Mid-Summer Summary and a Quick Look Forward

It's mid-summer, and many of our readers are off on well-deserved vacations. For those who are still in the office (and are as fascinated as we are by all things ‘workers’ comp'), we are taking this opportunity to offer some updates to one of the major subjects we've been following and to provide a heads up about what we'll be highlighting later this year.

Updates on Opioids

For more than two years, we've been profiling the challenges posed to the nation's workers and employers by opioids. We've tried to explain:

how the concern arose;
what the government is doing about it;
how it affects the Workers’ Compensation industry, and
even how it impacts the U.S. life expectancy statistics.

We've looked into what employers can to do (and their struggle with those activities) to reduce the likelihood that their injured workers will suffer the additional pain of a subsequent opioid addiction. And we've reported how some of America's medical professionals have contributed to (and profited dramatically by) the problem by prescribing so many of the drugs in inappropriate quantities and dosages.

Clearly, opioids as pain relief for workplace injuries have wreaked havoc across the country for at least two decades, and America's employers and employees have borne the economic and emotional brunt of that disaster.

Seeing a Turnaround?

However, increased attention to the issue has also increased responses to it, and all parties involved - employers, employees, insurers, healthcare providers, and government agencies - are now working in conjunction with each other to reduce the problem.

Consequently, we're now happy to report three good news stories about how those added attentions and intentions have had a positive impact on the opioid concern:

1) The Dollar Amount of Spending on Opioids is Falling

Recently released data reveals that in 2018, all 27 respondents to the 16th annual "Survey of Prescription Drug Management in Workers’ Comp" reduced their spending on opioids for injured workers by an aggregate of 23.2 percent in 2018. The drop signals the third year in a row that opioid spending was down, by 16% in 2017 and 13% in 2016.

Those reductions are the result of several changes in how medications are managed in the workers’ comp system. Insurers are now more careful about the number and dosage of opioids that they're will to cover, and ethical healthcare providers are reducing the numbers of opioid prescriptions that they write. And injured persons are also assuming more responsibility for their healthcare, by becoming more aware of the dosage and duration of prescriptions and moving off the drugs earlier in their recovery period.

In many cases, the shift in opioid usage reflects the growing reality that workers who remain on the drugs beyond medically accepted terms take longer to recover, are more likely to not return to work, and more likely to not regain their previous level of function even after they've recovered from the injury itself.

2) Adding Acupuncture to the List?

On a related note, in mid-July, the CMS (Centers for Medicare & Medicaid Services) for the first time suggested a willingness toauthorize the use of acupuncture treatments for their Medicare patients who suffer from chronic low back pain (cLBP). It's not available for everyone just yet, however; the agency issued a 'proposed' decision, indicating that they'd make a final determination on the question based on the results received by study participants who are enrolled patients in CMS-approved research or clinical trials sponsored by the NIH (National Institutes of Health).

Earlier in the year, CMS launched a National Coverage Analysis (NCA) of scientific evidence that supports or negates the use of acupuncture as a pain-relieving alternative to medical interventions such as opioids. While there's no posted information as to why cLBP is the current focus, again, statistics may reveal why the CMS chose that particular ailment. A 2016 National Health Survey showed that at least 50 million American adults suffered from some form of cLBP and that 19.6 million of those experienced "high impact chronic pain." Both levels of pain are associated with increased anxiety, depression, and, in many cases, opioid dependence. Using the non-medical intervention of acupuncture instead of opioids would be a game-changer for many people if it curtailed their pain and improved their quality of life without the need for opioids.

The NCA is also part of a Strategic Plan developed by the National Institute of Drug Abuse (NIDA) to reduce the impact of opioids on Americans. The strategy includes four approaches to improved pain management that might assist with the alleviation of pain but not exacerbate the health situation with an unnecessary opioid addiction. The approaches include exploring for more non-opioid medical interventions; assessing the efficacy of non-pharmacological pain treatments such as acupuncture and biofeedback; finding adjunctive supports for cases where opioids remain the best pain controlling mechanism and developing strategies to improve opioid management practices so that opioid use disorders don't develop.

3) The National Safety Council (NSC) Agrees with CMS

In a show of national unity, the NSC agreed publicly with the CMS and asserted its support of the decision to consider alternative pain treatment methods like acupuncture instead of opioids. The NSC put the opioid crisis in context by noting that the odds of dying prematurely because of a fatal opioid overdose have surpassed the odds of being killed in a car accident for the first time ever. The agency went on to encourage all employers and their benefits providers to consider accepting alternative pain treatments as a way to not just reduce the threat of opioid dependency but to avoid it altogether.

A Brighter Future

Both the reduction in opioid spending and the possibility of acupuncture coverage for controlling pain are significant strides toward a definitive solution to the opioid crisis. We will continue to monitor how the country is managing this scourge and keep our readers informed about how they can be part of that solution, too.

So, What IS an MSA?

CompEx MSA also intends to explore its roots and will be providing an overview of the need for and development of Medicare Set-Aside accounts. Protections for worker safety and healthcare management have evolved over a long period that also saw the institution of mandatory work hours, minimum wages, and safe working condition standards. Through it all, employers have had to walk a fine line between profitability and maintaining attention to emerging government and industry regulations. The MSA is one tool they can use to make that process easier.

At CompEx MSA, we believe we can assist our clients better if we help them to better understand how the MSA process works and how it works within America's industries and communities. We will be launching that series next month.

Dr. Criminal: Arrests Made for ‘Pushing’ Opioids

The true cost to the nation's employers of America's opioid crisis is almost inestimable. From lost wages to lost productivity to the thousands of unnecessary deaths caused by the over-prescription of opioids and their subsequent addictions, the value of the losses suffered by individuals, families, communities, and businesses is beyond calculation. Gaining control over the issue is an immense challenge, so it was gratifying to see that the Office of the Inspector General (OIG) is taking significant steps to hold to account those who created much of the problem, at least in the Appalachia region.

Surprising Arrests in Appalachia

In April, the OIG arrested 60+ individuals and charged them with health care fraud and opioid 'pushing.' Included in the group are 31 doctors, eight nurse practitioners, seven pharmacists, and seven other health care professionals, all of whom are believed to be responsible for the prescribing and dispensing of more than 350,000 prescriptions - more than 32 million doses- of opioids in 2016. That volume of doses is the equivalent of one per every personin the five states covered by the OIG's investigation: Kentucky, Ohio, Tennessee, West Virginia, and Alabama.

These arrests follow an exhaustive 2017 investigation into the opioid situation in that region because data suggested the problem was more significant there than it was in other parts of the country. In 2016, of the 42,000+ opioid-related deaths in the U.S., more than 7,000 occurred within those five Appalachian states. The agency's primary question for the investigation was whether the number of opioid-related deaths or overdoses occurred specifically in Medicare Part D beneficiaries, the direct population over which they have authority. If data revealed that that was the case, was there also an element of fraud in how those drugs were prescribed or dispensed?

The investigation found that more than one in three (36%) Medicare Part D beneficiaries in those five states had received at least one opioid prescription, and almost 49,000 of those Part D beneficiaries received doses and prescriptions at levels that 'far exceeded' the levels of concern as iterated by the Centers for Disease Control (CDC). The evidence led to the belief that yes, certain health care professionals were definitely selling opioids as a money-making operation, and not as a legitimate health care practice. The evidence also revealed not just the dosages and prescriptions, but also the identities of the medical professionals who were responsible for moving the drugs into the population through otherwise legitimate healthcare settings.

Not Just in Appalachia

More arrests are expected, too. The OIG has taken a methodical approach in its investigation into the opioid concern, focusing on three main issues: improving the efficiency of the HHS systems that prescribe opioids; empowering system partners by sharing data and information, and holding accountable the people who are exploiting and defrauding those systems. This third tact - accountability - is now pursued by a series of 'Medicare Fraud Strike Forces' that are deployed in 17 locations around the country, including Los Angeles, the New York metropolitan area, Miami, Chicago, Detroit, Texas and Louisiana. First established in 2007, the Strike Force teams have been investigating Medicare fraud in those areas where data suggests fraud may be occurring. They work in conjunction with the OIG and also with the Department of Justice, the F.B.I, the Offices of United States Attorneys, and local law enforcement agencies.

Regarding opioids, the Strike Forces look for instances where there is an excessive amount of opioids in a given community, then discovering if there is a legitimate reason for that reality. If they don't find that valid reason, then they look to see what other factors might indicate a crime is occurring. In the Appalachia cases, the health care professionals are accused of filling or writing prescriptions outside of their normal course of medical practices and dispensing the drugs with no legitimate medical reason for doing so. They are actually charged with illegally distributing Schedule 1 drugs, and their charges flow from standard drug enforcement laws. The Assistant Attorney General who filed the cases declared that the defendants would be treated like drug dealers if their actions are proven to be those of drug dealers.

Employers Remain on the Front Line of the Crisis

Medicare Part D beneficiaries aren't the only workers who can be negatively impacted by opioids, however. Employers in every industry should welcome the investigations and arrests because they shoulder much of the financial burden of the medical costs resulting from on-the-job injuries through their workers’ compensation insurance premiums. Not only is it expensive to maintain treatment for injured workers, but the employer also endures a loss of productivity if the injured party is a critical employee; the cost of any substitute worker, and even the cost to find and onboard a new worker if the injured person develops an opioid addiction and can't return to work.

Further, some employers may be more adversely affected than others:

Rural Employers

Appalachian employers may face higher than average odds of suffering economically due to the opioid crisis, too. A recent study revealed that workers in remote communities who sustain an on-the-job injury are 25% more likely to receive an opioid prescription for pain than their more urban counterparts. The Workers’ Compensation Research Institute (WCRI) reviewed more than one million post-injury pain medication prescriptions dated between October 2014 and September 2015 and found that two of every three injured folks in 'very rural' areas (<20,000 population) received at least one opioid prescription and one in three received two or more.

Small Business Employers

Other WCRI studies reveal additional challenges for owners of smaller companies, those with an annual payroll of less than $20 million. Injured workers in small businesses are also more likely to be prescribed an opioid for their injury-related pain. They're also more likely to receive more than one such prescription and to have those prescriptions last a longer term than do workers at companies with more employees.

Special Class Workers

Employers in the more labor-oriented industries are also more likely to experience opioid challenges in their injured workers' cases. People injured in mining, construction, and other heavy labor jobs are more likely to get an opioid prescription for the pain caused by that injury, as are those workers between the ages of 40 and 60 years.

Workers’ Compensation Burdens

Of course, all employers are at risk of economic losses caused by opioid-affected employees. The National Institute for Occupational Safety and Health (NIOSH) estimates that 95% of the people who died from a drug overdose in 2016 were people within the working age population - 15-64 years. That doesn't mean that all of those preceding injuries were on-the-job occurrences, but it does suggest that every employer should be alert to the possibility of an opioid challenge arising from any on-the-job injury and take precautions to reduce that likelihood. Those precautions would include maintaining a safe work environment to reduce the risk of injuries; maintaining a vigilant oversight of medical cases and drug prescriptions when injuries do occur and actively pursuing alternative treatments to opioids for ongoing pain management.

After 25 years of watching the opioid epidemic grow across the country, it is gratifying to see the federal government finally pursuing those people who are most likely the cause of much of the problem. The actions follow the CDC's 2016 restatement of its pain management protocols to reduce the volume of opioids as pain medications, so the actual number of opioid prescriptions is falling, too. Hopefully, the enhanced enforcement of drug laws as those relate to opioids will also reduce or eliminate the number of opioid deaths and workplace complications, so employers and their workers can avoid unnecessary losses even when on-the-job injuries do occur.

Are Employers Lagging on Their Opioid Response?

Despite the strong connection between workplace injuries and opioid addiction, a majority of the Nation's employers do not feel they are fully capable of dealing with the concern, says the National Safety Council (NSC). Data reveals that many employers remain hesitant to take the steps necessary to prevent or control the risks posed by a potential opioid problem in their workforce and, as a consequence, injured workers continue to suffer a higher than normal incidence rate of opioid addiction. However, by focusing their efforts on two primary objectives – drug use policies and health care oversight - corporate leadership can reduce both the likelihood of injury and the risk of potential opioid addiction if an on-the-job injury actually occurs.

The Status of Opioid Management in the Workplace

According to the NSC, three in four employers (75%) report work-based opioid challenges are negatively impacting their business, with more than a third (38%) experiencing poor performance or absenteeism, and almost a third (31%) suffering through an overdose or an on-the-job injury. In fact, workplace overdose deaths (by drugs or alcohol) have risen 25% in each of the past five years, another indicator that organizations are struggling to contribute all that they can to reduce (or at least stem) the tide of workplace-situated, addiction disasters.

A closer look at the NSC survey adds depth to the conclusion that employers are perplexed by the problem:

Significantly, their attention is not focused on the drug issue but instead, is focused on finding qualified applicants and providing them with sufficient benefits.
Of those that do have drug-related policies in place, only half are confident that those are appropriate to deal with any drug issue that arises.
Ironically, concerns about workers’ compensation costs, which are already high, do not also compel employers to try to reduce those costs by addressing their drivers: unsafe working conditions and on-the-job drug use, opioid or otherwise.

Despite years of data and information relating to the opioid crisis and its impact on America's workforce, it appears that the country's employers - the front line in many cases for injury and opioid addiction prevention - have not yet embraced the concern as their own or one they should be controlling.

Not New; Not Going Away

Ignoring the issue is not an appropriate response, however. At CompEx MSA, we've dedicated several articles over the past two years to the opioid concern, paying specific attention to its impact on the workers’ compensation sector.

Because on-the-job injuries are a common occurrence and frequently involve pain and pain management activities, doctors issue a high number of opioid prescriptions to injured workers for pain management.
Employers bear a significant financial burden for the crisis.
- According to the International Risk Management Institute (IRMI), companies paid over $50 billionfor opioid prescriptions for injured workers between 2007 and 2016. That statistic doesn't include the added costs of lost time, reduced productivity, or the costs of extended health care needed to manage not just the underlying injury but also the resulting opioid addiction (when those occur).
- Employers are also adding the expense of opioid treatment services to their employee's health care benefits, as a means of proactively keeping costs down.
Governments and agencies have stepped up their responses to the crisis by layering controls over the prescription of opioids that reduce their strength per pill, the number of pills available per fill, and the duration of the prescription.

Despite these efforts, the opioid challenge continues to take lives prematurely, to such an extent that it has single-handedly reduced the country's average life expectancy by 2.5 months (so far).

The Disconnect Needs Attention

These facts and figures about the prevalence and toxicity of the opioid concern across America's industrial complex should raise every employer's concern about their possibly less-than-comprehensive response to the issue. The best response would incorporate each of the three elements of the current concern to lay a sustainable and effective foundation for a comprehensive solution that:

addresses the employer's preferences (quality staff, appropriate benefits and cost controls);
reduces the number of injuries that occur at the workplace (preventing the opportunity to develop an opioid addiction), and
manages existing pain concerns with appropriate controls over prescribed opioids.

While maintaining the quality of staff and value of benefits is specific to each business, all businesses can benefit from addressing the other two legs of the triad, preventing injuries and properly caring for those that occur. In reality, attention to the latter two (prevention and care) also assists in the retention of the first (a high-quality staff).

Preventative Actions

Maintaining a safe workplace is perhaps the best route to an uninjured workforce, which is also key to keeping corporate costs in line. Most employers are careful to maintain the workplace safety guidelines established for their industry by the government; keeping those current is a critical component of managing a healthy workforce.

One element that is often missing from those 'workplace safety' standards, however, is a fully informed and enforced drug-free workplace policy. The NSC survey indicates that, although 86% of companies have such policies on their books, only 60% have procedures specifically requiring workers to report to their bosses their use of prescription opioids. Half of the survey respondents (49%) were not confident that their HR policies had sufficiently covered the issue of opioid misuse and use in the workplace. Further, even if the policies themselves were completely comprehensive about all opioid-related concerns, almost four in five (79%) employers did not believe that their workers would be able to identify the warning signs of a growing opioid dependency accurately.

Clearly, there are many policy and educational options available to employers today to improve how employers manage the use of drugs in the workplace that can escalate their risk of developing an opioid crisis within their staff. Accordingly, the NSC recommends that every organization review their existing documentation to ensure that it includes:

a clearly written statement regarding the use of drugs in the workplace;
policies that require workers to receive appropriate education about the issue (so they can determine for themselves if they have or are developing a problem), and
policies that require supervisors to receive training so they can ask about drug use and spot the signs and symptoms that might indicate an addiction is pending.

Remedial Actions

There are also actions employers can take after discovering an addiction in a worker, too, that can reduce overall costs and get the employee back on the job as quickly as possible.

They can ensure that their prescribers follow the opioid management guidelines set out by the Centers for Disease Control.
By working closely with insurers and pharmacies, employers can structure their health plans, benefits packages, and policies to keep an eye on pain management in general and the use of prescribed opioids in particular.
Tracking the data related to opioid prescriptions - dosage; the number of pills per fill, and the duration of the prescription - can flag if or when that situation is going off its course.
Not insignificantly, employers can offer education and support to workers who might need opioids because of a job-related injury, so they know what to watch for and where to get help.

Every day, over one hundred people die prematurely because of an opioid addiction or overdose. A significant percentage of those people began their journey to addiction because of a job-related injury. Employers, therefore, are in a singularly unique position to address the opioid crisis through better management of their organization and workforce. Ironically, by changing their corporate goals to prioritize safety and drug-use management, they will also achieve their ultimate goal: attracting and retaining a highly qualified – and drug-free, uninjured - staff. For thousands of workers across the country, it's becoming increasingly imperative that more employers adopt this reprioritization sooner rather than later.

Hidden in Plain Sight: America’s 'Benzo' Problem

Hidden behind America's disturbing opioid addiction and premature death rates is a related and equally troubling reality: the contribution to the crisis played by benzodiazepines in those numbers. When used appropriately, 'benzos' are perfectly good medications for the maladies they were designed to address. When used inappropriately and in conjunction with opioids, however, the drugs can drive individuals into an ever-spiraling drop into further addiction and destruction. Tragically, however, the over-use of benzos is tied to the same challenges posed by opioids, and now the country must also focus on this second front if it intends to reduce or eradicate the opioid (and its related benzodiazepine) epidemic.

Why Benzodiazepines?

Because of their effectiveness in treating alcohol withdrawal, anxiety, and sleep disorders, the various formulas of benzos are some of the most prescribed medications in the U.S. By triggering tranquilizing neurotransmitters in the brain, the benzodiazepine calms the nerves and provides relief for a variety of symptoms, including insomnia, seizures, panic attacks, and General Anxiety Disorder.

Not surprisingly, the drugs also come with side effects that can be disabling all by themselves, let alone when the benzo is used along with an opioid. Standard side effects of benzodiazepines include drowsiness, dizziness, confusion, trembling, and impaired coordination. In some people, the drugs may also impair vision and trigger depression. For users over 65 years, there may be a link to an increased risk of dementia.

Interactions with other drugs taken simultaneously with the benzodiazepine, especially antidepressants, can cause problems by enhancing the severity of the side effects. While not as likely as opioids to cause an overdose, benzos contribute to overdoses caused by other drugs (including opioids) by suppressing the central nervous system, which can lead to an inability to remain awake or to awaken, or the suppression of breathing sufficiently to cause suffocation.

Benzodiazepines go by several names, with the most recognized being Xanax, Librium, Klonopin, and Valium. Despite their value, there are a lot of factors that suggest that benzos should be used sparingly and with significant oversight.

Benzo's and Opioids

The co-prescribing of opioids and benzos has been concerning since the 1970's when medical systems first noticed the trend. Even back then, there was sufficient data to suggest that the dual-prescribing practices were increasing the risk of overdose and subsequent emergency medical interventions. Studies at the time noted that the benzos enhanced the effects of the opioids, which supported the conclusion that the combination of the two carried a high risk of abuse.

The value of the double-dosing, however, is hard to overlook. Opioids are prescribed to relieve pain from any cause and are frequently (although erroneously) prescribed to manage long-term pain. Many painful physical ailments also trigger fears and concerns in their sufferers, including concerns about their ability to pay for health care, return to work, or manage other aspects of their lives while living with the pain. While the opioids reduce the physical sensation of pain, the benzodiazepines reduce the anxiety that the pain has triggered.

The challenge is that using the two together exacerbates their individual threats and escalates the potential for misuse of both. A British Medical Journal study of 2,400 fatally overdosed veterans revealed that 49% had had dual prescriptions for the benzos and opioids. Further evaluation also pointed out that, in many people, the initial prescription by a physician of the two drugs together was the trigger for the higher risk of addiction and overdose.

The Impact of Benzo and Opioid Combinations

Even though medical research had raised concerns about the benzo-opioid threat back in the 1970s, healthcare professionals continued to prescribe the duo throughout the subsequent decades and even added a third class of drugs into the mix.

Overdose numbers grow ...

Between 1999 and 2014, the number of Americans prescribed both benzos and opioids grew by 250%, to about 4.3 million, and abuse of the combination has proven to be involved in 30% of all opioid overdoses, as of 2018.

As the number of benzo-specific prescriptions grew, so did the prescribing challenges they presented: the quantity of the drug per 100,000 adults grew from 1.1 kg to 3.6 kg Lorazepam equivalents, meaning patients were receiving a larger dose of the drug in each pill than they had received in previously prescribed pills. Also, prescription durations were extended to last much longer than the two-to-four week recommended duration. Patients were getting more drug volume over a longer period of time than ever before.

Follow-up studies have revealed that that people receiving the double prescriptions are ten times more likely to suffer a premature death caused by overdose than those who receive only opioids.

While the Workers’ Compensation system suffers

The opioid/benzo addiction situation impact on the workers’ compensation system can't be overestimated. Recently released statistics indicate:

that opioid users are more likely to become addicted even when they take the drug for a medically appropriate reason, such as an on-the-job injury, and
overlapping prescriptions of opioids and benzos at least some of the time can be signs of inappropriate prescribing or use or both.

Further, in the work world, circumstances related to the workplace or work-place injuries can accelerate the potential for an addiction to develop:

Psychosocial stress, such as concerns about letting coworkers down or a potential inability to return to work, can lead to increased reliance on benzodiazepines to relieve that anxiety, and on opioids to relieve pain, thereby facilitating the capacity to work.
Use of both drugs can also lead to additional injuries. Together, they can impede psychomotor capacities which can lead to falls or mishandling of machinery or tools.
The combined use of the drugs also contributes to higher healthcare costs as worker/patients attend more doctor visits and develop more disabilities.

Addressing the challenges

In 2016, the Centers for Disease Control (CDC) issued new directives that recommend avoiding prescribing benzodiazepines and opioids together. As a result, both prescriptions now carry 'black box' warning labels that clearly describe the dangers of using the two together. Injured workers should pay attention to those warnings and ask their doctors for alternatives to either or both medications as possible treatment for their particular injuries.

For employers, the rising concerns should justify enhanced attention to the treatments their injured workers are receiving. Any worker under the influence of either drug alone but especially the two together is at risk of further, potentially more damaging injury. Maintaining a drug-free workplace policy could alleviate the challenge while overseeing the use of any such drugs during the treatment of on-the-job injuries can curtail the possible development of addiction.

Additionally, it is in their best economic interest as well for business owners to retain vigilant over the concern. Not only do opioid prescriptions double the risk of developing a disability after one year, but Appellate courts have held that both insurers and employers can be held accountable for an injured worker's overdose death.

On-the-job injuries continue to represent a significant cost of doing business for employers across all industries. The challenges presented by the inappropriate use and combinations of prescription drugs to treat those injuries present additional economic concerns and should be managed with all the caution and attention they deserve. By keeping an eye on their injured workers, including the medications they are taking, today’s business owners can help to keep their costs down and their workforce healthy.

Can Cannabis Overthrow Opioids?

America's opioid epidemic continues to run rampant through communities across the country. As a primary medicine for pain relief, opioid medications have been the first medication choice for thousands of doctors and patients for over 20 years. However, too many of those Oxycontin™, Vicodin™, and Percocet™prescriptions have triggered addictions, which in turn drive subsequent heroin and fentanyl addictions, which in turn have resulted in thousands of unnecessary and premature deaths. While trying to stem that ugly tide, the scientific community is now looking at medical marijuana (also called cannabis) as a possible non-lethal response to the deadly opioid epidemic.

Why opioids?

After decades of ignoring the ramifications of chronic pain, in the early 1990s, the medical community determined to treat chronic pain with the same level of attention it provides for other physical conditions. At the time, the pharmaceutical industry was introducing new cancer drugs that were highly effective in treating the unrelenting pain caused by that disease. Using the medication to treat pain caused by other types of maladies seemed reasonable, and the initial trials for treating non-cancer-related pain were very successful. Further, because there were virtually no comparable options for managing chronic pain, many patients were acquiescent to their doctor's suggestion that they try the opioid option.

The challenge presented by opioids became apparent towards the end of the 1990s as more people became addicted to the drugs and were needing ever-higher dosages to maintain their reduced pain status. Doctors were comfortable modifying prescriptions to address those patient concerns, increasing the dose contained in each pill, increasing the number of pills prescribed and increasing the frequency of prescription refills.

The medical professionals had no reason to believe that their prescriptions were creating a health hazard, however. Despite an absence of scientific proof, the pharmaceutical companies had been telling physicians that opioids had a very low incidence of addiction so prescribing them early and often was both appropriate and advisable. Use of the drugs beyond the cancer ward soon became commonplace and, by 1999, over 85% of all opioid prescriptions were for non-cancer-related pain.

How addiction flows from opioid use

While then-existing science was confident that opioid medications could achieve their stated goal - the reduction of pain from any cause - it was not so aware of the impact of opioid medications on the human brain. Opioids work by reducing the perceived intensity of pain while also triggering a euphoric state in the user. The addiction develops when the patient seeks to maintain that euphoric state by ingesting higher dosages of the drugs as their effect wears off. Not insignificantly, many opioid users develop addictions inadvertently, trusting their doctor to have their best interests in mind when prescribing them. Constant exposure to opioid medications causes a persistent alteration in the brain's chemistry that compels users to consume higher dosages more often, and in greater volume than is necessary to simply control their pain.

Why not marijuana?

In short: marijuana has not been an option because it's illegal in the United States. The potential pain control properties of marijuana have been out of reach to both the general and medical public since 1937 when President FD Roosevelt made it illegal. There are several possible reasons why cannabis was out-lawed, including its effect on people who ingested or smoked it, and also perhaps because its parent plant, hemp, was a competitor for the country's cotton and paper industries. Eliminating access to hemp both eliminated marijuana as a medicine while also preserving the fortunes of the cotton industry.

Further, at the federal level, cannabis is classified as a Schedule I drug, which includes it in the class of drugs that have a "high potential for abuse" and "no currently accepted medical use." (Ironically, heroin - an illegal opioid comparable to legal opioids - is also a Schedule I drug.) As a result of this classification, there has been almost no credible recent American study on its effect on pain management.

Can marijuana stem the opioid crisis?

Despite the prohibition, the fact that 34 states have legalized cannabis in some form has recently opened the doors to more research on the impact of marijuana specifically on the opioid concern. Initial studies have shown that cannabis has had a positive effect on the opioid crisis in those states where it is legalized. In April 2018, the Journal of the American Medical Association(JAMA) reviewed the results of studies focused on how marijuana impacted the opioid crisis in particular:

One study learned that the number of daily doses per year of opioids in Medicare Part D participants dropped by 95% in states with legalized marijuana laws, especially those that had legalized cannabis for medicinal purposes.
Another study determined that opioid prescriptions to Medicaid patients dropped by almost 7% where cannabis was legal for both or either medical or recreational needs.

The JAMA editors cautioned against taking these limited studies as the final word on the effectiveness of cannabis as a response to the opioid epidemic, noting that the Medicare and Medicaid participants aren't representative of the nation's population as a whole. They encouraged more research to be done to identify exactly how (if at all) marijuana can replace opioids (thereby stemming the crisis) as a substitute for pain relief medication (assuming it works for that purpose).

Can marijuana ease pain?

Other countries that don’t have a marijuana prohibition, however, have been looking at marijuana as an option, especially in the last year.

In Israel, more than half of one study's cancer patients treated with cannabis reported 'significant' pain relief, and another study revealed that the medication reduced pain associated with Parkinson's disease in 27% of its subjects.
In Germany, more than half of chronic pain sufferers also reported a drop in pain by over 50%, although many also complained of increased dizziness and confusion.
Other health issues that responded positively to marijuana treatment include migraines (according to the European Academy of Neurology) and multiple sclerosis (Australia).

Further, as more American states legalize it for either or both medicinal and recreational purposes, more research is developing around discovering its health-related properties and the impact it's having on states that have already legalized it:

A San Diego physician and educator, Mark Wallace, M.D., reviewed several studies and noted many interesting developments:
- Reduction in opioid use was consistent across studies with no comparable rise in cannabis dependencies.
- The potential for cannabis abuse is decidedly less than that of other drugs, including heroin, nicotine, and cocaine.
- The preference modality for cannabis - taken orally, smoked, or used as a tincture - influences both the duration and the impact of the pain relief phenomenon.
- The relative purity of the effective cannabis chemicals, tetrahydrocannabinol (THC) and Cannabidiol (CBD), affects their potency and pain relief properties. Note also that these two chemicals operate differently from each other and users of one may not have the same response when using the other.
- Not insignificantly, Dr. Wallace advocates that anyone consuming marijuana for any purpose follow the same rule that is mandated for alcohol use: don't use and drive.
Taking another perspective, a different study revealed that Southern border states that had legalized medical marijuana had their violent crime rates drop by an average of 13%. The study noted that most of the cannabis consumed in the U.S. (at least until legalizations began) came from Mexico, where criminal cartels control its production and distribution. The research makes it clear that when demand for illegally produced marijuana goes down, so do its related criminal activities.

Reversing the marijuana prohibition

Taking a 'do-over' with the classification of marijuana is more difficult because of the complexity of America's drug policies and practices. However, even the country's Surgeon General, Jerome Adams is now advocating for its reclassification at least regarding the opportunity to study it for its medicinal properties. As those studies clarify how and when cannabis helps or hinders a health concern, they'll also provide the foundation for the arguments in support of (and against) reclassification and potentially frame a true path to victory in the nation’s battle against the opioid epidemic.

The Opioid Crisis: What Employers Can Do

Recently released Opioid Epidemic statistics from 2017 reveal that the country continues to convulse in the throes of this public health crisis. New laws aimed at addressing the issue are coming out of both state and federal sources, and even the tech industry is focusing more attention on using digital devices to prevent or reduce the need for opioid pain medications.

The most important participants in the fight against the epidemic, however, may well be the nation's employers, whose workers are most often the recipients of the drugs. By understanding how on-the-job injuries have driven the rise in opioid prescriptions, many employers can make subtle but significant changes in how they manage their worksites and injury responses so that their injured workers can recover in spite of or without the use of the addicting pain medications.

No End in Sight ...

Despite the recent legal and statutory developments offering enhanced guidance and support for opioid addiction sufferers, the number of victims continues to rise. In 2017, more than 72,000 Americans lost their lives to their opioid addiction, bringing the total estimate of premature deaths attributed to opioids to over 670,000 since 1999. (Compare that to the total 58,220 soldiers lost during the almost 20-year war in Viet Nam.)

Every day adds another 150 people to the opioid death total.

... But Multiple Avenues of Attack

Both governments and industries are focused on providing solutions:

In September of this year, U.S. Senate released its proposed Opioid Crisis Response Act (OCRA) of 2018, which attempts to coordinate the prevention and response efforts of several federal agencies. Suggested avenues of attack include reducing the supply of (legally produced) opioid medications; mandating stricter packaging and prescribing options that reduce the likelihood of over-prescribing, and the development of more effective treatment options and resources, to name just three.
Technology developers are also interested in turning the opioid tide. One common focus of several technology companies: utilizing electronic health records (EHRs) to track the prescription and use of opioid-based medicines. Data collected at several points of a patient's treatment cycle can help track how each individual patient is utilizing those medications and, in some cases, whether they needed an opioid prescription in the first place.
Approaching the crisis from a different angle are the nation's insurers, who are picking up the tab for millions of dollars of both injury and addiction treatment activities. Further, those metrics indicate that American's employers may hold at least one key to truly reducing the number of opioid addicts and the consequent suffering of both them and their communities.

While it is almost impossible to identify with certainty the percentage of opioid-affected injured workers that make up the whole of the opioid-affected population, at least one group puts that number at 60 percent. The International Risk Management Institute (IRMI) estimates that employers spent more than $25 billion on opioid prescriptions in 2007 and extrapolates that sum out to the equivalent of over $50 billion in 2016. If that total was reduced by even a small percentage - meaning that if the number of workplace injuries went down and/or the number of opioid prescriptions for workplace injuries went down - then the number of opioid addictions should also fall correspondingly.

Ergo, the IRMI suggests that America's employers, as a group, could do more to reduce the number of both injured and addicted workers, a premise which begs the question: How do they do that?

What Employers Can Do to Prevent Opioid Use and Abuse

Considering the strong connection between a boss and an employee, there are several opportunities within that relationship where the employer can avoid the risk of an employee's potential future opioid addiction:

1. Prevent injuries in the first place

Even with strong workplace safety rules in place, many employers fail to maintain those high standards throughout their worksite or shop. Injuries caused by over-exertion, falls, and inadvertent contact with machinery are often completely avoidable, requiring only improved oversight and attention to safety details. Engaging workers in the safety-related conversation also goes a long way to raising awareness about dangers and preventative actions.

2. After an injury has occurred, be alert to corresponding opioid prescriptions

Not every workplace injury requires an opioid prescription and not every worker should get one, regardless of the extent of their injury. The Traveler's Companies devised an "Early Severity Predictor" algorithm to measure the likelihood of an injured person developing chronic pain, one of the main drivers of opioid addiction. According to Traveler's, the algorithm identifies the types of injuries that might predispose patients to develop chronic pain, such as lower-back pain (#1), knee and shoulder injuries. It also tracks physicians who are more likely to prescribe opioids.

By identifying these 'sensitive' workers early in their treatment phase and before extensive medical interventions are carried out, physicians can prescribe non-opioid pain relief and avoid the risk of opioid addiction altogether.

3. Monitor pain treatment protocols

Despite the best of intentions, injured workers frequently require pain medications and, in many cases, the best medication for the purpose is an opioid. In these cases, employers can use their on-staff or insurer-provided Case Managers to monitor the patient's opioid use and deflect them if they indicate a growing addiction. These health professionals are trained to evaluate the impact of opioid use on recovery activities and to identify alternatives that will both address the pain concern while better facilitating the recovery effort.

Research reveals that investments in Nurse Case Managers in workers’ compensation cases resulted in reductions in worker treatment costs.

4. Follow all recommended protocols

There are many other recommendations for employers who are involved in the medical cases of their injured employees, all of which are aimed at reducing the opportunity for injury, maintaining vigilance over treatment activities and actively seeking alternatives to opioids when appropriate. Perhaps the most critical recommendation: make sure that treating physicians stick to the Opioid Prescribing Guidelines as issued by the American College of Occupational and Environmental Medicine:

Obtain informed consent before prescribing an opioid for pain relief by ensuring the patient understand the reasons for the prescription and the dangers posed by the medication.
Obtain a full medical history to alert the medical professional to potential 'sensitivities' that might predispose the patient to addictive behaviors. Update the historical screening if the prescription is to last beyond two weeks.
Avoid co-prescribing benzodiazepines with opioids.
Perform routine urine monitoring.
Cease opioid usage as soon as the patient achieves a meaningful functional recovery.

America's battle against opioid addiction is ongoing and requires the attention and effort of every group that is, or could possibly be, affected by it. America's employers are apparently on the front lines of the battle field and, by accepting that challenge and making incremental efforts to reduce its impact in their offices and worksites, they can play a big part in how that battle will eventually be won.

Governments and Opioids

Across the country, governments of all types are looking at how the opioid crisis is affecting their regions and communities. Both the federal Administration and Congress have issued new rules at the national level that reflect their cognizance of the concern and its causes. States, too, are addressing how their systems manage the crisis, including their workers’ compensation systems. The rising tide of new laws and intervention opportunities suggest that optimism is an appropriate response to how the nation is dealing with this epidemic. In Washington, and despite the polarizing election cycle, progress is being made:

The FDA

Risk Evaluation and Mitigation Strategy

On September 18, 2018, the Food and Drug Administration approved the Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS) as a control measure to curb the abuse, addiction, overdose, and premature death rates caused by prescription opioid pain relievers. Pursuant to the REMS, all healthcare providers (HCP's), including nurses and pharmacists, will be trained on the safe use of opioids to treat both acute and chronic pain to ensure they can select the appropriate product for the patient and provide appropriate oversight during its use. Drug companies that have approved opioid analgesics must offer accredited continuing education on the subject based on the agency's Education Blueprint for Healthcare Providers Involved in the Treatment and Monitoring of Patients with Pain.

Devices to Prevent and Treat Opioid Use Disorder (OUD)

The FDA is also taking a proactive position by issuing a challenge to the healthcare community to develop devices and tools to fight the opioid problem. In June 2018, the agency began accepting applications for the development of medical devices that can prevent or treat the addiction to opioids. "Devices" can be diagnostic tools or even digital health technologies (mobile apps or other soft- or hardware). When issuing the challenge, the FDA acknowledged that opioid addiction can arise as an unintended consequence to appropriate medical care and that the medical community is, therefore, an appropriate resource from which to seek answers to the problem. The challenge period ended on September 30, and the agency will announce its selections in November.

CMS

Help for MOMs

Pregnant women and new moms aren't immune to the opioid threat, so CMS has introduced a Maternal Opioid Misuse model (MOM) to improve their care and treatment options. Moving forward, maternally-minded Medicaid beneficiaries will receive coordinated care across service lines, including prenatal, neonatal, and maternal care plus opioid abuse and addiction services. Aimed at state Medicaid agencies, especially those in rural areas, the program plans to ensure front-line providers have the tools they need to address the needs of this very vulnerable population.

From Congress

Not to be outdone, the House managed to pass approximately 60 opioid-related bills this past summer, some of which also survived their trip through the Senate and were passed by the full Congress on October 4th. Most notably:

Funding for the above-referenced HCP training was approved, as was additional funding to expand state-based prescription drug monitoring programs.
Congress also now mandates that the FDA use evidence-based guidelines for the "indication-specific" acute pain treatment. The bill underscores the importance of using the guidelines to inform clinical decision-making and not to tacitly empower healthcare professionals to limit, restrict, deny or delay supports when those are needed. Further, CMS must also publish a guideline for treating Medicare patients with opioids.
Congress expands the authority of the National Institutes of Health (NIH) to divert research funds toward rapid responses to emerging public health threats, including research on non-opioid alternatives to address the current opioid public health crisis.
CMS is also now responsible for identifying 'outlier' opioid prescribers based on their health care specialty and geographic location. This directive may stem from statistics revealing that the highest levels of opioid issues - abuse, addiction, and premature deaths - occur in the South and Appalachia regions.

From the States

Many of the individual states are also addressing the concern as it manifests within their borders, and many of those bills address opioids in the workers’ compensation sector. According to a report issued by the National Council on Compensation Insurance (NCCI), in the first six months of 2018, more than 800 state and federal bills were introduced, and 76 of those had become law by the end of June. Additionally, there were 197 workers’ compensation-specific regulations promulgated, and 83 of those were adopted. Medical fee schedules and treatment guidelines including those applicable to opioids topped the list of subjects addressed in the new rules.

Almost every state worked on issues involving prescription drugs, and the topics ranged across the concern from drug formularies and compound drugs, to prescription drug fees and costs to drug rehabilitation programs and repackaged drugs.

· States that Passed Laws

Twenty states looked at the opioid concern specifically through the workers’ compensation lens, and four passed laws affecting that industry in those jurisdictions.

Arizona's SB 1111 modifies that state's Arizona Opioid Epidemic Act by limiting the duration of a first-time opioid prescription to five days, so long as the prescription is presented within 72 hours after the injured worker first sought medical treatment.
Hawaii's SB 2244 requires healthcare workers in the WC industry to mandate an informed consent process when an opioid prescription is an option for a "qualified" injured worker. Qualified workers are those who:
- would require the medicine to last more than three months; or
- receive co-occurring prescriptions for both opioids and benzodiazepines, in which case the concurrent prescriptions must be limited to seven days; or
- the prescribed does exceed 90 morphine equivalent doses (MEDs).
Indiana now prohibits reimbursement for "N" drugs (not recommended in the 'Official Disability Guidelines' (ODG) Workers’ Compensation Drug Formulary Appendix A) in workers’ compensation cases unless mitigating circumstances occur and the employer approves the treatment.
Kentucky's House Bill 2 now requires that the workers’ compensation healthcare providers adopt a pharmaceutical formulary and treatment guidelines with managing chronic pain and opioid use.

· States Still Working on it ....

Many states are still in the process of refining their responses to opioid addiction.

In Pennsylvania, Senate Bill 936 would generate a schedule of prescription medications suitable for reimbursement by workers’ compensation programs. The bill addresses two concerns: the prevalence of opioids in two-thirds of all pain-related workers’ compensation cases, and the potential for fraud when pharmacists and healthcare prescribers have unfettered authority to dish out the addicting medications.
In Ohio, the Bureau of Workers’ Compensation (BWC) made significant changes to its processes and systems and managed to drop the number of injured workers who received opioids by 51 percent, and the number of opioid-addicted workers by 50 percent. Ohio is unique because its workers’ compensation system uses a single, state-funded carrier; the BWC, therefore, holds sway over all treatments for all injured workers in the state.

In June, Ohio's governor John Kasich issued new chronic pain prescribing rules that introduce "safety checkpoints" at periodic stages in the recovery phase of opioid-using patients, including injured worker patients.

Looking Beyond Opioids

In addition to getting their in-border opioid problems under control, many states are also looking for alternatives to opioids to avoid the problem altogether in the future. For some states, the most favorable non-opioid option for treating pain is marijuana.

In Illinois, the Alternative to Opioids Act would open the state's existing medical marijuana pilot program to millions of pain sufferers.
In Georgia, intractable pain is now legally one of the conditions that justifies a medical marijuana card, and a new proposal would permit cannabis oil for use as an opioid alternative.
In New York, the Department of Health is developing an amendment to add opioid use as a 'qualifying condition' for justified medical marijuana use.

Progress is Being Made, Not a Moment Too Soon ...

Although the opioid epidemic continues to rage in all corners of the country, the steps being taken now by its governing bodies represent their acknowledgment that it won't abate without interventions, and that not just any intervention will suffice to reduce its crisis. As individual states adopt tighter controls over opioid access and widen their perspectives about possible opioid alternatives, the chances for the country to ultimately overcome the epidemic look brighter every day.

Opioids and America’s Workers’ Compensation System

As more entities study the impact of America's opioid crisis, reports are emerging that reveal a tragic tale unfolding for not just the addicts, but also the communities in which they live. The cost of the epidemic is born across several segments of society, and, because those segments also impact non-opioid affected people, essentially, everyone pays for the damage that is being caused by this insidious affliction. Businesses, in particular, are paying more for the care of injured workers who are prescribed, then become addicted to opioids, and they are paying for longer recovery periods, too.

In this second post of a four-part series on the opioid issue, CompEx MSA hopes to share the details about the size of the challenge it poses, especially in the workers’ compensation industry. Future posts will offer some hopeful notes about how its ugly tide may be turning. In addition, research has suggested some possible responses employers might adopt as they contemplate how the crisis, now or in the future, might negatively impact their enterprise and how they might avoid the consequential costs.

Workers’ Comp, On-the-job Injuries and Opioid Addiction

Injuries at work are not news. According to the National Safety Council, somewhere in America, a worker is injured on the jobevery seven seconds. That statistic extrapolates out to 510 injuries per hour; 12,300 a day; 86,500 per week and over 4,500,000 injuries per year. For employers, the lost time due to on-the-job injuries totals over 100,000,000 production days annually. Many, if not most, of those injuries will require some form of pain-controlling medication, and for those, since the mid-1990's, opioids have been the pain-reliever of choice by countless physicians. Employers are also responsible for covering the cost of these medications, too.

Further, not every injury is comparable to all injuries and not every injury requires the level of pain relief provided by an opioid medication. Those workers in the most dangerous occupations often suffer more significant injuries and require higher levels of pain relief for longer periods than workers who don't work in those riskier jobs. These three common types of injuries can occur at almost any worksite, while the more serious injuries occur more frequently in those occupations that expose workers to bigger risks and more significant injuries.

Typical Types of Workplace Injuries:

Overexertion is involved in one in three work-related injuries (34%). People lift heavy objects that overtax their capacity, or they lift them incorrectly, magnifying the risk of injury. Repetitive motions are also part of this category.
Inadvertent contact with objects is also fairly common, occurring in approximately one in every four workplace injuries. Being struck, caught, compressed or crushed by moving equipment such as forklifts or heavy objects stored overhead can cause a range of injuries from slight scratches to potentially fatal bodily trauma.
Trips, slips, and falls are also quite common, occurring in 25% of all workplace injuries. Workers slip on slick surfaces or on detritus littering the floor; trip over chairs, ladders, or other items they don't see, or fall down stairs, over chairs or other obstacles.

The injuries suffered in these types of worksite incidents are rarely life-threatening but may require pain medication during the acute and recovery phases.

Riskiest Occupations

Certain types of work create more significant risks of worse injuries simply by their very nature:

Service workers

Police officersand firefightersobviously risk personal injury simply by doing their jobs every day. For police people, the most common work-related injuries are soft-tissue sprains generated by wrestling with a non-compliant offender. For firefighters, more than half (57%) of their workplace injuries - which are also sprains and strains - occur at non-fireground sites. In 2016, more than 62,000 American firefighters reported on-the-job injuries (24,000+ were at the site of an active fire).

Construction Workers

In 2016, there were more than 77,000 construction-related injuries, and more than 11,000 of those were back injuries. Hand injuries accounted for another 1,000+ injuries. Further, almost all construction workers will report at least one job-related injury in their career, making construction the industry with the most number of workplace injuries that require medical attention and (potentially) pain relief medication. (Note, too, that 5,190 construction workers lost their liveson the job in 2016, which represents more than 20% of all work-related fatalities that year. However, the construction industry employs only 4% of the entire U.S. workforce.)

America's Top Ten Most Dangerous Jobs

Several industries are responsible for most of America's on-the-job injuries, and most, if not all non-fatal injuries usually require some level of pain management during both the acute and recovery phases:

From tenth to first, these are America's most dangerous jobs:

Grounds maintenance workers;
Supervisors of construction workers;
Agricultural workers, including farmers and ranchers;
Truck drivers and other transport workers;
Structural iron and steel workers;
Waste material collections workers;
Roofers;
Aircraft pilots and flight engineers;
The fishing industry, and
Loggers.

Work-Related Injuries and Opioid Prescriptions

Recent studies suggest that workers with large employer health care coveragecomprise more than one-third of all opioid prescriptions. Of those, workers aged 55 to 64 had the highest number of opioid prescriptions in 2016, consuming 22% of all such prescriptions compared to only 12% for younger adults. Women get more prescriptions (15%) compared to men (12%), and the workers in the South get the drugs at a higher rate (15%) than those in the West (12%) or the Northeast (11%).

Are Opioids Worth the Risk (or the Expense)?

The question for employers is whether opioid medicines are actually helping them get their workers back on the job sooner than they would be without the opioid (or its risks). At least one recent study says no.

Researchers working through the auspices of Princeton Universitydetermined that opioid medications received by workers cost their employers an average of three times as much as non-opioid pain medications and that those workers treated with the opioids also stayed off the job for longer periods than their non-opioid-treated colleagues. After controlling their data for worker age, industry and regional variables, the study (which was focused on work-related low-back pain) noted that it produced at least some evidence of an overuse of opioids over longer terms, and that some workers would or could return to work faster if they had been given non-opioid pain medications in the first place.

Other studies support those conclusions. In a 2017 Blue Cross Blue Shield (BCBS) study:

Worker/patients who filled at least one high dose prescription for opioids had 'much' higher rates of developing 'opioid use disorder' (addiction) than those who took lower doses;
Women over 45 had a higher rate of developing opioid use disorder than did men;
Longer-term opioid use and use disorders develop at the highest rates in the South and Appalachian regions, and
Opioid prescriptions that for chronic conditions are twice as likely to extend past six weeks and three times as likely to trigger the 'high-dose' threshold that frequently leads to opioid use disorder.

Further, those people who develop opioid use disorder are also most likely to develop a heroin addictionafter their opioid prescriptions (and opportunities for prescriptions) expire. Those people who become addicted to opioid pain relievers are 40 times more likely to turn to heroin when their opioid supply dries up.

There are several conclusions that can be drawn from the research:

Opioids are often not the best option for pain management of work-related injuries;
Employers whose workers are prescribed opioids pay more for those medications for longer periods than they do for workers who aren't given the opioid drugs, and
Employers with workers on opioid-based protocols usually wait longer (and pay more) for those employees to return to work if they recover sufficiently from their injury to return at all.

Not only do America's employers lose over 100,000,000 production workdays annually because of work-related injuries, but they also pay exorbitantly for the opioid pain medications used to treat those injuries, too, through higher costs made over longer periods of time. Recent studies appear to indicate that there are only a few benefits to opioid prescriptions for injured workers and that those are decidedly off-set by their drawbacks and costs.

In our next Opioid Epidemic post, we will look at what governments around the country are doing to address the challenge.

America’s Opioid Epidemic: How it Impacts Work Comp

CompEx MSA is proud to provide this primer series on America's opioid epidemic to help its colleagues and fellow community members be more aware of the problem and mindful of what they can do to avoid contributing to it in the future.

Part One: What it is and how it got started

The 'opioid epidemic' is at the top of every day's news cycle it seems, but many people are baffled about what it is and what it might mean for them and their community. In the workers’ compensation (WC) industry, the concern has more significant ramifications as people who have been injured on the job continue to receive prescriptions for opioids as pain relief medication. The short- and long-term impact of those prescriptions can be extreme, from premature death to lingering addiction and trauma years after the injury fades into memory.

To avoid unnecessary grief due to the consequences of opioid addiction flowing from a WC claim, industry participants who are involved in MSA account establishment and management should understand how the epidemic got started, how it's being managed today, and what they can do to curtail its future growth.

What is an Opioid?

'Opioids' are medications prescribed to relieve pain. The word refers to any substance that has an impact on those parts of the brain that control pain, reward, and addictive behaviors. Opioids provide short-term relief for the cravings that originate in those brain sectors.

The word 'opioid' is a derivation of 'opium,' the addictive milk produced by the opium poppy. Drugs derived from an opium base are called 'opiates.' For centuries, people have harvested opiate milk for both medicinal and recreational use, and its source poppies are currently legally grown in India, Australia, and Turkey. Well-known street and prescription opiates include morphine (also sold as MS Contin and Kadian), heroin, and codeine.

Pharmaceutical science has replicated the impact of opiates on the brain using foundational sources that are not opium or opium-derived. However, these substances mimic an opiate's effect on the brain and cause the same response in the body as the opium-based substances. As a group, they are known as 'opioids,' and individually, they are known as hydrocodone (also sold as Vicodin and Hycondan); oxycodone (Oxycontin and Percoset), hydromorphone (Dilaudid), and fentanyl (Duragesic).

Note that while all opiates are also opioids, not all opioids are also opiates.

Why are Opioids so Popular?

Opioids generate a euphoric sense of well-being that supersedes any pain or anxiety the sufferer may be feeling. When used correctly, they provide temporary relief from many of life's struggles, including pain caused by on-the-job injuries. However, opioids also pose risks even if they are not abused. High doses of opioids can trigger a heart attack or respiratory arrest.

Challenges to opioids arise when people stay on them longer than is advised, become increasingly tolerant of them (thus requiring a higher dosage to achieve the same effect), or develop a full-blown addiction to the sensation generated by taking the drug. In many cases that result in overdoses and premature deaths, the patients have been taking some form of opioid (natural or synthetic) in too high of a dose for too long of a time.

How did the epidemic start?

Tragically, the epidemic is the consequence of a convergence of well-intended but misguided assertionsthat opioid-based pain medications were a reasonable response to undertreated pain and could be safely used to relieve pain throughout the course of treatment for disease or injury.

Throughout most of the 20th Century, treatment for pain from any source was non-existent or underutilized. In response, in the 1990's, many scientific experts queried why opioids were not used more for that purpose. At the time, opioids were limited to use in cancer cases where they provided successful relief for malignant cancer pain. Without sufficient research on whether non-malignant pain was appropriate for opioid treatment, many in the medical community presumed that the drug's success in the oncology field would be replicated in the general pain-management field as well.

Subsequently, as more healthcare agencies encouraged reducing pain as a standard aspect of medical care, more physicians were encouraged to adopt opioids as a preferred medication for pain management. Drug companies began developing long-lasting or delayed-release versions (OxyContin) to add 'value' to the opioid pain management protocol. Between 1997 and 2002, the number of OxyContin prescriptions rose from 670,000 to over six million. Since 2003, both the number of opioid prescriptions and the number of related premature deaths have quadrupled. More than 33,000 people died of an opioid overdose in 2015; more than two million more were diagnosed as addicted to the drugs, and the cost to address the epidemic was estimated to be over $78 billion per year.

Adding to the tragedy: as doctors reduced their opioid prescriptions and/or patients completed their pain treatment protocols, those who remained addicted to the opioid sought its effect from street drugs or illegally sourced prescription drugs. Often heroin was both cheaper and easier to access so those people who had become dependent on the prescription medication were able to transition onto a street version without too much difficulty. Now, the incidence of addiction among users of both prescription and non-prescription opioids is high and growing.

Workers’ Compensation Cases and Opioids

Next time, we'll look at how the opioid epidemic has impacted the worker compensation industry. Recent research indicates that, even in the face of these challenging statistics, more than two-thirds of currently approved MSAs that include medications also include opioids, and one in five of those include two different forms of the drug. When the costs to maintain that coverage (both human and economic) span years or even decades, the long-term impact on both the worker and the funders of those MSA accounts can be devastating.

Check in for that post in September.

Evolving CMS Controls on Opioid Prescriptions

Despite notable guidance available in other arenas, more than two thirds (69.4%) of California's submitted WCMSA proposals include extended funding for opioid medications. The statistic is startling considering that Medicare itself does not recommend using opioids for long-term use or chronic pain. The National Alliance of Medicare Set-Aside Professionals (NAMSAP) and the National Council of Self-Insurers (NCSI) have joined to review the situation and identify how the MSA industry can collectively address the nation's opioid crisis, and new opioid prescribing guidelines recently issued by CMS are designed to address the challenge, too.

Managing America's Opioid Crisis

Since 1999, the Centers for Medicare and Medicaid Services (CMS) have been tracking the growing opioid addiction crisis. Deaths caused by opioid overdoses have risen alarmingly in number, accounting for over 500,000 premature deaths between 2000 and 2014. Further, the number of prescription overdoses quadrupledin that timeframe, indicating that those using and abusing the drugs are frequently getting them from a legitimate healthcare professional and not a black-market street dealer.

From the CMS perspective, gaining control over the epidemic within the CMS beneficiary population has been challenging. CMS oversees the funding of healthcare servicesfor millions of Americans, including paying for the services of hundreds of thousands of healthcare professionals and their clinics, labs, and supporting facilities. CMS patients, including both Medicare and Medicaid beneficiaries, access CMS services through many portals, depending on their status and/or health condition. These various CMS systems have each grown independently of the others over time, so the rules governing one do not necessarily comport with the regulations of another. The resulting complicated matrix of directives, rules, and guidances makes it difficult to structure comprehensive regulations to govern any one issue (such as opioid management) that encompass and apply to all CMS departments. The opioid epidemic is now shining a light on how significant a challenge that complicated matrix poses to both CMS and its constituents.

NAMSAP and NCSI Highlight a Conflict

At its June 2018 annual conference, leadership for both entities presented data reflecting the apparent conflict in CMS documentation regarding opioid management. According to NAMSAP president Rita Wilson, the review policy for WCMSAs requires future, MSA-funded opioid prescriptions to match the dosage and frequency of orders posted within six to 12 months of the MSA submission date. However, Medicare Part D guidelines set out different directives, as do the evidence-based guidelines issued by the CDC. As the WCMSA guidelines stand now, the prescribers treating WCMSA beneficiaries are required to maintain opioid dosages and frequencies at unnecessarily high levels if they want their patient's WCMSA submission to pass the review process.

Opioid Management in Medicare Part D

In 2013, CMS issued a directive that shifted attention to the opioid concernto Part D sponsors. From that point in time, Part D sponsors were expected to identify and address opioid medication overutilization by implementing claims controls, signifying high-risk patient populations, and modifying case management practices to stem the flow of opioids into their patient base. The CMS then launched the "Overutilization Monitoring System" (OMS) so it could oversee compliance by those sponsors with the new directives. Although progress is slow, data reveals that opioid "overutilization" numbers are decreasing in the Medicare Part D population.

Notably, CMS is revising its Part D guidelines again in 2019 to continue improvements in that department. In April, CMS released its proposal for new guidelines(specifically directed at high-dose opioid prescriptions) to be included in its 2019 Medicare Advantage and Part D Rate Announcement and Call Letter. Those revisions include the expectation that all Part D sponsors will limit to seven days an opioid prescription for acute pain, and the expansion of the OMS to integrate it with the standards established by the 2016 Comprehensive Addiction and Recovery Act(CARA).

Opioid Management per the CDC

Also converse to the WCMSA policy is the CDC's guidance on opioid management, which balances the need for controlling chronic pain with the concurrent need to prevent opioid misuse disorder. Prescribers following the CDC recommendations will access opioid therapy only after other, less addictive therapies have been proven ineffective, and will start with a low dose, immediate-release opioid medication for a specified duration after discussing the challenge presented by opioid use to the patient. Further, physicians are encouraged to pursue regular reassessments over time to determine the continuing validity of the opioid as the preferred medication and to test for evidence of excessive opioid use. If or when they suspect an addiction has occurred despite their cautious use of the drug, the CDC also supports a referral for treatment of an opioid use disorder as early as possible. A subsequent survey indicated that almost 90 percent of surveyed doctors welcomed and would use the guidance.

California's Stats are Troubling - and Revealing

Despite the national awareness of the opioid problem and the various strategies in place to combat it, the California Workers Compensation Institute (CWCI) surveyreveals that it remains almost intractable, at least in that state's workers’ compensation cases. Released in October 2017 by the CWCI, the study paints a dismal picture of the future for more than two-thirds of the state's WCMSA beneficiaries. The group compared the statistics of WCMSA submissions in 2015 and 2016 with those of a closed control group consisting of similar cases with similar injuries. The data is disturbing:

Over 69 percent (69.4) of all California WCMSA's included funding for opioids specifically, more than double the volume of any other class of drugs;
Many of those opioid prescriptions were in significantly higher dosages than those in the closed cases, averaging 45 times the "morphine milligram equivalent" (MMEs) of the dosage found in the control group, and
the WCMSA cases proposed funding for the equivalent of 54.7 "morphine equivalents" (MEDs) per day for an average of 20.9 years.

Not surprisingly, two popular opioid brands, Norco and Vicodin, were prescribed in almost half the WCMSA cases (44 percent), and medication funding itself (for all medications) totaled almost half (47.6 percent) of all the included WCMSA submissions.

CMS is working hard to curb the opioid crisis within its Part D population, but the California survey indicates that its Workers’ Compensation sector is equally in need of that attention, if not more so. With the assistance of the CDC’s nuanced approach to the concern, CMS would do well to overhaul the WCMSA review rules to reduce or eliminate the egregious levels of opioids that continue to plague the WCMSA industry.