New studies and research on Narcotics In Workers’ Compensation.

The  American College of Occupational and Environmental Medicine states, “the overuse of opioid therapy to treat chronic pain conditions is becoming epidemic in the United States,” and, “there are many treatments that should be considered before opioids”. According to this organization:

• “Opioids are  becoming more controversial in large part because of … markedly elevated eath risks that have paralleled increases in consumption of opioids narcotics)”
• “Routine use of opioids for the treatment of chronic nonmalignant pain conditions is not recommended”
• “Opioids are recommended for select patients with chronic persistent pain, neuropathic pain, or CRPS (complex regional pain syndrome).”

Two years ago, NCCI released a study on the use of narcotics in workers compensation. Findings from that study include the following:

• There is a correlation between drug abuse treatments and heavy narcotic use
• There has been an increase in early narcotic use
• The use of narcotics can continue for many years

In the update released on June 5, 2012, changes and key trends identified by NCCI were as follows:

• Per-claim narcotic costs have increased
• There have been changes in which narcotics are most commonly used
• Narcotic use is concentrated among a small percentage of claimants
• Initial narcotic use is indicative of future use

Overall Trends

The study begins with a look at the average narcotic cost per workers compensation claim with medical transactions. NCCI found that per-claim costs grew steadily from 2001 to  2004, remained fairly flat for a few years, and then increased in 2009. From 2001 to 2004, per-claim narcotic costs grew at an average of 18 percent per year. From 2004 to 2008, per-claim narcotic costs grew at an average of 1 percent per year. While there has generally been lower growth in recent years, the narcotic cost per-claim in 2009 is 14 percent greater than it was in 2008.

Narcotic use in workers compensation is becoming more common. In 2001, 28 percent of all claimants with medical transactions received at least one prescription drug within one year following injury and 8 percent received narcotics. In 2008, these numbers increased to 38 and 13 percent respectively. This implies that in 2008, over one-third of claimants with prescriptions received narcotics, up from 27 percent in 2001.

 Trends in Active Ingredients

NCCI identified seven active ingredients that account for more than 95 percent of the total cost of narcotics used in workers compensation. These include: morphine sulfate, oxymorphone, fentanyl citrate, fentanyl, oxycodone, oxycodone with acetaminophen, and hydrocodone BIT with acetaminophen.

The only major shifts in market share by active ingredient over the past few years have been a simultaneous reduction in the use of Fentanyl Citrate and an increase in the use of Oxymorphone HCL. While Oxymorphone HCL has been available through an injection since 1959, it only became available as an oral tablet in mid-2006.

Narcotic Consumption Among Claimants

Narcotic use in workers compensation is highly concentrated among a small percentage of claimants.  The narcotics consumed by the top 1 percent of claimants receiving narcotics accounts for close to 40 percent of all narcotic costs; the narcotics consumed by the top 10 percent of claimants receiving narcotics accounts for about 80 percent of all workers compensation narcotic costs. While narcotic use is highly concentrated, NCCI also noted a slight downward trend in the share of narcotic costs for the top users.

Tracking Morphine Equivalent Dosage (MEQ)

NCCI first investigated the persistence of narcotic use in workers compensation in 2009 and found that, while the probability of continued use declined with time, narcotic use could continue for many years. This study expands the 2009 analysis by investigating the relationship between the amount of narcotics initially consumed and the persistence of their use by tracking each drug based on its respective morphine quivalent dosage (MEQ).

Example:  According to drugs.com, the usual adult dose for time-released Oxycodone (OxyContin®) is 10 mg orally every 12 hours.  Assuming a claimant consumes 10 mg pills:

• 100 MEQ is equivalent to approximately 7 tablets of 10mg OxyContin®
• 370 MEQ is equivalent to approximately 25 tablets of 10mg OxyContin®
• 825 MEQ is equivalent to approximately 55 tabletss of 10mg OxyContin®

In its findings NCCI first noted that early narcotic use was indicative of  long term use with the average MEQ per claim receiving narcotics increasing with claim maturity. Second, NCCI found that the MEQ ranking was maintained in subsequent quarters; for example, those claims defined the by highest MEQ in initial use maintained its higher-than-other-claimant status throughout the life of the claim.

Conclusions and Commentary

Pain management is a necessary part of the worker’s compensation rehabilitation process, but the abuse of opioids can cause hazardous, life-threatening side effects for which payers may ultimately be held responsible. Payers who track and identify use patterns can better uncover any potential abuses before they become a litigious issue.

PBM reports that identify triggers such as chronic opioid narcotic use, high dollar narcotic spend, multiple physicians, multiple pharmacies are widely available across all providers.  With this level of information regarding claimants at risk readily available, why then does the opioid narcotic issue appear to be getting worse?  It is my belief that there is a disconnect between the information and the action.

How do we get the appropriate information into the hands of those who can, and will,
act on it?  What is the appropriate action to take for each claimant?  Are there jurisdictional requirements that must be met when intervention is warranted?  When and by whom should contact be made to the treating physician?  How do we get the agreement from the treating physicians to modify treatment?  Who follows through to verify that treatment is modified?

The items listed above are a subset of the many questions we ask at Tower MSA
Partners with every referral.  We work with clients to ‘stage’ claims prior to settlement and the MSA, and to address medical, pharmacy and legal issues as early in the claims process as possible.  We contact the treating physician when changes are needed and obtain written agreement.  We then follow through to make certain the changes are made and outcomes are achieved.

When physicians refuse to modify treatment, we also work with clients to identify specific, jurisdictionally approved strategies to obtain positive outcomes.  Depending on state of jurisdiction, we assist clients to challenge treatment, pursue a change in treatment  provider, close formularies, initiate dispute resolution, send the claim through utilization review, etc.

Potential strategies to address the rising problem with opioid narcotics involve 4
critical steps:

1. First, establish the internal triggers you wish to track;
2. Be proactive in identifying cases that meet your triggers;
3. Act on the information;
4. Follow through.

NCCI’s full report on opioid narcotics in workers’ compensation can be found at NCCI: Narcotics in Workers Compensation