December 15, 2017

Nikki Wilson: Stepping Up to Reduce Risks of Opioid Misuse and Overdose

By Nikki Wilson, Director of Pharmacy Product Development, Coventry Workers’ Comp Services

Nikki WilsonThe worst drug overdose crisis in U.S. history is driving policymakers to declare opioid-use disorder a national emergency and to seek new ways to battle the epidemic. The workers’ compensation industry must likewise step up efforts to protect patients and better understand how the No. 1 drug class among injured workers affects return-to-work and quality of life.

We should start by recognizing the best methods to prevent overdose as well as to manage injured workers taking opioids. The next step is to attack the source of the problem by further constricting the flow of opioids going to injured workers. Last, we must find new, more effective ways to help injured workers recover from the negative effects of opioid misuse and, ultimately, return to productivity and good health.

Here we will examine opioid misuse and some of the steps we can take to avoid it. In our next installment, we will discuss protocols around prescribing and possible new templates for successful return-to-work programs.

The Costs — From Health to Families to Business
Opioid misuse is costly in every sense. Beyond the consequences for a person’s health, the levy on a family can be devastating. These assaults on the wellbeing of individuals and families also feed broader societal harms. In workers’ comp, the fallout from opioid misuse emerges in additional forms such as lost productivity, damage to workplace morale, and the expense of hospitalization and other treatments.

Coventry LS Opioid 42 DeathsThe numbers are akin to battlefield statistics in an unceasing war — grim, familiar, and yet hard to fathom:

  • Drug overdose has overtaken automobile accidents to become the leading cause of accidental death among U.S. adults.
  • More than one third of the nation’s adults reported using a prescription opioid in 2015, according to the National Institute on Drug Abuse.
  • Prescribers are writing fewer opioid scripts than in recent years though the number is still triple what it was in 1999.
  • Prescription opioids are involved in roughly 42 deaths per day, according to the Centers for Disease Control & Prevention (CDC). This already sobering number excludes pharmaceutical fentanyl, tramadol, and synthetic opioids other than methadone because statistics on fatal overdoses do not delineate between pharmaceutical fentanyl and illicit fentanyl. Counting synthetics, the daily mortality rate involving opioid analgesics jumps to 62. Over all, including both legal and illicit opioids, more than 90 people die every day in the U.S. from overdose.

The fallout from the crisis can be seen in other ways. Prescription opioid misuse siphoned $78.5 billion from the U.S. economy in 2013, reports the National Center for Injury Prevention and Control, in its most recent findings. More than one third — $28.9 billion — reflects increased costs for health care and substance-use treatment. About one quarter of the cost falls on the public sector in the form of health care, substance-use treatment and criminal justice spending.

The severity of the problem prompted the White House to proclaim opioid misuse a national emergency. This latest salvo could inject more federal dollars into the fight and waive some regulations in order to give policy makers and caregivers more options in squaring off against the epidemic.

Overdose: The Ultimate Threat
The gravest risk from misusing opioids remains fatal overdose. This occurs when an opioid slows breathing to the point it ceases. The CDC reports that nearly half of the nation’s fatal opioid overdoses involve a prescription analgesic and that deadly overdoses involving a prescribed opioid have quadrupled since 1999. But even after seeing such large increases, the industry must consider what is most relevant to injured workers. For example, headlines in the mainstream press have rightly called attention to a shocking rise in deaths tied to fentanyl. From 2014 to 2015, fatal overdoses caused by this synthetic opioid surged more than 70%. But data gathered by the CDC reveal that the jump appears linked to illicit fentanyl and not to an increase in fentanyl prescriptions. So while fentanyl remains an important concern, there are other steps the industry can take to try to curb misuse. We have to work more effectively with prescribers and caregivers to disrupt a cycle of repeat overdoses. Among the overall U.S. population, nine in 10 people who survive an overdose continue to be prescribed opioids — usually by the same prescriber. Depending on the dose, eight to 17 percent of those who experience a nonfatal overdose will overdose again.

Coventry LS Opioid 9in10If an overdose does occur, first-responders often will administer the overdose-reversal agent naloxone. That is followed by further treatment at a hospital. Beyond the immediate steps following an overdose, or even if a prescriber suspects there is a risk of one occurring, clinicians have a number of options for care. These include making a referral to a treatment program, medication-assisted therapy, a weaning program, and recommending alternatives to opioids. Prescribers can refer to the Diagnostic and Statistical Manual of Mental Disorders, or DSM–5, for diagnosis criteria around substance-use disorder or guidelines for using medicine such as methadone or buprenorphine.

The characteristics of the opioids themselves are important. Long-acting or extended-release formulations can carry higher risk and an increase in a patient’s dosage poses an obvious threat. Doctors also must consider whether a patient is opioid tolerant. The U.S. Food & Drug Administration defines opioid tolerance as taking 60 mg of oral morphine or its equivalent for seven days or more during the immediately preceding days. Guidelines indicate prescribers should not order extended-release or long-acting formulations for patients who have never taken opioids; this includes transdermal fentanyl.

As Always, Comorbidities Also Play a Role
Like a drug’s formulation, the patient’s complete medication regimen and comorbid conditions can shape his or her response. Doctors should exercise extreme caution when prescribing opioids for patients taking other central nervous system depressants such as sedative hypnotics (sleep aids), skeletal muscle relaxants, benzodiazepines, antihistamines, and illicit substances as well as alcohol or tobacco. Patients facing mental health conditions, untreated sleep disorders such as sleep apnea, and pulmonary disease also merit particular caution.

The CDC identifies men, middle-aged adults, people who live in rural areas, whites and American Indians or Alaskan Natives, and residents of states with higher sales per person and more non-medical use of prescription painkillers as those facing greater threat of overdose.

Deliberate Action Can Protect Patients
Asking the fundamental question of whether a patient even needs opioids can help prescribers sidestep an array of complications. Opioids are not recommended to treat pain that is not severe. ACOEM reports there is little evidence to support long-term opioid use for chronic pain unrelated to cancer. Morphine equivalency dosing (MED) should be limited to 50 mg per day, according to ACOEM. Furthermore, the CDC recommends naloxone accompany a daily MED of 50 mg or greater.

The well-documented challenges around opioids and a raft of updated protocols make clear much can and should be done to limit patients’ exposure to danger. This undertaking could not be more profound given the enormous number of people whose lives are upended, endangered, and even cut short when opioids go from relieving pain to causing it.

In our next installment, we will discuss how to reduce the amount of opioids injured workers are given and will further examine prescribing protocols. We also will look at how we can better help injured workers recover and return to productive lives.

About Nikki Wilson
Nikki Wilson is director of pharmacy product development for Coventry Workers’ Comp Services. Wilson is a Pharm.D. who graduated with her Doctor of Pharmacy and MBA from Creighton University. Prior to joining Coventry Nikki served as the Clinical Department Manager for Applied Underwriters for 5 years where she oversaw their Pharmacy Benefit Management (PBM) and home delivery programs and managed all clinical pharmacy operations.

About Coventry
Coventry NewCoventry offers workers’ compensation cost and care management solutions for employers, insurance carriers and third-party administrators. With roots in both clinical and network services, Coventry leverages more than 30 years of industry experience, knowledge and data analytics. The company offers an integrated suite of solutions, powered by technology to enhance network development, clinical integration and operational efficiencies at the client desktop, with a focus on total claims cost.

Disclosure:
Coventry is a WorkCompWire ad partner.
This is not a paid placement.

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