Executive Summary
Prescription opioid misuse and abuse is an expensive and dangerous problem nationwide as injured workers stay on the drugs too long, hurting their recovery and dampening their motivation to return to work.
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A worker who has been on prescription opioids for a month or longer should be an automatic trigger for a case manager to review.
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Workers’ compensation case managers can help prevent problems by educating and encouraging workers about the dangers of opioid use.
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Case managers also can watch for trends that suggest opioid misuse, including identifying physicians who prescribe significantly more opioid medications than do other doctors.
From a healthcare perspective, drug misuse and abuse resulted in 2.5 million emergency department visits in 2011, and 1.4 million of these were related to prescription medications.1
"Drug abuse has become a huge epidemic in all aspects," says Kathleen Fraser, RN-BC, MSN, MHA, CCM, CRRN, regional director of case management for Zurich Services Managed Care. Based in Houston, Fraser also is the president of the national Case Management Society of America (CMSA) through 2016.
Prescription opioids are the biggest problem: "There are more prescription opioid overdoses than heroin, cocaine, suicide, and car accidents all together," Fraser says.
Fraser suggests that case managers should pay close attention to cases in which workers are on opioids for a month or longer. "A month should be an automatic trigger, and the worker should have a case manager who keeps an eye on the case, making sure the patient is okay."
Monitoring the places that have higher than predicted opioid prescribing is a good method for finding bad doctors who cluster to workers’ compensation because they can keep their patients longer, Fraser notes.
"Patients who have surgery and are prescribed opioids won’t say on the pain medications as long because they’re not being paid to be off of work," she explains. "It’s a whole different mindset with workers’ comp."
Workers’ compensation costs
Opioid abuse is a huge healthcare burden that drives up medical and lost-work costs for society, says Janet S. Coulter, RN, MSN, MS, CCM, director of case management for WorkStar, a managed care organization for the Ohio Bureau of Workers’ Compensation in West Chester, OH. Coulter also is a director for the national CMSA.
When workers are prescribed opioids, case managers can carefully monitor their use, looking for signs of abuse and trends, Coulter notes.
Trends to monitor include the doctor or facility where the patient receives the medication, how long workers have been off work, and how early they started on opioids, she adds.
"If they start on opioids early in the claim then they tend to be off work longer and cost more, often becoming hooked," Coulter says.
Temporary disability payments cost insurance companies 3.5 times more when the worker is prescribed opioids. Also, opioid use leads to a 322% greater likelihood of litigation, Fraser says.
According to the National Council on Compensation Insurance (NCCI), 38% of pharmacy costs and work costs are for opioids, which cost more than $1.5 billion a year. "Opioids contribute to more than $100 billion in lost productivity, medical costs, and disability payments through workers’ compensation," Fraser says.
Coulter learned about the dark side of opioid prescriptions when she discovered a worker she knew had accidentally overdosed and died. "That was when it became clear to me this was a major issue, especially in Ohio," Coulter says. "In some parts of our state people have lined up for blocks to get their opioid prescriptions."
While the Drug Enforcement Administration (DEA) might close down the more blatant opioid prescribers, there remain a number of doctors in every state who will overprescribe the drug. The CDC reports that Alabama has the highest rate of opioid painkiller prescriptions in the nation with nearly three times as many prescriptions per person as in Hawaii — the lowest-prescribing state.
Fraser and Coulter have spoken at national conferences about opioid abuse to make certain the problem is on the radar for case managers. Their goal is to highlight how this problem interferes with the goal of helping workers improve their health and return to their jobs. Workers’ motivations crater the longer they’re on opioids, they say.
"They either lie consciously or subconsciously because they’re afraid of being off the opioid," Fraser says. "They don’t get out and exercise or show up for physical therapy."
Workers who stay on opioids for too long become focused on getting more opioids and staying home, rather than improving their health, Coulter says.
Typically, case managers have held off on these cases until after the worker is on the prescription opioid while taking leave from work. Then if the person remains out of work for several months and is still on the opioid, the case manager might review the file and speak with the physician. But since opioid abuse has grown significantly in the past decade, a proactive approach might work better, Coulter and Fraser say.
CMs can educate patients
Depending on state laws, case managers can educate and make suggestions.
"We try to contact the patient within three days of injury," Coulter says. "If the doctor prescribes a long-acting opioid, I’ll plant the seed with the injured worker that they’ll need it for initial pain relief, but they should start backing off on the dosage within a few days — depending on their injury — because they won’t need it for the long term."
Case managers also can educate injured workers about opioid addiction and side effects like constipation. "There are many side effects, including withdrawal symptoms, and constipation is a major one for a lot of people," Coulter says.
When workers receive opioids, case managers could meet with the patient and physician and discuss the use of short-acting opioids like Percocet to help the injured worker get through the early aspects of their injury, Fraser says. "Often, doctors will prescribe the hardcore opioids out of habit."
Case managers might discuss alternative methods of pain control, Coulter suggests.
"We had one woman who was receiving acupuncture and it really helped her, and she has backed off all prescription medications and is doing very well," she says. "Others might try biofeedback or get injections of anti-inflammatory medication."
Drug overdoses are on the rise in the United States with a 117% increase since 1999. It’s the leading cause of injury death, and among people ages 25 to 64 there are more deaths from overdoses than from motor vehicle accidents. And more than half of these deaths resulted from overdoses of pharmaceuticals, according to the Centers for Disease Control and Prevention (CDC) in Atlanta.
Some states have laws and resources that help mitigate and prevent prescription opiate use, but case managers also can be on the front lines of those paying attention to the problem.
"The case manager is essential to holding down the cost of the claim and preventing opioid addiction," Fraser says.
"The case manager is the only one who is communicating with all parties concerned, and we’re always the patient’s advocate," Fraser says. "Yes, we want to save costs, and we want to make sure they don’t become addicted, and we’re the ones who help them through their injury."
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Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. The DAWN Report. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2013. Available from URL: http://www.samhsa.gov/data/2k13/DAWN127/sr127-DAWN-highlights.htm.
