issue 010, 2018

Alternatives for pain management 010

BY Dr. Teresa Bartlett SVP, Senior Medical Officer, Sedgwick

Opioid use continues to be a significant problem, but we are seeing success in mitigating the use of these addictive drugs through complex pharmacy management and the utilization review (UR) process. Along with pharmacy and UR efforts, there are key areas along the continuum of care where our industry can guide consumers and help them explore alternatives for managing pain following an injury at work

Prescription pain relievers and synthetic opioids, such as fentanyl, are contributing factors to the current opioid epidemic. It has been reported that every day, more than 115 Americans die from overdosing on opioids.1 More than three out of five drug overdose deaths involve an opioid. The economic burden of prescription opioid misuse in the United States is $78.5 billion a year.2 This includes healthcare, lost productivity, addiction treatment and criminal justice involvement.

A key area that we are focusing on is monitoring and investigating second fill opioid prescriptions. According to Sedgwick’s data, we are seeing that after that first opioid prescription, 60-70% of the patients never get another fill. It is that second fill that is the trigger. According to the Centers for Disease Control and Prevention, if the first fill exceeds a six-day supply of opioids, then 15% of the people taking them are going to be on them in a year. Some states have put rules in place to ensure the initial scripts do not exceed a six-day supply. States should also create limitations for second fills.

Sedgwick evaluated claim data and found that overall cost and duration increased exponentially with each additional opioid prescription for non-surgery claims. We compared claims with two prescription opioid fills and claims with five or more opioid fills and found the average claim duration was 88% higher for claims with five or more refills. In addition, our data showed that the average total paid on the claims with five or more refills was 191% more. In fact, non-surgical claim duration exceeded major surgery claim average duration by 4.4% when five or more opioid refills were prescribed. Early pharmacy clinician intervention is critically important for controlling claim costs and ensuring employee safety.

Prescription drugs for chronic pain are dangerous and long-term use damages vital organs and diminishes quality of life. Once a person is addicted, it can be devastating and extremely difficult to stop. Chronic pain has to be addressed in multiple ways and cannot be stopped by a pill or procedure. Intervention is important. A long-term opioid user should be weaned from medication following a weaning plan coordinated with the physician by a pharmacist or peer physician.

By putting together the managed care and pharmacy data after a claim is reported and connecting the dots, we can take our efforts a step further to control the use of opioids, and ensure injured employees are recovering as quickly and safely as possible.

Innovative approaches to reducing opioid use
As summarized below, some of the new areas to help control the use of opioids include adding pain management discussions before surgery and exploring other alternatives to help patients manage pain.

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  • Pre-surgery discussions
    We are looking at surgeries across the country and pre-certifying them. If we have a nurse case manager involved, they will have a dialogue with the surgeon and explain what the opioid management protocols should be. It is also important for a nurse to preemptively prepare the patient. They will discuss pain management before the surgery, explaining the dangers of opioids and how they should expect some pain after surgery. The clinician will also gauge the anxiety the patient may be feeling about the procedure and post-operative pain. Co-morbidities and use of prescription drugs for other conditions are confirmed and considered as the nurse coordinates a care plan with the treating physician. A nurse will proactively inform the patient that the most important thing to do after surgery is make the decision to take ownership of their own health and care. Whether that means getting the needed rest, eating a healthy diet, or engaging in the recommended physical therapy or exercise routine, it’s important to remind the patient that the more they own their recovery, the better the outcome.
  • Pain coaching, behavioral health or psychological support
    • Claims administrators will secure information about potential behavioral health issues, such as a history of addiction or treatment for depression, during the initial investigation of a claim. Pre-existing health conditions and medications taken prior to the injury are also obtained.
    • Nurse case managers trained to provide pain coaching will assist with opioid weaning and pain management. These nurses are trained specifically in techniques and strategies to help the injured worker overcome the mental and physical aspects of the injury and avoid possible addiction. The nurses act as advocates, active listeners, motivators and clinical experts. They help with goal setting for achievements in areas such as diet, exercise, medication, positive reinforcement, shifting pain perception and physical stress techniques.
    • Claims examiners and nurses helping injured employees should also be provided clear pathways to engage behavioral health specialists or psychologists experienced in occupational injury care for more severe pain management needs. For those cases, cognitive behavioral therapy (CBT) can address employees’ experiences and perceptions of severe or chronic pain. Through CBT, they can develop and maintain coping skills to address severe or chronic pain and restore a sense of normalcy.

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  • Alternatives
    In response to the opioid epidemic, doctors are considering other options for pain relief such as over-the-counter (OTC) medications and alternative therapies.

    • OTC options – A study published by the American Medical Association found that OTC painkillers offer similar pain relief to opioids in some emergency department patients. They compared 400 mg ibuprofen and 1000 mg acetaminophen to 5 mg oxycodone and 325 mg acetaminophen, 5 mg hydrocodone and 300 mg acetaminophen, or 30 mg codeine and 300 mg acetaminophen on acute arm or leg pain. None of the differences between the four groups were statistically significant. In addition, a group of surgeons at the University of Michigan have begun an initiative to curb the opioid epidemic by prescribing fewer opioids post-surgery. Acetaminophen and ibuprofen were used instead. The team used the findings to create new hospital guidelines that cut back on the standard opioid prescription for gallbladder surgeries. This study highlighted the fact that patients do not always need a month’s supply of tablets post-surgery and found, on average, patients only used six out of 50 tablets prescribed.
    • Alternative therapies – Other possible paths to pain relief in place of opioids may include mindfulness, acupuncture, CBT, massage, yoga and exercise, as well as aqua, schema and biofeedback therapies. While these options are starting to be considered, it is important to be proactive and build in the protocols and criteria to determine when they would be used and why to remove concern for employers. For example, the criteria may include a trial with two to four visits over two weeks and the therapy must show functional, demonstrated improvement to continue. These parameters provide objective evidence that it is actually helping and not just adding costs. Like acute and short-term pain, chronic pain can be managed through alternative therapies such as these.

It is important to educate patients on what pain is, how the brain interprets it and what influences that – whether it is anxiety, stress, and positive or negative thoughts. One of the best things a patient can do is keep their mind on getting back to their normal activities and talk with their doctor about setting the right goals. Focusing on avoiding pain at all costs is not helpful and it prioritizes fear over function. Patients should be also taught to be an active participant in their own pain management.

We are here to help
Sedgwick’s managed care team understands the ongoing challenges associated with opioid use. We continue to look for ways to help employers address these issues and improve the health and safety of their employees.

References

National Institutes of Health. Opioid Overdose Crisis. February 2018.
https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis

 

Centers for Disease Control and Prevention. Opioid Overdose. August 30, 2017.
https://www.cdc.gov/drugoverdose/epidemic/index.html

Resources

Chang, A. K., Bijur, P. E., Esses D., Barnaby, D. P., Baer, J. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department, A Randomized Clinical Trial. American Medical Association. JAMA Volume 318, Number 17. November 7, 2017.

Reduction in Opioid Prescribing Through Evidence-Based Prescribing Guidelines. JAMA Surgery. December 6, 2017.

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