January 15, 2018

Nikki Wilson: Opioid Use Disorders – Treatment Options, Tools, and More

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

Nikki WilsonIn last week’s installment, we shared some insights on the need to understand when opioids are (or are not) indicated for the treatment of specific types of pain commonly seen in workers’ comp. We also highlighted the need for being familiar with prescribing guidelines should opioids be warranted and the warning signs that an individual may be exhibiting signs of opioid use disorder. This begs the question, how do we discontinue the pattern of abuse? While there is no one answer, we can start with the prescriber.

Tapering, Weaning, Detox
Regardless of whether signs of abuse are present, risk from opioids may be mitigated by discontinuing the drugs. Whenever it is considered appropriate to stop opioid therapy, establishing a thorough plan to assist patients in tapering opioid intake with frequent follow-up is critical. Prescribers should make decisions around weaning in consultation with the patient and roll out any program gradually. The process might take months or even years, warns the government’s National Institute on Drug Abuse (NIDA). The go-slow approach is to avoid withdrawal symptoms expected from the physical dependence caused by this class of drugs. In cases where patients are misusing, it is important to remember opioid use disorder is a chronic condition. This means there are no quick fixes.

Weaning often works in tandem with detoxification. “Detox” essentially refers to medical interventions surrounding the process of managing a patient through withdrawal syndromes related to stopping a particular drug such as opioids. For best results, the process of weaning should be agreed upon with and managed under the supervision of the injured worker’s treating provider.

The type of opioid and the patient’s comorbid conditions, including substance use disorder and the need for additional treatment, can affect the rate, intensity, and duration of the taper, as well as whether the patient is best suited for inpatient or outpatient detoxification. For example, psych conditions, risk of suicide, or a high risk of aberrant behavior could indicate that tapering in a primary care setting would be most appropriate. All of these considerations should be discussed with the provider.

As a general guide, the CDC calls for (PDF) decreasing an opioid at a rate of 10 percent per week, while the U.S. Department of Veterans Affairs recommends (PDF) decreasing an opioid at 20 percent to 50 percent of the original dose every week. Whatever the rate or weaning method, the patient should be evaluated at regular intervals, and adjustments to the intensity of the taper should be made as needed.

What Tools Can Prescribers Use to Help Wean Patients?
Coventry-LS-Opioids-Prescribers-Should-Make-DecisionsSeveral medications have proven helpful in managing symptoms associated with opioid withdrawal. It is important to understand that many of these assistive medications are not typically seen in workers’ comp and might not be covered. It would be wise to coordinate with the claims adjuster should any of these medications be requested for an injured worker.

An approach referred to as medication-assisted treatment, or MAT, may help reduce a range of poor outcomes and is supported by several guidelines. The prescribers most adept at deploying MAT do so along with support services such as counseling. Typically, MAT incorporates the drugs methadone or buprenorphine as part of the opioid weaning process. The National Institute on Drug Abuse recommends using methadone and buprenorphine to help ease symptoms of withdrawal without giving patients feelings of euphoria. Methadone and buprenorphine are opioids themselves; however, they are associated with a lower incidence of producing a euphoric effect among patients who already have an addiction to opioids when used as part of an MAT plan and are FDA-approved for the treatment of opioid dependence. Due to the way these drugs perform at opioid receptor sites and because the body clears them more slowly, they are less likely to generate a euphoric feeling but can still curb cravings. Therefore, the risk is minimal if these medications are used as directed within a broader treatment program, according to the NIDA.

Non-opioid medications may also be incorporated to address specific withdrawal symptoms. For example, clonidine is an alpha-2 agonist typically used to treat heart-related conditions. This drug has been found to be helpful in attenuating the autonomic symptoms of withdrawal such as hypertension, nausea, cramps, sweating, and/or rapid heart rate. NSAIDs may be an option for muscle aches, dicyclomine for abdominal cramps, and antihistamines or trazodone have been shown to help with insomnia and restlessness.

When using any of these medications, it is important that prescribers carefully monitor patients. Follow-ups, counseling, and continuing support are critical if a weaning program is to have the best chance of succeeding.

What Else Can Be Done To Help?
Coventry-LS-Opioids-All PlayersPrescribers cannot counter the challenges of opioid use disorder on their own. In treating injured workers, enhanced clinical controls can help ensure patients, especially those struggling with dependency, have access to appropriate supports including cognitive behavioral therapy and alternatives for managing pain such as physical therapy. Pharmacy benefit managers (PBMs) can require that opioid refills receive prior authorization from the claims adjuster. PBMs also can routinely mine pharmaceutical data to help uncover signs of misuse. As potential patterns of abuse or inappropriate prescribing are identified, the PBM can communicate with the claims adjuster and, where appropriate, the medical providers.

All players from prescribers, case managers, adjusters, and policymakers to employers and injured workers have a role in helping reduce misuse of opioids. All those who help care for injured workers must strive to achieve the highest possible degree of coordinated care. We must follow best-practice protocols and increase access to networks of providers who specialize in areas like detoxification and management of opioid use disorder. Payors also can boost coverage for alternative treatments that reduce pain such as cognitive behavioral therapy, and insurers can fully reimburse for substance-abuse treatment programs.

Like many prescribers, federal and state officials are responding. The Department of Health & Human Services (HHS) developed a five-point plan to fight the crisis. The top priority is improving access to prevention, treatment, and recovery services, including the full range of medication-assisted treatments. The agency also wants to more precisely distribute overdose-reversal drugs like naloxone, improve reporting and data on the crisis, foster research on pain and addiction, and advocate improved practices for managing pain.

A White House commission on the opioid crisis outlined 56 recommendations (PDF) that include providing greatly expanded access to MAT, mandating prescriber education around proper prescribing, and increasing the number of drug courts. Congress would have to act to implement many of the recommendations including stepped-up funding for treatment. The commission’s report came after President Trump instructed HHS to declare the opioid epidemic a public health emergency. The designation brings added focus to the problem though not additional funding. That would, again, require action from Congress.

The action is not limited to the federal level. Many states are marking wins in their fight to constrict the overall flow of opioids going to injured workers. WCRI reported in June that a majority of about two dozen states that it studied showed reductions in the frequency and amount of opioids dispensed to injured workers.

Where Do We Go From Here?
Those of us who are involved in helping injured workers recover—prescribers, health care providers, payors, case managers, PBMs, and others—share a profound responsibility to make a difference in the most pressing health crisis of our time. We must continue to sharpen our understanding of opioid use disorder and learn how we can intervene as effectively as possible when patients begin to drift toward misuse. This approach offers a critical path forward to help neutralize the frightening lethality of opioid use disorder. More than ever, the costs to the welfare of injured workers—and all patients—are simply too great to do anything less.

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 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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