beyond the traditional pathway of walking into a physician’s office,” she said. 

Dr. Dwight Robertson, Pasadena, California-based vice president of managed care services and national medical director for comp insurer Employers Holdings Inc., said a program started in 2017 that zeroes in on opioid prescriptions at the 30-day mark following a claim wasn’t hampered by the pandemic, in part because of telehealth. Other workers comp insurers and third-party administrators have similar programs in place.

The program at Employers calls for interventions after 30 days, involving both provider and patient, to reduce opioid prescriptions. “That discussion resulted in us having 98% of our claimants — new opioid users — off opioids within 12 months, and 100% within the second year,” Dr. Robertson said. “When COVID hit, we continued that.” 

Yet, the industry is now grappling with proposed U.S. Centers for Disease Control and Prevention guidelines on opioid prescribing, introduced in February, that some say represent a step away from 2016 guidelines that drastically limited opioid prescribing by doctors who were fearful of ramifications. Proponents say the voluntary guidelines will put pain management back in the hands of physicians, while critics say the recommendations have the potential to create dependency issues among patients, which prompted the creation of the original 2016 guidelines. 

“There’s still a concern on the part of providers that we have gone too far with restricting opioids,” said Brian Allen, Salt Lake City-based vice president of government affairs, pharmacy solutions, for Mitchell International Inc.

Ms. Hammoud said the proposed guidelines are problematic in that they are unclear on the upper limits of opioid dosing. “In the 2016 guidelines, it was clear what the thresholds are for opioid overdose. They are very blurry in the new guidelines, almost like we are going backwards.”

The new guidelines are the pendulum swinging back, Ms. Sacalis said, adding that the shift is not a bad move and that a more patient-centered approach is better. 

“We literally have gone too far the other way. There are patients with pain that is not adequately managed,” she said. 

“You can use guidelines, analytics, but at the end, you have to figure out what is or is not working for the patient,” she said. “You cannot completely eradicate opioids, and it doesn’t make sense to eradicate opioids.”

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Prolonged painkiller dependency  still hard to overcome 

Long-term opioid use in older workers compensation claims continue to be a problem. 

“The opioids issue is going to be around for another decade and just because fewer are getting opioids and fewer doses … that’s not consequential. What’s consequential are the existing, older claims,” said Joe Paduda, Skaneateles, New York-based principal for the comp consulting firm Health Strategy Associates LLC. “The legacy claims issue is a really difficult one.” 

“Are we getting all those long-term users off opioids? The answer is no,” said Dr. Dwight Robertson, Pasadena, California-based vice president of managed care services and national medical director for Employers Holdings Inc. 

“When they have been on them for 10 years it is very hard” to eliminate opioids, he said. “But we can reduce the (morphine equivalent dose) and bring it down to a better level. That has happened.” 

Reema Hammoud, Southfield, Michigan-based assistant vice president of clinical pharmacy for Sedgwick Claims Management Services Inc., said stronger prescriptions in long-term claims are down thanks to constant contact and state guidelines that call for providers to document usage.

“It’s not that the medications are not allowed anymore, we just need proper documentation” she said. “If there is proper documentation and it is helping the patient, they can get the medication.” 

Providers “have to do their due diligence and show that they are re-assessing the injured worker,” Ms. Hammoud said.

Nikki Wilson, Omaha, Nebraska-based director of clinical products at Mitchell Pharmacy Solutions, said being proactive on the legacy claims has been successful. 

“There’s a lot of high touch on those older claims in terms of coming up with resolutions,” she said.