By Nikki Wilson, Director of Pharmacy Product Development, Coventry Workers’ Comp Services
The rampant opioid misuse battering the nation represents one of the most virulent threats to employee welfare in the more than 100-year history of workers’ compensation protections. Equipping key players with an understanding of when opioids are necessary and how to identify opioid use disorder will lead to better chances of deterring the abuse of opioid analgesics that has proven so costly to workers’ wellbeing.
Will Opioids Address the Problem or Create One?
Knowing the warning signs of misuse is critical. But before that, let’s focus on when and how opioids should be used. The first question one should ask is whether opioids are likely to alleviate the individual’s pain and whether an alternative could work as well or better. Other questions can help guide decision-making and avoid a path of risk often associated with opioid use. These include asking whether an evidence-based treatment plan has been established for the patient, whether non-pharmacologic and non-opioid therapies have been tried and failed first, and whether the patient has experienced improvements in pain and function or has returned to work. Then, if opioids are warranted, complying with sensible standards can decrease the likelihood that misuse will occur.
Opioids often are directed toward problems like chronic back pain even though these drugs are ill-equipped to ameliorate long-term discomfort. Opioids were designed for reducing pain in end-of-life care involving conditions like cancer and may also be appropriate in certain acute or short-term pain scenarios where other drugs are not effective. For long-term pain, over-the-counter remedies such as acetaminophen and ibuprofen can be just as effective at fighting pain and do so without risk of addiction. The distinction is important because several studies put the prevalence of opioid misuse among chronic pain patients around 20 percent; the Institute of Addiction Medicine reports it is as high as 58 percent.
Some prescribers and patients look to opioids because of a lack of understanding around the effectiveness of alternatives such as over-the-counter drugs. A poll (PDF) from the National Safety Council, a nonprofit chartered by Congress, found three quarters of doctors erroneously believed morphine and oxycodone were more effective than acetaminophen and ibuprofen. More education is also needed for the individuals taking prescription opioids. Roughly nine in 10 patients taking opioids were not concerned about addiction, according to a separate National Safety Council survey (PDF). While we as an industry have several resources when it comes to recommended management of pain and opioids and risk, these guidelines are only useful if they are applied. Educating providers and injured workers as to the best practices for opioid therapy may be the first step in achieving this objective.
If Opioids are Needed, Refer to Guidelines
When opioids are in order, complying with prescribing guidelines and engaging patients can help reduce the chances of errant use. There are helpful protocols from state-based medical societies, the Official Disability Guidelines (ODG), the American College of Occupational and Environmental Medicine (ACOEM), and agencies such as the CDC. Although guidelines and evidence-based medicine represent best practices, such recommendations are not always incorporated into everyday care.
In a 2017 review of nearly 400,000 nonsurgical claims, the Workers Compensation Research Institute (WCRI) found that use of recommended services such as urine drug testing and psychological evaluation and treatment remained very low for injured workers being treated with chronic opioids. The National Safety Council reported in 2016 that a survey of doctors revealed 99 percent were prescribing far more than the CDC recommends. Nearly one in four were writing scripts for at least a month’s worth of opioids. That is alarming because physical dependence is more likely to occur among patients who take opioids beyond two weeks.
Opioid Use Disorder — The Warning Signs
To best respond to the crisis, we need to be clear about what opioid use disorder is and how we identify it. The way we define issues with opioid use has evolved. In recent years, the view of addiction has shifted from that of a poor choice pathway to one of disease state management. Under the diagnostic criteria found in the DSM–5, a person is designated as having opioid use disorder if, within a 12-month period, he or she exhibits a problematic pattern of opioid use that meets with at least two of nine to 11 characteristics and that pattern of use leads to clinically significant impairment or distress. The characteristics include experiencing craving or a strong desire to use the opioid, continued use despite harm, or taking the medication for a longer period of time or in larger amounts than intended by prescription. Prescribers can monitor for these characteristics or behavior patterns in their patients who are taking opioids. Similarly, prescribers can incorporate urine drug screening as a best practice for patients who are taking opioids to rule out the inappropriate use of the prescription or illicit drugs as well as to identify cases of opioid prescription diversion.
Protocols from ODG can also help providers distinguish possible occurrences of opioid use disorder. At the outset of an opioid regimen, ODG recommends prescribers watch patients for decreased functioning, intoxication, or a negative affective state. These and a number of other signs can indicate that patients are starting to display a preoccupation with opioids and perhaps starting to lose control over their medication use. These include:
- Failing to bring in unused medications
- Obtaining a higher dosage without approval of the prescribing physician
- Requesting early refills
- Reporting medication lost or stolen
- Arriving for unscheduled clinical appointments in a state of distress or missing appointments
- Making frequent visits to emergency departments
- Failing to comply with other treatment modalities
- Showing interest only in symptom control rather than rehabilitation
- Hearing reports from family of overuse or intoxication
- In general, failing to show improved function or relief from pain
There are still other red flags that are more pronounced than most of the above warning signs and could be identified by the prescriber or case manager. These include the selling of prescription drugs, forging or modifying prescriptions, stealing drugs, using prescription drugs in ways other than prescribed (such as injecting oral formulations, chewing long-acting agents, or using prescribed opioids for other conditions), using alcohol or other illicit drugs (as detected on urine screens), obtaining prescription drugs from outside the medical system, and doctor shopping.
Understanding when opioids will benefit the individual’s recovery can help sidestep opioid use disorder. When ineffective opioid prescriptions are avoided, so are risks of misuse. Understanding and complying with guidelines and best practices ensures that those who need opioids receive the benefit with fewer risks. Closely monitoring for the warning signs associated with opioid use disorder ensures that those who do veer into trouble get help as quickly as possible. In our next installment, we will examine practical steps to tackle opioid use disorder.
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.
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.
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This is not a paid placement.