By Robert Goldberg, MD, FACOEM
Chief Medical Officer and Senior Vice President, Healthesystems
The release of the new ACOEM opioids treatment guideline can be the catalyst for workers’ compensation payers to implement new strategies and reverse the problematic trend of inappropriate and excessive use of opioids. The guideline incorporates many new evidence-based medicine recommendations for the medical community. One significantly reduces the recommended maximum dose of morphine equivalents (MED) from what was previously thought to be safe. Morphine is the standard against which the potency of all opioids is measured. The new guideline can provide a great foundation from which payers can update their existing pain management strategies and use when partnering with prescribers to minimize opioid prescribing.
An updated pain management strategy would curtail opioid use in favor of conservative treatment measures that focus care on helping patients recover from injury, rather than on managing pain. Evidence has shown a speedy return to work is more likely, and the risks and costs associated with long-term opioid therapy are minimized with this approach.
Conservative therapy emphasizes recovery. As an occupational medicine specialist with many years of experience, I have treated workers with injuries ranging from the most complex to the less serious by following evidence-based guidelines. For example, when treating injuries such as ankle and knee sprains frequently seen in workers’ compensation, the guidelines dictate use of conservative measures that include rest, ice, compression, elevation, modified activity and nothing stronger than an anti-inflammatory or acetaminophen. Most patients respond well after one to four weeks without ever needing an opioid. There are no opioid side effects to cope with and no risk of the patient becoming habituated on medication. If moderate or severe pain persists beyond five to seven days, only then would I consider hydrocodone or tramadol. Physicians who take this kind of conservative approach to treating musculoskeletal injuries tend to achieve better outcomes for patients because significantly fewer opioids are involved.
The pendulum has swung too far. The focus of care shifted to more aggressively treating a patient’s pain 10-15 years ago. Physicians began prescribing opioids earlier and more aggressively for injuries that previously required little or no such medication. More opioid prescriptions and higher doses escalated risks to patients, payers and employers. The pendulum has swung too far. The results have been disastrous — opioid dependence and abuse, adverse effects from long-term opioid therapy, increased medical treatment costs and a decreased likelihood that injured workers will return to work.
How do we move the pendulum back? When participating in presentations on the treatment of work-related injuries at conferences, I often start by emphasizing a basic principle of occupational medicine — focus on the patient’s recovery, not just the pain. That is our best hope of reducing excessive reliance on pharmacy in general and opioids in particular. It requires payers and physicians to rethink their opioid strategy and put into practice current opioid treatment guidelines.
The new ACOEM opioids treatment guideline — and those published by specialty societies and a number of states — can form the foundation of a new strategy that shifts the focus of care back to functional recovery. ACOEM advocates a conservative holistic treatment approach and recognizes pain management as a tool that enables patients to participate in recovery, rather than the ultimate goal of treatment.
It starts with the physician. I frequently state, “If a physician does not write the opioid prescription, then there will not be a problem.” Therefore, efforts to swing back the pendulum should include educating physicians on the most current evidence-based treatment guidelines. Payers need to redouble their commitment to restore as much function as possible. In turn, physicians need to set clear expectations with injured workers around recovery, pain management and return to work. Patients will fare better if they are educated to expect that some pain may continue or even persist.
New strategy requires new policies and procedures. PBMs can help payers incorporate the most current evidence-based guidelines by developing new policies and procedures to apply in appropriate circumstances:
- Approve a short course of opioid therapy only when appropriate, per guidelines.
- Approve treatment with physical or occupational therapy to speed functional recovery.
- Approve adjunctive therapies to reduce reliance on pain medication, including chiropractic, acupuncture, massage, yoga and other therapies.
- Approve cognitive behavior therapy to help patients better cope with the presence of persistent pain.
New policies and procedures should also delineate:
- Which jurisdictional and professional guidelines will be applied.
- What circumstances will trigger clinical interventions — MED level over 50mg, a certain number of prescriptions, multiple prescribers and multiple medications.
- Which cases will be escalated for higher level clinical intervention — claims that reach a certain dollar value or involve certain complex conditions or injuries.
- Which alerts, letters, outreach efforts and other interventions will be deployed and by whom.
Myriad benefits. Once payers make a fundamental shift to a holistic treatment approach, the outcomes will improve and can include the following:
- Increased likelihood that the injured worker will remain at work or return to work quickly
- Reduced adverse effects of opioids and other medications
- Reduced length and cost of opioid treatment
- Enhanced recovery with decreased temporary and permanent disability
- Reduced pharmacy, medical and overall case costs
We have a real opportunity to improve outcomes if physicians and payers work together to quickly and efficiently treat injuries and enhance recovery with a minimum of medication, particularly opioids.
About Dr. Robert Goldberg
Robert Goldberg, MD, FACOEM, is board certified specialist in occupational medicine, and the Chief Medical Officer at Healthesystems. As a past president of the American College of Occupational and Environmental Medicine, Dr. Goldberg is a nationally recognized authority on occupational medicine and musculoskeletal injuries. He has an extensive multidisciplinary background that incorporates 25 years of experience in a variety of roles. Dr. Goldberg has treated injured workers in private practice and academic settings and directed the residency training program at the University of California at San Francisco. He has also served as a researcher, consultant and corporate executive providing clinical direction to the development of evidence-based medical guidelines and workers’ compensation public policy initiatives.
Healthesystems is a specialty provider of innovative medical cost management solutions for the workers’ compensation industry. The company’s comprehensive product portfolio includes a leading pharmacy benefit management (PBM) program, expert clinical review services, and a revolutionary ancillary benefits management (ABM) solution for prospectively managing ancillary medical services such as durable medical equipment (DME), home health, transportation and translation services. By leveraging innovation, powerful technology, clinical expertise and enhanced workflow automation tools, Healthesystems provides clients with flexible programs that reduce the total cost of medical care while increasing the quality of care for injured workers. To learn more about Healthesystems or to sign up for newsletters, visit www.healthesystems.com or email firstname.lastname@example.org.
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