Transcript From NCCI 12/09 Narcotics in WC

The Impact of Narcotic Misuse
in Workers’ Comp
Sherri Hickey, Director of Medical Management
The Impact of Narcotic Misuse
in Workers’ Comp
I.
Background – definitions, statistics, and
regulatory issues
II. Red Flags
III. What can an adjuster or NCM do
IV. Consequences of RTW
Definitions
• An Opioid is defined as any morphine-like
compound that produces pain relief
• Chronic Pain Syndrome – when a claimant
complains of pain for 3-6 months or more, or
beyond normal healing time for an injury.
• American Pain Society – The primary goal of
using narcotics or opioids in treatment of
chronic pain is to increase their level of function
rather than to provide pain relief.*
Narcotics (opioids) are Abundant
Codeine: Tylenol #3
Hydrocodone: Vicodin, Lortab, Lorcet
Hydromophone: Dilaudid, Exalgo
Morphine: MSIR
Morphine Sustained Release: MsContin, Avinza, Kadian
Fentanyl: Duragesic Patch, Actiq, Fentora, Onsolis
Oxycodone: Percocet, OxyContin, Percodan
Oxymorphone: Opana
Methadone
Propoxyphene: Darvon
Statistics
• Temporary disability claimants who treat with
opioids average 105 paid days off vs. those with
no opioids average 30 paid days off.
• When opioids are in a claim, there is a
– 322% greater likelihood for litigation,
– 264% greater likelihood of lost time from
work
Business and Insurance writer Roberto Ceniceros
Statistics
• More and more physicians are prescribing
opioids early in the injury. From 2004 – 2009,
there was a 61.1% increase in early use narcotics
in medical WC claims.
 Narcotics account for nearly ¼ of all WC
prescription costs. This percentage increases as
the claim ages.
From NCCI 12/09 Narcotics in WC
Statistics – The top prescribed
drugs
The Top Prescribed Drugs
Oxycodone (active ingredient)
Share of
Narcotics Cost
37.4%
Share of
Narcotics Scripts
21.3%
Hydrocodone
23.0%
57.6%
Fentanyl
11.8%
2.4%
From NCCI 12/09 Narcotics in WC
Statistics – The top ICD-9’s
The Top ICD-9
Dollars Pd
Scripts Written
Intervertebral disc disorders
33.5%
23.3%
724 Other & unspecified disorders
of the back
723 Other disorders of cervical
region
Peripheral enthesopathies
and allied syndromes
10.7%
8.7%
9.0%
7.1%
3.4%
5.4%
From NCCI 12/09 Narcotics in WC
Statistics
Higher amounts of narcotics in treating acute workrelated low back pain cause injured workers to be
• away from work longer
(up to 69 days longer),
• have higher medical costs,
• be 3X more likely to have
surgery,
• have a 6X greater chance
of using narcotics beyond
the recommended time.
WorkComp Central 7/20/09
Statistics
Prescription Drug Abuse and Diversion
• 60% of patients cannot identify their own
medications
• 30-50% of patients ignore instructions
• 14-21% of patients never fill their original
prescription
• Up to 20% of patients take other people’s
medications
• 81% of physicians do not urine test their patients
who are prescribed controlled Rx medications.
Lack of Regulation
There is little to no regulation to control narcotics
use and abuse in workers’ comp.
• No requirements for monitoring or
accountability by prescribers for their patients.
• No mandatory drug monitoring or drug testing
of claimants prescribed narcotics.
• No control of pain management offices opening
everywhere.
Lack of Regulation
• No control for off-label prescribing
• Where is the State Medical Board?
• Where is the DEA?
Lack of Regulation
• Is this just a workers’ comp issue? Group
Health vs. Workers’ Comp
• What about UR?
• My IME said to discontinue the narcotics!
Now what?
Lack of Regulation
Pill Mills
Flags
Screens for Risk
• Prior substance abuse history including
alcohol, or illegal drugs
• Tobacco dependence
• History of severe depression or anxiety
• Family history of substance abuse
Flags
Yellow Flags
• Complaints of more medications needed
• Drug hoarding
• Requesting specific pain medications
• Seeking treatment from multiple providers
• Occasional unsanctioned dose escalation
• Non-adherence to other recommendations for
pain therapy
• Early prescribing by the physician
• Frequent physician changing within in the
specialty
Flags
Red Flags
• Deterioration in functioning at work and socially
• Illegal activities – selling, forging, buying, from
nonmedical sources
• Injecting and snorting medication
• Multiple episodes of ‘lost’ or ‘stolen’ scripts
• Resistance to change therapy despite adverse
effects
• Refusal to comply with random drug screens
• Concurrent abuse of alcohol or illicit drugs
• Use of multiple physicians and pharmacies
What Can an Adjuster or
NCM Do?
• Assign a Nurse Case Manager
• PBM that specializes in
Workers Comp
– Step Therapy
– Automated DUR
– Automated Proactive DUR
– Retrospective Review or
Pharmacy Review
What Can an Adjuster or
NCM Do?
Expert Physician Model- Best Doctors
• Record Review
• Make recommendations for treatment
modifications
• Conference calls
• Written reports
• IME or QME
What Can an Adjuster or
NCM Do?
• Alternative treatment options – PT/OT
• IME/QME
• Multi-disciplinary Treatment Centers
– Medication management (reducing or eliminating
opioids)
– Physical exercise
– Cognitive behavioral training
– Behavioral skills
– Functional life roles
What Can an Adjuster or
NCM Do?
Interventional Medicine• Spinal Cord Stimulators
• Joint Injections
What is going on ….
•
•
•
•
State or legal support
UR
State drug monitoring
State legislature
What is going on ….
• Federal Actions
• REMS by the FDA
• New drug designs
Taking a proactive management approach is the
key to yielding profitable results…..
Consequences to RTW or
Settlement
• Limited positions open with this restriction
• Unable to operate machinery or drive a car
• MSA
Thank You!