By Nikki Wilson, PharmD, MBA, Director of Pharmacy Product Development, Coventry
For all the progress our nation has made in reducing opioid prescriptions, misuse of these powerful analgesics remains an intractable problem. And while much work remains, the health care system has grown more adept at deploying the right resources at the right time to give patients the best chance at recovery.
These hard-won lessons, borne from wearisome experience, are particularly relevant in the treatment of injured workers, who often face the dual challenge of requiring assistance with an opioid use disorder while trying to endure the strains that can arise from being away from work.
Here we’ll look at some of the considerations around treating an opioid misuse disorder. First, it makes sense to review some of the knowledge we’ve amassed from years of combatting opioid use disorders. Most of the time, recovery is difficult for patients and it’s often protracted. We’ve also learned that the greatest chance for success arises when the most accomplished health care professionals are empowered to deliver care that is well-coordinated, that incorporates multiple treatment methods, and that adopts a biopsychosocial perspective.
Experience Can Offer Harsh Warnings
Far too often, understanding about the potential fallout from inappropriate use of opioids comes from firsthand experience. The scale of the problem is sobering: One in four Americans has an opioid use disorder, knows someone who does, or knows someone who has died from it, according to the nonprofit National Safety Council.
The urgency of the problem is clear to employers, too. In 2017, 95 percent of opioid overdoses occurred among those aged 15 to 64, the prime working years. It’s little surprise then that three in four employers report having had an issue with opioids in the workplace. Knowing these statistics and risks, there are several approaches that have aided in preventing opioid use disorder. These range from early intervention screening tools, risk-factor monitoring, best-practice prescribing guideline adherence, and careful patient selection and follow-up. But what is the best approach once opioid use disorder has been diagnosed?
What We’re Trying to Achieve with Treatment
When we screen for injured workers who might be struggling with an opioid use disorder, we first should consider who meets the criteria for treatment. Among the overall patient population, there is ample reason for concern. That’s because more than six in 10 people who are prescribed opioids have at least one risk factor for developing an opioid use disorder.
The goal of therapeutic treatment for an opioid use disorder is, of course, to lower the risk of harm to the patient and to others. Specifically, this means reducing the chance of illicit or unwanted drug use and the associated health risks. It’s important to recall that opioid use disorder, like addiction in general, is a chronic disease that can subjugate both the brain and a person’s behavior to deleterious ends. So, while an alcoholic will always be an alcoholic, the goal is to help a person become a recovering alcoholic — always creating distance from the claws of the disease though never reaching an inviolable cure. The same holds for opioid use disorder. The goal is to eliminate opioid misuse knowing that while the risk of relapse might diminish, it never disappears.
Beyond the obvious physiological gains of curbing misuse of opioids, there are broader treatment benefits concerning improvements to an injured worker’s overall quality of life. This can mean striving for enhancements in how a person is able to discontinue the drug of abuse, remain free of the drug, and be productive at work, at home, and with family and friends. It’s about helping someone resume a position as a full-functioning member of society.
To reach these important yet often-elusive ends, it’s crucial that treatments consider the whole person. It’s not sufficient to simply prescribe a treatment regimen or rely solely on diligent medical management. Instead, the various players orbiting an injured worker in treatment must act in concert to establish the most solid foothold that could lead to a successful outcome. Clinicians and prescribers, case managers, employers, and family and friends all have a role to play. An injured worker trying to recover from an opioid use disorder will require an array of supports from the home to the workplace.
Medication-Assisted Treatment is an Essential Tool
Even if all those trying to help an injured worker pull together and align their efforts, recovery is still difficult. That’s where additional measures offer the best chance of arriving at a positive recovery. This includes medication-assisted treatment (MAT), which has been established as an effective treatment for opioid use disorder. Yet for all the good it can do, medicine on its own isn’t enough if it’s not part of a broader effort. That’s why the Food and Drug Administration (FDA) describes MAT as medication delivered alongside counseling and behavioral therapies.
There are a handful of MAT drugs that various guidelines support. Both the Centers for Disease Control & Prevention (CDC) and the World Health Organization, for example, endorse methadone and buprenorphine for opioid use disorder where appropriate. The CDC specifically calls on clinicians to “offer or arrange evidence-based treatment, usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies.”
The Official Disability Guidelines (ODG) also support use of either buprenorphine or methadone for the treatment of opioid dependence in certain patients and by select prescribers, such as those specializing in addiction recovery. Overall, the various protocols align in that each recommends controlled use of medicines to help wean patients from inappropriate opioid use along with supports such as therapy and counseling.
Drugs such as methadone and buprenorphine are themselves opioids though when used appropriately as part of an overall treatment program the euphoric effects are avoided. This minimizes the risk that a patient could be swapping one problem for another. Instead, the dosages involved in treating an opioid use disorder help reduce opioid cravings and withdrawal. The medications help restore balance to the brain circuits that opioids hijacked to cause addictive behaviors. Wresting control of these critical pathways allows an injured worker’s brain to begin to heal as he or she works toward recovery.
There are other drugs that have a place in a MAT plan. One is naltrexone, a type of antagonist treatment that blocks the effects of heroin and most other opioids. As such, it doesn’t carry the risks of dependence that opioids do. Plus, its therapeutic effects can last up to three days. Yet there are downsides. Patients with an opioid use disorder would still suffer cravings because naltrexone doesn’t take up a position at any of the body’s opioid receptors the way buprenorphine or methadone do. In addition, patients need to be withdrawn from all opioids for as long as two weeks before they can begin a naltrexone treatment. And once patients have started on naltrexone, there can be increased risk of fatal overdose if a relapse occurs. Naltrexone has shown effectiveness among patients who display strong motivation to overcome opioid use disorder. Even then, however, it’s still important to ensure patients have support services such as counseling.
As Always, There are Many Considerations
There are numerous steps to consider when establishing a recovery regimen for opioid use disorder. They are:
- Personalized diagnosis and treatment planning
- Coordinated care
- Behavioral therapies
- Access to FDA-approved medications
- Evaluation and treatment of comorbid mental health issues
- Best practices for ongoing pain management
- Long-term follow-up to prevent relapse
- Recovery-support services
Perhaps most important of these measures is the idea that the diagnosis and treatment planning should be tailored for an individual and his or her support systems such as family and friends. From there, clinicians overseeing recovery treatment should be sure care remains coordinated. This means aligning the potential use of MAT with simultaneous efforts to address possible behavioral health conditions such as anxiety and depression. FDA-approved medical treatments can fight addiction on one front while trained professionals can help patients modify their attitudes and behaviors relating to opioid use.
Given the inherent murkiness surrounding a patient’s response to treatment for opioid use disorder it’s critical to remain vigilant for the possibility of relapse. That’s why detoxification alone remains an insufficient and easy-to-topple treatment. A relapse-prevention program is essential. This can include a variety of measures beyond MAT including hypnosis, relaxation techniques, or acupuncture. Psychosocial treatments can help patients hone their coping skills, change their environment, engage in further counseling, and perhaps group therapy, 12-step, or other self-help programs. For these types of recovery support services to work, it’s important to put in place a plan for long-term follow-up. That’s the surest way to help reduce the likelihood of relapse.
While there are numerous considerations, what remains clear is that whatever method a clinician leans on to help an injured worker, it’s important to engage in regular and frequent follow-ups, careful monitoring, and support.
Next week, my colleague Kate Farley-Agee, Vice President of Network Products, will walk through aspects of specialty networks that focus on opioid misuse treatment.
About Nikki Wilson
Nikki Wilson is a Pharm.D. who graduated with her Doctor of Pharmacy and Master of Business Administration (MBA) from Creighton University. As a licensed Pharmacist, Nikki has over ten years of comprehensive industry experience through leadership roles overseeing prescription home delivery programs, clinical pharmacy operations and benefit management, and product development. Today, she is responsible for developing pharmacy product strategy and program capabilities at Coventry with a focus on enhancing patient safety and returning people to work, to play, and to life.
Coventry offers workers’ compensation, auto, and disability care-management and cost-containment solutions for employers, insurance carriers, and third-party administrators. With roots in both clinical and network services, Coventry leverages more than 35 years of industry experience, knowledge, and data analytics. Our mission is to return people to work, to play, and to life. And our care-management and cost-containment solutions do just that. Our networks, clinical solutions, specialty programs, and business tools will help you focus on total outcomes.
Coventry is a WorkCompWire ad partner.
This is not a paid placement.