MSP Compliance Blog

Expert summary, analysis and recommendations on issues impacting Medicare Secondary Payer compliance.

Is Opioid Use Under Control in Workers’ Compensation?

Posted on April 15, 2014 by Rita Wilson

With the recent publication of the ACOEM Guidelines for Opioid Use and new guidelines from the American Chronic Pain Association (ACPA) that include very specific recommendations to monitor opioid use, the question was raised generically as to whether opioid use is under control in workers’ compensation.  Certainly, with greater specificity in Morphine Equivalent Dosage (MED) directives, reducing the maximum threshold for potential concern for dependency to 50MED, our experiences and research have intensified our understanding of where and how the problem begins.  Does this, then, mean that opioid use is under control?

According to the CDC, the US makes up only 4.5% of the world’s population, yet consumes more than 80% of all opioids.  My short answer, then, is “No, opioid use is not under control in any industry in the US.”

 The title of the cover article in this month’s (April 2014) issue of ‘The American Legion Magazine’ is “Pain’s Addiction: Opioids and the Military Veteran.’  Quoting from the first line of the article,  

By the time Justin Minyard discovered the video of himself stoned, drooling and unable to help his daughter unwrap her Christmas presents, he was taking enough OxyContin, oxycodone and Valium every day to deaden the pain of several terminally ill cancer patients.

And later, from a veteran’s widow,

Just before Ricky’s overdose and death, his medication list included oxycodone (short-acting opioid, pain), hydrocodone (short-acting opioid, pain), Valium (anti-anxiety), Ambien (insomnia), Zoloft (anti-depressant), Gabapentin (Neurontin, neuropathic pain) and Tramadol (Ultram, ‘narcotic like’ medication for moderate to severe pain).

The shocking realization for me…  I can’t tell you the number of times I’ve seen this exact drug regimen in a legacy workers’ compensation claim referred to Tower for an MSA. 

Other Recent Opioid Related Announcements:

  • March, 2014, Attorneys General from 29 states sent letters to the FDA to request the withdrawal of FDA approval for ZOHYDRO, a pure version of the opioid, hydrocodone.
  • 6 days ago, Business Insurance released its latest white paper, “Opioid Abuse, How to Tackle a Growing Problem.”   
  • March, 2014, the Reed Group announced that it dedicated an entire chapter to its Disability Guidelines to provide opioid guidance, documented and independently researched by ACOEM (the American College of Occupational and Environmental Medicine.)
  • February, 2014, the ACPA (American Chronic Pain Association) released its 2014 Resource Guide to Chronic Pain Management.  The guide specifically noted that 30% of hospital admissions among the elderly can be linked to an adverse drug event or toxic effect of opioids and sedatives.

While it remains the exception, I believe this 16-20% segment of the workers’ compensation population consumes more than its reciprocal 85% of the system’s money, time and expertise.  I believe opioid use, combined with its side effects, interactions and impact on quality of life, to be the key driver of cost and appropriate care with the MSA and associated settlement. I support and follow PROP (Physicians for Responsible Opioid Prescribing  http://www.supportprop.org).  I will also continue use our blog, http://www.mspcomplianceblog.com to communicate issues, strategies, treatment guidelines, etc. 

The more we understand about chronic pain, as compared to acute pain, and the effects of long term opioid use, the more aggressive we will be in our efforts to identify and address its potential for misuse early in the claim. 

 

Managing Chronic Pain in Older Adults

Posted on April 8, 2014 by Rita Wilson

According to the ACPA (American Chronic Pain Association) Resource Guide to Chronic Pain Management, “persistent or chronic pain is prevalent in older adults.”

“Nearly one third of all prescribed medications are for patients over the age of 65 years.   More than thirty percent of hospital admissions among the elderly may be linked to an adverse drug related event or toxic effect from opioids and sedatives.  Unfortunately, many adverse drug effects in older adults are overlooked as age-related changes (general weakness, dizziness, and upset stomach) when in fact the patient is experiencing a medication-related problem.  In addition, some older individuals may be more sensitive to medications, more likely to experience side effects, and more likely to be using multiple drugs with the associated risk of interactions between the drugs.”

Workers’ Comp Implications

For those who manage workers’ compensation claims, these statistics should highlight the importance of a consistently executed decision making paradigm when authorizing prescription medications for older patients. 

  • Before approving a new pain medication for an elderly injured worker, confirm that the initial dose is being prescribed at the lowest possible strength and frequency. 

  • When increases are requested, approve only those changes to strength and frequency that are adjusted slowly to optimize pain relief. 

  • When possible, confirm that the patient is monitoring and managing his / her own side effects.

When dealing with less dangerous treatment options for injuries in the elderly population, potential treatment options include:

  • Use of multiple drugs together – Careful  use of multiple drugs is potentially advantageous as the combination of smaller doses of more than one medication may minimize the dose-limiting adverse effects of using a particular single drug.

  • Alternatives to pharmacologic treatment – As an alternative to prescription drugs, physical rehabilitation and other interventional therapies, including targeted injections and acupuncture, can be helpful to minimize side-effects and maximize physical function with pain relief

Triggers For Potential Concern

Pain management in the elderly is a unique challenge.  Beyond the normal concerns of addiction and overuse, those who authorize treatment in a workers’ compensation claim for an older worker must also compare the potential dangers associated with the side effects of the medication against its promised value.  Triggers that may warrant intervention for an older injured worker include:

  • Opioid treatment that continues for more than 90 days post injury / surgery

  • An increase in the strength or frequency of an opioid prescribed more than 90 days post injury / surgery

  • A request to change from an orthopedic or other specialist to a pain management specialist more than 90 days post injury/surgery

  • A decrease in opioid drug use followed by a request for a new treating physician

  • The appearance of a long acting opioid medication following continued use and/or an increase in dosage of a short acting opioid more than 60 months post injury

Identify, Intervene and Remain Involved

By peeling back the onion one layer at a time, questions can be raised, physicians can be challenged and evidence based treatment guidelines can be used to confront the status quo.   The first step is to ask your workers’ comp PBM to identify claims that meet your triggers.   Once identified, intervene with the treating physician either directly, or through a formal peer review.  Once intervention is complete, remain involved until changes are complete.  

When preparing for settlement, it’s critical to work with an MSA partner who will serve as gatekeeper to identify the same triggers and  intercept problem claims before the MSA is prepared.  Working hand in hand, positive outcomes can be achieved for the elderly.   The process is simple.  Consistent execution is the key.

For more information on medical and pharmacological issues related to pain management in the elderly population, I encourage you to review the publications made available by the American Geriatrics Society  (http://www.americangeritrics.org).  For questions related to pain management issues related to Medicare Set Asides, email us at info@towermsa.com.

 

DEA Proposes Reclassification of Hydrocodone Products

Posted on April 6, 2014 by Rita Wilson

On  March 5, 2014, the DEA issued an NPRM (Notice of Proposed Rule Making) to move hydrocodone combination products (HCPs) from their current classification as Schedule III narcotics to Schedule II, a classification reserved for the most harmful and potentially addictive medications.  http://www.deadiversion.usdoj.gov/fed_regs/rules/2014/fr0227.htm.

As one of the most frequently prescribed drugs in workers compensation, this is a most interesting development and its impact will be felt across our industry.  Also, in light of the announcement last week that Zohydro, a new formulation of 100% pure hydrocodone being manufactured by Zogenix, is scheduled for release later this month, I find it to be more than coincidence that this more benign version of hydrocodone is now being recommended for movement to the Schedule II classification.

All substances placed under the control of the CSA since it was passed by Congress in 1970 are scheduled or rescheduled by the DEA, as required by the CSA and its implementing regulations, found in Title 21 of the Code of Federal Regulations. Scheduling or rescheduling of a substance can be initiated by the DEA, by the HHS Assistant Secretary of Health, or on the petition of any interested party. (Detailed information on the scheduling and rescheduling process can be found in the first chapter of Drugs of Abuse on the DEA’s website.)

For those who manage claims in workers’ compensation, the rescheduling of HCPs to Schedule II will create more changes than just a reclassification.  Procedural requirements include the following:

  • Every Class II Rx requires a written prescription from a practicing physician.
  • While most states limit Class II Rx’s to 30 days, there are no federal limits to days supply.
  • A physician may write multiple paper Rx’s for up to a 90-day supply, but the Rx’s must be written separately.
  • Refills for a Class II narcotic are prohibited

While the logistics may present a challenge in our day to day management of claims, I believe this to be a very positive move in our fight against opioid addiction in the US, particularly in workers’ compensation.  I strongly believe that the DEA, in its proposed movement of HCPs to the same classification as drugs like Oxycontin, Opana, ACTIQ, etc., is making a clear statement of its concern over the overuse, over prescribing  and abuse potential of HCPs.

I trust that all those in the medical community who respond to the NPRM will affirm support of the reclassification and that the result will be less frequent use of HCPs as long term therapy in workers’ compensation.

Read More At WorkCompWire

High-Risk Opioid Abuse Is Just As High In Prescribed Users

Posted on March 27, 2014 by Rita Wilson

In this JAMA research letter findings show that doctor prescribed opioids cause over-doses just as much, if not more, as non-medical use of prescription pain medicine. People who are at the greatest risk for abuse are those being prescribed pain medication. CDC’s new analysis shows that while non-medical users abuse opioids, prescribed users are even more likely to purchase opioids illegally.
Precautions need to be in place to prevent this type of abuse. Educating physicians and the general public about the dangers of opioid abuse is a crucial step in prevention. Some states are taking steps to prevent opioid abuse by implementing electronic databases that track patient history. This prevents a patient from filling multiple prescriptions at different pharmacies, which is one of the most common occurrences in opioid abuse.

“Many abusers of opioid pain relievers are going directly to doctors for their drugs,” said CDC Director Tom Frieden, M.D., M.P.H. “Health care providers need to screen for abuse risk and prescribe judiciously by checking past records in state prescription drug monitoring programs. It’s time we stop the source and treat the troubled.”

FDA Approves Long-Lasting Narcotic – Oxycodone / Acetaminophen

Posted on March 19, 2014 by Rita Wilson

The first FDA approved long-acting combination of narcotic analgesic oxycodone with acetaminophen is now available for pain management. It will be manufactured by Mallinckrodt and is a single strength tablet to be dosed twice daily. This new form of pain medicine is sold under the name Xartemis XR, and will treat patients with severe pain who don’t respond to alternate therapies.   Xartemis XR should not be used with other medicines that contain acetaminophen, nor should it be used in place of other oxycodone/acetaminophen products. Mallinckrodt is looking to provide more abuse-deterrent features for the FDA, as Xartemis does not currently have them.

“The FDA approval of Xartemis XR exemplifies Mallinckrodt’s dedication to developing and providing new treatment options for people with pain,” said Mark Trudeau, President and Chief Executive Officer of Mallinckrodt. “Mallinckrodt remains committed to continuing its work to develop innovative formulations for our product lines to help ensure access to appropriate pain treatment for the millions of patients suffering from acute pain, and we will continue to work closely with the FDA as we engage in further development programs for Xartemis XR and other products utilizing this technology platform.”

Warnings and Precautions
For those who manage workers’ compensation claims, the following warnings and precautions should be reviewed with claimants and their treating physicians before approval of this long acting opioid medication.
  • XARTEMIS XR contains oxycodone, a Schedule II controlled substance. As an opioid, XARTEMIS XR exposes users to the risks of addiction, abuse, and misuse. Abuse or misuse of XARTEMIS XR by crushing, chewing, snorting, or injecting the dissolved product will result in the uncontrolled delivery of the oxycodone and can result in overdose and death. With intravenous abuse, the inactive ingredients in XARTEMIS XR can result in death, local tissue necrosis, infection, pulmonary granulomas, and increased risk of endocarditis and valvular heart injury. Parenteral drug abuse is commonly associated with transmission of infectious diseases such as hepatitis and HIV.
  • Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended. While serious, life-threatening, or fatal respiratory depression can occur at any time during the use of XARTEMIS XR, the risk is greatest during the initiation of therapy or following a dose increase. Life-threatening respiratory depression is more likely to occur in elderly, cachectic, or debilitated patients as they may have altered pharmacokinetics or altered clearance compared to younger, healthier patients. In patients with significant chronic obstructive pulmonary disease or cor pulmonale, and patients having a substantially decreased respiratory reserve, hypoxia, hypercapnia, or preexisting respiratory depression, XARTEMIS XR may decrease respiratory drive to the point of apnea.
  • Hypotension, profound sedation, coma, respiratory depression, and death may result if XARTEMIS XR is used concomitantly with alcohol or other central nervous system (CNS) depressants.
  • Oxycodone may cause severe hypotension particularly in individuals whose ability to maintain blood pressure has been compromised by a depleted blood volume, or after concurrent administration with drugs which compromise vasomotor tone such as phenothiazines.
  • Due to the potential for acetaminophen hepatotoxicity at doses higher than 4000 milligrams/day, XARTEMIS XR should not be used concomitantly with other acetaminophen-containing products.

Impact on Settlement and MSA Projections

As a long acting opioid, XARTEMIS XR represents yet another medication to be added to the list of potentially addictive drugs approved by the FDA in 2014 (Zohydro, a new formulation of pure hydrocodone is scheduled for release in late March, 2014).  When the US represents only 5% of the world’s population, yet consumes more than 75% of the world’s prescription drugs, one should question the need for another opioid drug; especially when this formulation of oxycodone / acetaminophen is not available in a tamper proof formulation.  With overdose deaths involving opioid analgesics increasing from 4,030 deaths in 1999 to 16,651 in 2010, how can the benefits of this drug possibly outweigh the danger?

As a trigger for potential intervention, use of XARTEMIS XR to treat chronic pain for periods of more than 30 days, will be escalated to our medical team for review.  With availability as a single source drug only, XARTEMIS XR is extremely expensive.  If included in the drug regimen for an MSA beneficiary at the time of settlement, this would result in a high dollar.  When identified in the treatment regimen of an injured worker during the pre-MSA review our medical team with will dialogue with the treating physician in an effort to discontinue or replace XARTEMIS XR with a therapeutic equivalent medication to mitigate exposure with the MSA and achieve an optimal settlement.

For Media Inquires, Contact:

Helen King Patterson
813.690.4787
helen@kingknight.com

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