This article is the third and final installment in NCCI’s series On Opioids. This series is aimed at exploring three viewpoints on issues surrounding opioid use and workers compensation: those of doctors, insurers, and regulators. NCCI conducted interviews with professionals from each of these areas and the articles in this series reflect their opinions on the topic.
In the closing chapter of our three-part series, we hear from regulators from Colorado, Kentucky, and Maine, and share their thoughts on the impact that opioid use is having on the system.
Talking to Regulators
Although the opioid epidemic touches every corner of the country, the extent of the impact varies widely from state to state. According to the Centers for Disease Control and Prevention (CDC)1, “opioids—prescription and illicit—are the main driver of drug overdose deaths.” The CDC data shows that in 2016 there were 353 overdose deaths in Maine, 942 in Colorado, and 1,419 in Kentucky. In a concerted effort to address the opioid epidemic, regulation of opioid prescribing at the state level has increasingly been reverberating in state legislatures—some 1,700 bills have been introduced over the last two years.
In talking to regulators regarding efforts to address the opioid epidemic, they shared that:
- State regulation of opioid prescribing is a key factor
- Prescription drug monitoring programs (PDMPs) play a critical role in controlling opioid over-prescribing and abuse
- Physician buy-in is an important driver
- Transition programs for long-term users and opioid alternatives are emerging
- Healthcare literacy is part of the needed solution
Regulators shared that the extent of opioid use and the seriousness of the issue vary from state to state and even within states. Some states began addressing the opioid epidemic early on, while other states have focused greater attention only recently. In July 2016, governors from 40 states signed a compact2 to fight opioid addiction by adopting a series of steps with the following goals:
- Reduce inappropriate opioid prescribing
- Understand opioids and addiction better
- Ensure a pathway to recovery for individuals with addiction
This has resulted in several states adopting rules and laws, and others having several pieces of legislation in the works.
Some of the adopted regulatory and statutory provisions were aimed at regulating payment as well as prescribing patterns, thus enabling the adopting states to target operations dispensing large quantities of opioids, sometimes known as pill mills. Some of these opioid dispensers, one regulator shared, required significant effort to rein in.
State rules regarding opioid prescribing may differentiate between acute conditions and chronic ailments, said one regulator. Several states have enacted laws that establish limits on the initial prescription dose of opioids for the acute phase of injuries, providing a tool for prescribers to manage patient expectations regarding the pain medication.
Additional limits for long-term use or chronic pain are also being considered, but not quite as often, according to the regulators. One challenge of controlling opioid prescriptions for the so-called “legacy” claims was the need to facilitate change for the long-term users. The goal of this type of regulation is to provide a transition time to wean off those patients who are already accustomed to certain amounts of opioids and provide them with some pain treatment alternatives.
PDMPs and Drug Formularies
Prescription drug management programs, or PDMPs—state-operated databases that contain prescribing and dispensing information submitted by physicians and pharmacies—have been in place for several years. Regulators shared that early adoption of compulsory use of PDMPs, as was the case in Colorado and Kentucky, has helped curtail opioid abuse in those states. Some earlier versions of the PDMPs were said to be not very user-friendly, and several were not mandatory. Recent efforts have aimed to render them easy to use, allow for different state PDMPS to share information, and make them mandatory for both prescribers and dispensers alike.
Texas, which has adopted a drug formulary and accompanying treatment guidelines for the state workers compensation system, was hailed for its promising impact on the fight to contain opioid misuse and addiction. One key to ensuring the effectiveness of drug formularies and treatment guidelines is physician buy-in because they are on the front lines of prescribing, regulators said. But they added that some states may not have a political environment conducive to the kinds of regulations implemented in Texas.
Regulation of payments made to physicians who prescribe opioids can also be a powerful tool, said one regulator. These types of regulations encourage appropriate prescribing practices based on medical evidence. They tie payments for medical services to treatment guidelines and scientific evidence that the injured workers will benefit from the prescribing regimen.
Physician Practices and Treatment Guidelines
According to the regulators, injured workers who may not have access to specialized physicians, such as workers in more rural areas, may in some instances be susceptible to receiving more opioid prescriptions than workers who are treated by and have easier access to occupational medicine or pain management specialists.
The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain3 helped steer physicians to safer prescribing practices, regulators noted. The new guideline gives more weight to alternative, non-narcotic medications such as gabapentin.
In workers compensation, treatment guidelines play an important role in establishing a general philosophy for practicing physicians and other system stakeholders regarding opioids and their intended use. For example, one regulator shared that it is widely believed that opioids are not meant to treat chronic pain. Rather, they are meant for the acute phase of pain management for serious injuries and for improving an injured worker’s functionality during physical therapy. The treatment guidelines should reflect that. He added that one important feature of treatment guidelines is to ensure adherence to the indicated drug regimen through regular drug testing and thereby, hopefully, avoid having the prescribed drugs ending up on the street.
Transition to Non-Opioids/Alternatives
Regulators cautioned that transitioning a patient from opioids to an alternative, non-opioid treatment is a process that should be afforded appropriate care and time. One unintended consequence of this change could be leading a habitual opioid user to seek illicit drugs to replace the morphine that their body has grown accustomed to.
One regulator highlighted an example of success against this unintended consequence: an injured worker using medical marijuana instead of opioids and never going back to opioids. However, as marijuana remains illegal at the federal level and is classified as a Schedule I drug under the federal Controlled Substances Act, insurers may still be reluctant to reimburse for this alternative, he said. Allowing or requiring reimbursement of medical marijuana treatment for injured workers is a dynamic area, with state courts continuing to evaluate the law impacting the potential for such treatment in the future.4
Another regulator observed that there has been a slight increase in cases where injured workers and their treating physicians are seeking alternative treatments such as cognitive behavioral therapy and physical therapy, as well as other less traditional alternatives such as tai chi and yoga. However, the responsiveness from payers to such alternatives varies, the regulator shared.
Regulators agreed that healthcare literacy is important for all those involved in the process of prescribing and receiving opioids. Prescribers are now having to participate in continuing education courses on the effects of opioids—courses which were not previously required. But a fuller understanding of the complexity of opioids and their effects is a continuing need in the medical community at large, according to one regulator, particularly for prescribers who are not specialized in opioid management.
It is also as important for injured workers seeking treatment for their pain to more fully understand the risk of addiction and that opioids alter the patient’s perception of pain, said one regulator. Similar to what we heard in our
Claims Professionals’ Perspective article, the regulator shared that some state rules require the use of a contract between the prescriber and the injured worker. The contract explains the dangers of opioids, how the medication ought to be used, and includes a patient agreement to not seek other opioids or other specific types of medication. These contracts also set out how the use of the opioid will be reduced over time and ultimately end. That said, the regulators noted that workers compensation professionals must recognize that in some unique and limited cases, there can be reasons for an injured worker to stay on a “small” opioid dose that keeps the worker at their highest level of function, without the downstream effects of addiction.
Regulators also shared that they, too, have been expanding their understanding of opioids and the successes and failures in addressing the epidemic. Organizations such as the International Association of Industrial Accident Boards and Commissions (IAIABC) and the Southern Association of Workers’ Compensation Administrators (SAWCA) have provided a great forum for regulators to share information, innovative solutions, and best practices in implementing rules and regulations.
Regulation is responding to the opioid epidemic through new state laws and efforts specifically directed at the workers compensation system. Regulators have several tools that they are deploying, including reimbursement rates, the use of evidence-based treatment protocols, drug formularies, and treatment guidelines. Other areas have also been identified as critical in fighting the opioid epidemic in workers compensation. It is important to address multiple types of regulation while also continuing efforts to strengthen PDMPs, physician practices, and guidelines; increasing the number of alternatives to opioids; and improving overall healthcare literacy.
At our Annual Issues Symposium 2018, we will explore opioids and workers compensation further as we present Opioids—Killer Pain Relief.
Special thanks to regulators Paul Sighinolfi (Executive Director/Chair, Maine Workers’ Compensation Board), Paul Tauriello (Director, Colorado Division of Workers’ Compensation), and Robert L. Swisher (Commissioner, Kentucky Department of Workers’ Claims), who generously shared their insights.