December 14, 2017

Nikki Wilson: Best Practices and Partnerships Can Help Combat Opioid Misuse

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

Nikki WilsonReducing the devastating fallout from opioid-use disorder is a clear priority for the nation as well as the workers’ compensation industry. What is not always as evident is how best to reduce the risks brought by the largest drug class among injured workers.

Last week, we looked at some of the stunning numbers around opioid overdoses and how we can improve management of patients taking these analgesics. Here we will consider additional actions we can take to help prevent opioid use from morphing into misuse and abuse. We will discuss how we might end-run the problem entirely by working with prescribers to reduce the number of opioids that make their way to injured workers. Finally, we will examine what can be done to help those ensnared by opioid misuse to recover and return to productivity.

MED of 50Guidelines Can Help Us Avoid Some Problems from the Start
Evidence about what works should be the signposts guiding our collective response. Several national organizations have produced recommendations around when to prescribe opioids and when to continue or discontinue them. These evidence-based protocols include the appropriate durations of use according to injury type, dosing limitations, when to involve a pain specialist, how to identify whether a patient is a candidate for opioid therapy, what to monitor throughout treatment, and how to manage side effects. For example, studies have shown that the risk of death from opioid overdose increases roughly fourfold at a morphine equivalent dose (MED) of 50 or above. This risk jumps ninefold at MED of 100 or more. Other studies have shown that physical dependence to an opioid can occur in as little as two weeks with continuous daily use. Setting MED thresholds (or MED-directed recommendations) as well as limiting durations of treatment are just two ways guidelines can help prevent problems from occurring. The Official Disability Guidelines (ODG) and frameworks from the Centers for Disease Control & Prevention (CDC) and other organizations outline what should occur if prescribers identify risk or if an overdose takes place. The CDC created a mobile app to help prescribers adhere to its best practices.

Physical DependencePartnerships Play a Vital Role in Enabling Success
Guidelines are critical because they are rooted in science and empirical evidence. Still, we cannot rely on these alone. We also must seek out additional clinical and social indicators that could help us better identify those most at risk for misuse, abuse, or the threat of overdose. Employing a biopsychosocial model in which we consider the whole patient is a strong approach. One important measure is identifying opportunities for partnerships in the addiction-recovery process. This means building relationships among prescribers, injured workers, clinicians, employers, and other caregivers. This web of interactions must foster trust and hold each party to account for their role in recovery.

There are other partnerships that can help prescribers safeguard patient safety and even forestall addiction. Both a Pharmacy Benefit Manager (PBM) and case management partner can prove strong allies. A robust PBM program can mitigate some of the risks associated with opioid use and help identify patients who might require direct clinical intervention and support. For example, risk-modeling tools can mine data for emerging patient risk around several of the indicators for opioid misuse, abuse, or overdose. These include opioid prescriptions filled from multiple prescribers or pharmacies, high-risk drug combinations, prolonged opioid use, and a high MED. Risk-modeling can trigger alerts for instances in which urine drug testing might be appropriate; and the system should guide the testing process and any necessary subsequent patient management. A PBM also should be alerting prescribers to suspicious prescribing behavior and requesting that specific scripts be evaluated further before being approved. At a more fundamental level, prescribing protocols surrounding a PBM’s drug formulary should include recommendations to avoid long-acting opioids for first-line use and to consider the addition of the overdose-reversal agent naloxone where appropriate. In essence, the PBM should be prompting claims personnel to engage clinical resources that can prevent a problem from taking root and also should have in place tools that can be deployed if signs of opioid-use disorder do emerge.

Another way to support program outcomes is through the triage of appropriate cases for further clinician engagement or additional oversight through case management. This extra scrutiny can pay dividends when the case manager is specially trained to focus on claims deemed at-risk based on pharmacy utilization. The use of a specially trained pharmacy nurse case manager can promote patient engagement, safety, and education. With the appropriate data resources — made available through the PBM and medical bill review — the pharmacy nurses can target the cases in which they can make the greatest impact. The nurses can work with the prescriber, injured worker, and claims personnel to confirm pharmacy utilization is medically appropriate and supports a timely recovery.

Nurse Case ManagerThere Are Other Steps We Can Take
Strong prescribing guidelines and strong partners are a necessity. Yet there are still other ways prescribers can work to reduce the risk of adverse outcomes from opioid use. The Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD) draws on 14 patient variables when calculating the likelihood of opioid-induced respiratory depression, which is the leading cause of death related to opioid analgesics.

Prescribers can establish a pain agreement or an informed-consent agreement to ensure all sides understand the risks, commitments, proposed course of treatment, and the consequences of a breach. Additional risk-screening tools such as SOAPP-R, ORT, and DIRE have proven useful as have PADT, COMM, and ABC, which help flag opioid misuse. Simple steps such as providing baseline and random urine drug testing and practicing safe storage and disposal of the drugs can help deter abuse.

Prescribers can review state databases for prescription drug monitoring; these often are referred to as PDMPs or PMPs. Signs of errant utilization can prompt discussions around treatment options for opioid-use disorder. Prescribers also can help educate patients about pain and the risk of opioid-use disorder and, when warranted, recommend non-opioid analgesic medications or non-pharmacologic therapies.

Prescribers can begin to taper injured workers off opioids where appropriate, such as when a patient develops increased dependence on the drugs or demonstrates aberrant drug-taking behavior. In cases in which injured workers show signs of opioid-use disorder, prescribers can consider Medication-Assisted Therapy (MAT) with drugs such as methadone or buprenorphine. These types of drugs, combined with counseling and support from family and friends, can offer another viable option for combating opioid-use disorder, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), the primary federal agency responsible for substance abuse and mental health services. SAMHSA recommends employers make clear that help is available for workers struggling with opioid-use disorders in part because employees who seek treatment of their own accord — rather than solely at the behest of family and friends — are more likely to find success.

The Best Path Forward Is One That Welcomes Many Partners
There is no single fix that will eliminate opioid-use disorder within workers’ compensation or within society in general. Arresting this deadly epidemic will instead require an assemblage of committed partners that includes injured workers, families, employers, PBMs, prescribers, clinicians, and other caregivers such as specially trained nurse case managers. These groups can employ a range of measures that, taken together, offer the best hope for reducing the scourge of opioid-use disorder and, in essence, decreasing adverse outcomes associated with opioid use, including death from overdose. These tools include patient education, evidence-based guidelines, biopsychosocial models that consider the full range of patients’ needs, medication-assisted therapy, and countermeasures such as naloxone. The grievous toll these painkillers can exact is clearer than ever as is the need to do all we can to help injured workers either avoid or recover from the ill effects of opioid-use disorder and return to good health.

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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