Posts Tagged ‘opioids’

Medical Care Experts: Where Would We Be Without Them?

Monday, August 7th, 2017

If you’ve been following the blog-o-sphere and the LinkedIn-o-sphere, you know that the space is crowded. Lots of workers’ comp practitioners have glommed on to the idea that the way to get ahead is to write and post frequently. Connect with more than 500 others in the profession. Write something, anything, put your name on it and throw it up against the wall to see if anything sticks. Kind of the way Garrison Keillor used to say he changed socks on a book tour.

Every once in a while, something helpful and interesting appears and gains a bit of temporary caché for itself and for its author. Mostly, the topics center on the persistent rise in medical costs and, even more often, on the insidious and often criminal use of opioids, which a regrettable number of alleged doctors, having checked their Hippocratic Oath at the door, are prescribing at a hell-bent-for-leather rate at a hell-bent-for-leather profit. The poor, unfortunate souls for whom these scripts are written are nothing more than high-cost collateral damage.

Consequently, efforts to control workers’ compensation costs are now almost entirely dedicated to reining in costs associated with medical care with a huge emphasis on prescription drugs.

And why not? Injury frequency continues its 13 year, asymptotic approach to zero. While the same can’t be said for injury severity, these are, nonetheless, heady times for insurers. Kind of hard not to make money when the combined ratio is in the 90s.

Regardless of how good things are getting in workers’ comp world, the workplace is still the best place to control and manage the work injuries and costs that are bound to occur despite frequency’s decline and the rise of the robots. But that requires educated employers who understand that they, not the vendors to whom they outsource payment responsibilities, are the hub of the workers’ comp wheel.  Who approach workers’ compensation in a Management 101 kind of way understanding that a systemic, accountable process will reduce costs to a minimum and bolster profits as well as employee morale and productivity.

This means training supervisors in the proper response to work injuries, keeping close communication with injured workers, creating good relationships with treating physicians, bringing injured workers back to work as soon as possible under medical supervision, seeing that injured workers receive full pay while on modified duty, and measuring success every month just as one measures success in every other business enterprise.

These, and other program components, give enlightened employers a distinctive competitive advantage, and the results will speak for themselves.

But not all employers are enlightened; many have lost their way. Why?

Well, could it be we took a system we had made relatively simple for employers to manage (and let’s not forget that it is employers who ultimately pay the bills) and made it progressively more complicated with progressively more vested interests?

Many middle market employers, realizing they have no hope of navigating the haunted house maze medical care has become, have relinquished control to a myriad of vendors, the “experts.” Climbing this Tower of Babel is beyond them.

The question is: Can we do anything about this? Should we? Or, has this ship long ago sailed?

More on the opioid crisis and the fentanyl factor

Wednesday, May 4th, 2016

Here in the state where the world headquarters of Lynch Ryan is housed, we learn the unsettling news that Massachusetts has seen a 190% increase in opioid deaths in five years. Jessica Bartlett of Boston Business Journal notes:

“Despite Gov. Charlie Baker releasing a $27 million plan to address the opioid epidemic in June, opioid deaths have continued to rise, with recent data from the Department of Public Health showing a 12.5 percent increase in estimated deaths in 2015 compared to the year before.

Compared to just five years ago, the estimated 1,526 unintentional opioid-related deaths in 2015 represents a 190 percent increase.”

Things might have been even worse. In 2015, the “opioid antagonist” Naloxone was administered 12,982 times, so we can only guess what the tally might have been without such intervention. It doesn’t look like 2016 will bring much relief: An estimated 400 deaths have have already occurred in the first three months of the year.

Bartlett notes a disturbing trend:

“While the high number of deaths is nothing new, the state has for the first time released the number of deaths with a confirmed presence of fentanyl, a synthetic opioid 50 to 100 times more potent than morphine.

Of the 1,319 confirmed opioid deaths in 2015, 754 of them tested positive for fentanyl.”

Felice J. Freyer and J.D. Capelouto recently reported on this in the Boston Globe: Fentanyl factored in more than half of 2015 OD deaths, state reports

A Massachusetts law criminalizing fentanyl trafficking took effect in February, with sentences of up to 20 years in prison for selling more than 10 grams.

The health department data released Monday provide the most reliable portrait to date of the opioid crisis in 2015, confirming that 1,379 people died from overdoses. A deeper analysis of cases from 2014 raised the number of confirmed fatal overdoses for that year, to 1,282.

The state’s findings do not distinguish between heroin overdoses and those caused by prescription opioids. Health officials are unable to make that distinction because most prescription opioids, as well as heroin, break down into morphine in the bloodstream. But fentanyl, a synthetic drug, turns into a substance that can be detected by a test.

Southern California Public Radio features a story on Why it’s so hard to track the powerful opioid fentanyl. Rebecca Plevin reports:

First, doctors treating overdose victims are mainly looking for the better-known opioids, like Vicodin. And when they check for drugs, standard tests often miss fentanyl. A special lab analysis is often necessary, and doctors – especially in busy ER’s – don’t always think of that. Another problem is that not all hospitals are set up to conduct the special lab analysis.

All of this is complicated by the fact that illegally manufactured fentanyl may be mixed with heroin or counterfeit pills that look like normal prescription medications, so people may not be aware that they’re exposing themselves to the drug.

The rise in fentanyl use has health officials particularly worried, given its tremendous potency. To try to get a handle on the problem, the state has asked all local hospitals to report suspected fentanyl overdoses. State officials have also asked providers to test for fentanyl when ordering drug screening in cases of suspected overdose.

This is a disturbing news in the worsening opioid crisis. A simple search of Google news will show that officials in Ohio, Pennsylvania and other states are seeing surges in fentanyl overdoses.

In his post Opioids, spines, and dead people, Joe Paduda talks about physicians and prescribing, giving context to the issue:

In a related piece, Michael Van Korff ScD andGary Franklin MD MPH summarize the iatrogenic disaster driven by opioid over-prescribing. Over the last fifteen years, almost 200,000 prescription opioid overdose deaths have occurred in the US, with most deaths from medically-prescribed opioids.

Doctors prescribed opioids that killed well over a hundred thousand people.

Today, about 10 million Americans are using doctor-prescribed opioids; somewhere between 10% – 40% may have prescription opioid use disorder – they may well be addicted.

Van Korff and Franklin note that 60% of overdose fatalities were prescribed dosages greater than a 50 mg morphine equivalent.

In days gone by, drug deaths were primarily associated with illicit or street drugs, but today, it’s prescription drugs – and prescriptions are seen as the gateway to street drugs, rather than the reverse.  We now lose more people annually to drug overdoses than by car crashes or firearms.

In 2013, the most recent year for which data is available, 46,471 people in the United States died from drug overdoses, and more than half of those deaths were caused by prescription painkillers and heroin.

That compares with the 35,369 who died in motor vehicle crashes and 33,636 who died from firearms, as tallied by the federal Centers for Disease Control and Prevention.

Combating the public health scourge of prescription drug-related addiction and deaths will require a concerted effort on all fronts: physicians as prescribers; employers and insurers in the workplace; public health, elected officials and law enforcement in our communities. On that front, there have been some promising approaches in moving from a crime to a treatment approach: Connecticut Cops Consider ‘Angel’ Program to Combat Heroin Scourge

Another approach, pioneered in Gloucester, Massachusetts, shows promise and has been attracting increasing attention around the country. In Connecticut, Groton has adopted it and Manchester is considering a similar program.

Launched on June 1, the Gloucester Angel Initiative makes police the point agency in moving addicts directly into treatment. Addicts are allowed to surrender any drugs and needles they have with the understanding that they will not face arrest and that police and community volunteers called “angels” will help them toward recovery.

About 350 admitted addicts have sought help in Gloucester through the program, department spokesman John Guilfoil said on Jan. 8. As a side benefit, crime fueled by addiction, particularly thefts, dropped 33 percent last summer compared with the summer of 2014, Guilfoil said.

Fifty-three police agencies in the country have adopted similar programs, and two to three more join each week through a partnership called the Police Assisted Addiction and Recovery Initiative, Guilfoil said.

Prior related posts:

 

Studies: Opioid epidemic grows; Is obesity a smoking gun in rise of prescription drugs?

Wednesday, January 13th, 2016

You may have taken hope from studies that pointed to a decrease or leveling of the rate of deaths related to opioid and prescription drug use in 2012-2013. If so, the Centers for Disease Control wasted no time this year in throwing some cold water on those hopes.

On January 1, via the Morbidity and Mortality Weekly Report (MMWR), the CDC issued new data on Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014.

                      Age-adjusted rate of drug overdose deaths and drug overdose deaths involving opioids: US 2000–2014

mmwr opioid trends

Here are some of the key findings:

  • During 2014, a total of 47,055 drug overdose deaths occurred in the United States, representing a 1-year increase of 6.5%, from 13.8 per 100,000 persons in 2013 to 14.7 per 100,000 persons in 2014.
  • Rates of opioid overdose deaths also increased significantly, from 7.9 per 100,000 in 2013 to 9.0 per 100,000 in 2014, a 14% increase.
  • In 2014, there were approximately one and a half times more drug overdose deaths in the United States than deaths from motor vehicle crashes
  • The 2014 data demonstrate that the United States’ opioid overdose epidemic includes two distinct but interrelated trends: a 15-year increase in overdose deaths involving prescription opioid pain relievers and a recent surge in illicit opioid overdose deaths, driven largely by heroin.
  • From 2000 to 2014 nearly half a million persons in the United States have died from drug overdoses.
  • The rate of deaths from drug overdoses has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (opioid pain relievers and heroin).

The 2013-2014 increase was geographically pervasive. In 2014, the five states with the highest rates of drug overdose deaths were:

  • West Virginia (35.5 deaths per 100,000)
  • New Mexico (27.3)
  • New Hampshire (26.2)
  • Kentucky (24.7)
  • Ohio (24.6).

States with statistically significant increases in the rate of drug overdose deaths from 2013 to 2014 included Alabama, Georgia, Illinois, Indiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Mexico, North Dakota, Ohio, Pennsylvania, and Virginia.

For more analysis of the data, see Kim Krisberg’s story at The Pump Handle.

Obesity: A Smoking Gun?

Is obesity a contributing factor to the opioid epidemic? That’s certainly an avenue worth further investigation. Recent research shows more evidence of the increase in prescription drug use and study authors suggest an obesity connection.

In November, researchers at Harvard’s T.H. Chan School of Public Health issued a report which was published in in JAMA, the journal of the American Medical Association: Trends in Prescription Drug Use Among Adults in the United States From 1999-2012

NPR’s Alison Kodjak reports on the study in Americans Are Using More Prescription Drugs; Is Obesity To Blame?

Two of the key findings:

  • 59% of adults used a prescription drug in a 30-day period, up from 50% a decade earlier.
  • The share of people taking more than five prescription drugs in a month doubled to 15%.

Lead author Elizabeth Kantor said that:

” … the rise in prescription drug use may have to do with the rise in obesity, since many of the most widely prescribed drugs treat obesity-related conditions such as diabetes, high blood pressure, and high cholesterol. The study found, for example, that the share of people using cholesterol-lowering agents, mostly statins, jumped from 7% to 17%.”

 

Related opioid reading matter:

Peter Rousmaniere Takes On The Opioid Controversy And Offers A Prescription For The Future

Monday, June 29th, 2015

Work Comp Central has published We’re Beating Back Opioids – Now What? written by columnist Peter Rousmaniere in cooperation with CompPharma, a consortium of workers’ compensation Pharmacy Benefit Managers.

To say the Mr. Rousmaniere is a “workers’ compensation thought leader” is a little like saying Ted Williams was a pretty good baseball player. In this provocative analysis he expertly  chronicles the increasingly alarming rise in opioid usage to treat work injuries from the early 1990s through the first decade of this century, what he calls “the twenty year crisis.” He describes how Purdue Pharma’s introduction and heavy-handed marketing of Oxycontin in 1996 lit the fuse of the opioid rocket ride to the moon, setting off a series of  cataclysmically destructive personal odysseys on a grand scale. Lives ruined, families torn apart. And he documents the myriad counterattacks mounted by responsible parties around the country, most notably Dr. Gary Franklin, the neurologist and medical director for the Washington State Department of Labor & Industries, who, by anyone’s standard has been a torchbearer in the battle.

Rousmaniere describes how the responsible physician community, recognizing that things were getting more than a little out of control, began to question the effectiveness of opioids in treating pain:

In 2013, the American Medical Association published a review of pain medications, in which it concluded that “Narcotics provide little to no benefit in acute back pain, they have no proven efficacy in chronic back pain, and 43% of patients have concurrent substance abuse disorders, with aberrant medication-taking disorders [in] as high as 24% of cases of chronic back pain.” The “no evidence” concept has been stretched to raise more questions, as in this conclusion published in early 2015: “There is no evidence that opioids improve return to work or reduce the use of other treatments. They may even limit the effectiveness of other treatments.”

Finally, he tells the story of how the federal government as well as almost all the states, the insurance industry, the American Medical Association and workers’ comp pharmacy benefit managers took definitive action to bend the opioid curve to the point where all of the leading indicators have been significantly slowed or reversed.

But Peter Rousmaniere’s report up to this point, the halfway mark, is merely preamble to the real thrust of We’re Beating Back Opioids – Now What? It’s the “Now What?” that concerns Mr. Rousmaniere. The “baby and the bathwater” question. He writes:

The workers’ comp industry was victimized by opioids and their well-resourced purveyors and ardent advocates. But it also made a costly, unforced strategic error. It paid more attention to wrestling with this flawed solution than to the underlying problem: chronic pain.

In short, Rousmaniere says, “We have equated pain management with drug use.” He isn’t shy about making his point:

Too much attention was diverted to fighting the opioid threat. For example, when states introduce hard hitting formularies, such as Texas did and others are doing, hardly any thought is given to making sure patients and physicians have access to a balanced array of non-opioid treatment. This needs to change – now.

Well, chronic pain is real. So, if not with opioids, how should the medical community be treating it?

Rousmaniere’s prescription is an elastic version of conservative care. He describes the approach of California’s second largest private employer, Albertsons / Safeway / Vons, who “learned through experience” that every injured person is a unique individual and that new ideas need to be brought to the recovery process.

For example, it’s almost a cliche  to say that chronic pain sufferers tend to depression as well as other mental and behavioral health issues. Consequently, Cognitive Behavioral Therapy, an underused treatment because of its perceived fuzziness, is gaining traction within the world of claims management.  As is the idea of treating injured workers in a biopsychosocial way. And, because opioid treatment is still an option, many in the medical community are saying that before any injured workers receive opioid prescriptions they should be screened for depression.

Rousmaniere argues persuasively that “one size fits all” treatment just doesn’t work for many people and that the solution to this thorniest of workers’ comp problems will take a heretofore unheard of level of cooperation and coordination among and between the industry’s disparate factions. He even goes so far as to compare the effort required to the largest single public infrastructure project in the nation’s history, Boston’s Big Dig. Although, having lived through the Big Dig and its daily remapping of Boston’s streets, that’s a bit of a long pull for me. But I get his point:

The goal of the Big Dig was to improve the livelihood of the Boston metropolis – more than reworking traffic flow. The goal of a chronic pain initiative is to keep workers productive – more than managing drugs.

Peter Rousmaniere’s  We’re Beating Back Opioids – Now What? is a compelling, stimulating and thought provoking work by a person with 30 years in the workers’ comp trenches and the scars to prove it. It should be required reading for anyone whose job it is to help injured workers return to the productive future each deserves.

 

 

Opioids: the Gateway to Heroin

Wednesday, February 12th, 2014

The surprising overdose death of acclaimed actor Philip Seymour Hoffman has put a spotlight on a national epidemic: prescription drug abuse. In workers’ comp, prescription drugs have been an area of great concern for a number of years; so too in the public health and policy arena. But has the message — and the necessary education — filtered to the general public? It would seem not: According to the CDC, prescription painkiller overdoses nearly quadrupled in the decade from 1999 to 2008.
This past week, the New York Times framed the new reality: Prescription Painkillers Seen as a Gateway to Heroin

“Dr. Jason Jerry, an addiction specialist at the Cleveland Clinic’s Alcohol and Drug Recovery Center, estimates that half of the 200 or so heroin addicts the clinic sees every month started on prescription opiates.

“Often it’s a legitimate prescription, but next thing they know, they’re obtaining the pills illicitly,” Dr. Jerry said.

In many parts of the country, heroin is much cheaper than prescription opiates. “So people eventually say, ‘Why am I paying $1 per milligram for oxy when for a tenth of the price I can get an equivalent dose of heroin?’ ” Dr. Jerry said.

In many parts of the country, heroin is much cheaper than prescription opiates. “So people eventually say, ‘Why am I paying $1 per milligram for oxy when for a tenth of the price I can get an equivalent dose of heroin?’ ” Dr. Jerry said.”

drug-1
Oklahoma: One state’s experience
The investigative journalism non-profit Oklahoma Watch recently published a report on the state’s addiction: As Drug Deaths Rise, Millions of Narcotic Prescriptions Filled
According to this report, Once occupying the ignominious position of first in the list of states with prescription drug abuse, Oklahoma is now #8 on the list. In 2012, 844 Oklahomans were killed by overdoses, eclipsing the year’s 708 traffic fatalities. The state has a real-time Prescription Monitoring Program that is reported to be one of the best in the nation, but doctors are not required by law to check the database before prescribing controlled dangerous substances. There was an average of 68 prescriptions per patient.
Oklahoma is also seeing a steep rise in heroin use, echoing the concept and experience that opioids are the gateway drug.

“Hal Vorse, a physician who treats habitual drug users and teaches new doctors about addiction at the University of Oklahoma Health Sciences Center, said he’s seen the phenomenon in his own practice.

“We’re seeing a big surge in heroin, and 85 percent of those people started on prescription opiates,” said Vorse. “The cost of their addiction got so high that they switched to heroin because it’s cheaper.”

Vorse said the price on the street for OxyContin has risen to $1 to $1.50 per milligram. Addicts typically use 200 to 300 milligrams per day, he said. “They find out they can get an equivalent dose of heroin for a third of what it costs for Oxys,” Vorse said.”

On the Workers Comp front
Meanwhile, in workers’ comp’s battle against opioids, Joe Paduda says that Opioid guidelines are about to get a whole lot better with the anticipated upcoming release of guidelines by ACOEM. He’s has a sneak peek and finds them to be “comprehensive, extremely well-researched and well-documented, and desperately needed.”
But he also points out that more progress is needed: Why don’t workers’ comp payers have pharmacists on staff?.

“I’m only aware of three major work comp insurers (Travelers, BWC-Ohio, Washington L&I) that have pharmacists on staff; the North Dakota State Fund does as well.

With pharmacy costs accounting for somewhere around 15% of total medical spend, that seems like a “miss”. Yes, pharmacy costs have been flat in recent years, but the impact of drugs on work comp claim duration and the medical and indemnity expense associated with long-term drug use is quite significant.

by-state
Resources:
The National Conference of State Legislatures offers an overview of state laws
CDC on the Drug Overdose issue
Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999–2008
Prescription Drug Overdose: State Laws

News roundup: Risk, Dispensing Docs, Costs for Employees, Litigation & more

Wednesday, October 3rd, 2012

Risk roundup – Our Down-Under friend Russell Hutchinson of Chatswood moneyblog posts this week’s Cavalcade of Risk, with a global roundup of posts. Check it out.
Costs for EmployeesInsurance Journal reports on the latest Bureau of Labor Statistics report on the cost of U.S. employees, noting that the nationwide average cost for private industry employers was $28.80 per hour worked in June 2012. “The costs ranged within each region, with total compensation costs of $24.44 in the East South Central division to $33.47 in New England.” The article offers more detail on the report, noting that costs were collected from a sample of 47,400 occupations from about 9,500 establishments in private industry. Data excludes self-employed and farm and private household workers.
Physician Dispensing – Joe Paduda looks at potential conflict of interest issues in a post about ABRY Partners, he asks, “How is it that an investment firm owns stakes in a TPA, MSA company, subrogation firm – and a physician dispensing and billing company?” Is one company cleaning up a mess that another company makes? In other repackaging news, he notes that Miami-Dade Schools has taken a stand on physician-dispensed repackaged drugs – they are refusing to pay the markups, a move that saved more than half a million dollars. Employers take note: Is this a potential area of savings in your comp program.
Narcotics Studies – Rita M. Ayers reports on a recent study by Accident Fund Holdings and Johns Hopkins University that links opioid use to an escalation in overall claim cost in the Tower MSA Blog. She notes that the study reveals that 55% to 85% of injured workers receive narcotics for chronic pain. She says that the study, “…examined the interrelationship between the utilization of short- and long-acting opioid medications and the likelihood of claim cost escalating to a catastrophic level (> $100,000). Analyzing 12,000 workers’ compensation claims in Michigan during a four-year period, the study focused on whether the presence of opioids alone accounted for the cost increase or whether costs increased because opioids were associated with known cost-drivers, such as legal involvement and injury severity.” Related: WCRI: Nearly 1 in 12 Injured Workers Who Started Narcotics Still Using 3-6 Months Later.
Worst States for Lawsuits – “Lawsuit Climate 2012″ is a study evaluating how fair and reasonable states’ tort liability systems are perceived by businesses in the U.S. It was conducted by the U.S. Chamber Institute for Legal Reform. According to those surveyed, Delaware has the best legal climate for businesses.See respondents’ picks for the Top 10 Worst States for Lawsuits, along with more on the study’s results.
High Costs for Police Dept. – The LA Daily News reports that Los Angeles spends more on LAPD workers’ comp claims than for all others combined – some $65 million in 2010-2011 alone. The department averages 250 claims a month. Authorities say that it is “…one of four drivers of the city budget deficit. Others include the costs of salaries, pensions and health care.”
News Briefs

Addendum As a follow-on to yesterday’s post about Shackleton’s Medical Kit, we found more information and a photo of Shackleton’s medical kit at The Science Museum of London, and a related post from NPR’s Health Blog: ‘Cocaine For Snowblindness’: What Polar Explorers Packed For First Aid.
shackleton-medical-kit.JPG

Annals of Compensability: Confusion and Death from an East Texas Cocktail

Monday, September 10th, 2012

We have been tracking the compelling issue of compensability in drug overdoses within the workers comp system. We have blogged drug-induced fatalities that are compensable (Tennessee) and non-compensable (Ohio and Connecticut). Given the prevalence – make that rampant over-use – of opioids in the workers comp system, prescription drug abuse is an issue with profound implications for injured workers, their employers and the insurers writing workers comp policies across the country.
Which brings us to the saga of Bruce Ferguson-Stewart. He was injured on May 25, 2004 while working for AltairStrickland, an industrial contracting firm in Texas. A bolt weighing several pounds fell from above, striking Ferguson-Stewart and injuring his shoulder and neck. The MRI showed “minor disc bulges” at three levels on his cervical vertebrae. His treating physician diagnosed him with a left shoulder contusion and prescribed hydrocodone as part of the treatment plan. The doctor also recommended surgery to repair the shoulder.
Denial and its Consequences
For reasons that are not clear from the trial documents, the claim was denied by Commerce & Industry Insurance, the employer’s carrier. The carrier lost the initial appeal and then lost again. The insurer then sought judicial review of the Division-level finding of compensability.
Meanwhile, with his shoulder untreated and in extreme pain, Stewart continued to take his prescribed Hydrocodone, known locally as an “East Texas cocktail.” At every level of appeal, the compensability of the claim was upheld, but the surgery was delayed – with apparently disastrous results. (The delaying tactics may have been related to Stewart’s alleged history of abusing prescription drugs.)
On October 3, 2004, while his worker’s compensation claim was still being contested, Ferguson-Stewart died from an overdose of hydrocodone. His blood contained a hydrocodone level of 0.38 mg/L, which is consistent with acute severe toxicity. The blood also contained carisoprodol, a prescription muscle relaxant, and marihuana.
Trial by Jury
Ferguson-Stewart’s widow filed for death benefits under workers comp, but the case was denied. The widow appealed.
At trial, Ferguson-Stewart presented two theories as to how and why Stewart might have unintentionally or unknowingly ingested a lethal dose of hydrocodone. First, in what CIIC describes as the “accidental overdose” theory, Ferguson-Stewart alleged that the overdose must have been accidental because her husband did not intentionally or knowingly commit suicide.
Tommy J. Brown, a forensic pathologist who performed an autopsy on Stewart, concluded that the cause of death was hydrocodone toxicity and that the manner of death was “accidental.” Brown’s testimony is right out of central casting:

Well, I–I see it a lot. I do autopsies on people with chronic pain a lot and
this–like before I see them, start out with their drugs and then they
increase the drugs, and then to try the [sic] alleviate the pain more, and pretty soon they’re taking more than prescribed, and pretty soon they will
overdose theirselves [sic] or they will overdose theirselves [sic], some
people do. And then they die and it’s usually in a low lethal range [like
that observed in Stewart]. So I consider that an accidental death because
they were overdosing due to the chronic pain.

With its pathos and illuminating detail, the widow’s testimony reads like a monologue from a Faulkner novel:

The day before or the day of–that he died. They say he actually died
early in the morning; so, I guess the day before. He was really disoriented. He was not acting normal or the way he had been acting since he was hurt. He wasn’t acting normal at all. His speech was slurred. He was stumbling and falling all over things. I remember–I think I remember one time he actually falling [sic] out of a chair and–in the yard
because he was trying to get up and he tripped over a root and he fell on
the shoulder he had injured. And that made it even that much more
painful for him. He was–he was very–he was crying about it. He really
had hurt himself.
. . . .
He was–in the last couple of days before he died, he was getting really
bad about forgetting that he had already taken his medicine and taking it
again; and you know, sometimes I would have to tell him, “Hey, you
already took it. You can’t take it again.” And usually he would agree with me; but there were times when he would say, “No. No. No. I didn’t take it. I’m sure I didn’t take it. I’m still hurting too bad, and I don’t remember taking it.” So, he’d take it again.
But especially the day of [his death], he was entirely too confused. He
wasn’t–like I said, he wasn’t himself at all.

The jury charge instructed that “[a] claimant’s death does not
result from medical treatment instituted to relieve the effects of his compensable injury if the death results solely from a claimant intentionally or knowingly failing to comply with his doctor’s instructions[emphasis added].” The jury concluded that Ferguson-Stewart’s death was unintentional, resulting from the treatment for his compensable injury. The widow was granted death benefits.
Intention, Confusion and Compensability
Under Texas law, compensability hinges on Ferguson-Stewart’s intent: was the death an intentional suicide or was it an accident? He had no intention of killing himself, so the death was compensable. In a somewhat similar Connecticut case (see above), the overdose was the result of the deliberate (and illegal) act of using a needle to ingest drugs. That case was denied.
Behind every death due to prescription drugs lies a story worth telling. Powerful and effective pain killers are transformed into instruments of death. When it comes to the compensability of these cases, disorientation and confusion are not limited to injured workers experiencing pain. The medical and workers comp systems struggle with the ambiguous legacy of medications: while opioids offer immediate, short-term relief from pain, the relief is followed all-too-often by a downward spiral of addiction and dependency.
I truly wish the testimony of Ferguson-Stewart’s widow could be played in the examination room of any doctor about to write a script for an “East Texas cocktail.” The doctor just might consider a more benign and less toxic alternative.

Opioids: Altered Minds and Bottom Lines

Wednesday, August 29th, 2012

In this era of data mining and predictive analytics, it’s really not that difficult to project which comp claims are headed for “catastrophic” levels. Just follow the meds. A new study entitled “The Effects of Opioid Use on Workers Compensation Claims Cost in Michigan” establishes a direct link between long-acting medications and the eventual magnitude of the claim. Where short-acting opioids are involved, the claim is 1.76 times more likely to break the $100K barrier; with long-acting medications, the likelihood increases to a whopping 3.94. The researchers, including Jeffrey Austin White and Jack Tower of Accident Fund Holdings in Lansing MI, demonstrate what has been long known anecdotally: the use of opioids is an “independent risk factor for development of catastrophic claims.”
The study examined over 12,000 claims that opened and closed between January 2006 and February 2010. (Had they included claims that were still open, the numbers may have been even more dramatic.) In an effort to isolate just how much opioids drove up the costs, the study accounted for other risk factors including sex, age, attorney involvement, the number of medical treatments and claim duration.
Pain and Dr. Sajedi
There is a relatively simple logic at work: injuries cause pain and opioids alleviate extreme pain. The question, naturally, is which injuries require extreme pain relief and which could be managed with lesser medications. Far too many doctors are too quick to prescribe narcotics, even as they fail to implement the most elementary safeguards to ensure that the drugs are used properly and for as short a duration as possible. (A comparable problem exists with the overuse of antibiotics; doctor training clearly needs more emphasis on pharmacology.)
Which brings us to Dr. Ebrahim Sajedi, 46, an internal medicine specialist in California who gets good reviews from his patients. Trained at the Rochester School of Medicine, Sajedi was busted on 12 felony counts of prescribing medications without a legitimate purpose. He provided scripts for Vicodin, Adderall, Klonopin and similar drugs to four undercover police officers without examining them and for no medical purpose. Why buy drugs on the street when you can get the good stuff from a certified specialist?
Bottom Lines
The prevalence of strong drugs in the comp system should come as no surprise. We live in a culture where we are supposed to live pain free, virtually forever, stimulated and distracted in every waking moment. We can hardly fathom the pain that mankind endured in every generation up until recent times. There is a complex, perhaps ultimately incomprehensible alchemy that takes place when pain relievers are introduced into the body. But this relief comes at great cost and even greater risk.
In workers comp, the cost is borne by the employer. The quick pain fix of opioids inevitably finds its way to the employer’s bottom line in the form of prolonged absence from work, higher costs, higher experience mods and bigger insurance premiums. We have long suspected that injured workers on opioids stay out of work far longer than is medically necessary and often find themselves in the downward spiral toward a permanent disability lifestyle. With this Michigan study, we have further documentation that the promiscuous use of drugs undermines the recovery of injured workers and the financial stability of their employers.

Cost Containment Piracy

Monday, April 23rd, 2012

When looking for cutting edge activities in workers comp abuse, it’s a good idea to start in California, where key stakeholders occasionally function like pirates in the Gulf of Aden. We have frequently focused on the burgeoning costs of opioids in the workers comp system. As we learned at the Workers Comp Research Institute conference last November, too many doctors who prescribe opioids have no idea what they are doing, no idea how to manage opioid-based treatment and no clue about the potential for harm.
In the entrepreneurial free-for-all that is California, we see the latest trend in opioid abuse: turning the “best practice” of drug testing into an opportunity to milk the system. (The details are available in Greg Jones’s article at WorkComp Central – subscription required.)
Here’s how it works: doctors who tend to over-prescribe opioids are jumping on the drug testing bandwagon: either through their own testing, or through contracted services, they are able to parlay a simple $200 drug test into a bill for $1,700 or even $3,000. The labs are playing with billing codes, performing the less expensive qualitative tests but charging for the more expensive quantitative tests. It’s a clever scam: first over-prescribe, then drug test and over-bill.
The WorkCompCentral article quotes Howard Appel, president of Millennium Laboratories of San Diego: “I’m offended when workers’ comp is paying $3,000 for a drug test that cost $200.” Appel’s company operates under a “responsibility pledge” where explicit ethical standards are used for drug testing and billing.
Genuine Best Practices
We remind Insider readers of the best practices that should accompany virtually any prescription for opioids:
1. Above all, use opioids sparingly; most prescriptions for opioids in the comp system are unnecessary, ill-advised and poorly managed.
2. Virtually all injured workers prescribed opioids should be evaluated for dependency issues prior to beginning an opioid regimen, drug tested prior to receiving opioids and throughout the course of treatment. Without these pre-conditions, opioid use is full of uncertainty and fraught with danger.
3. Ideally, opioids should come with a written contract and a User’s Manual. Workers should be tested on their knowledge of the benefits and the risks.
Note that drug testing is a necessary component of the treatment protocol. The problem in California – and probably elsewhere – is that drug testing is of little value where opioids have been mis-prescribed in the first place. Under best practices, opioids are a last resort, rarely used and carefully managed. Under California scheming, they are over-prescribed, over-monitored and over-billed. All of which goes to show that you don’t need a fishing boat and a few automatic rifles to become a pirate. A nice white coat and a plastic cup can work just as well.

Health Wonk Review and assorted news of note

Thursday, April 12th, 2012

Brad Wright of Wright on Health tees up all the health wonkery this week as he hosts Health Wonk Review: A Masterful Edition.
Texas – Texas does things differently and their work comp program is true to course. Employers are not mandated to have workers comp insurance – they can opt out. According to a 2010 survey, 15% of businesses with 500+ employees choose to opt out. And now Walmart is opting out of work comp in Texas. See more on this at PropertyCasualyt360, including a graph of market share for the top 10 insurers comparing 2010 to 2011: Concerns Arise over Texas Workers’ Comp. State System After Walmart Drops Out
Mississippi reform – Mississippi is working on workers comp reform and we note that one provision about “medical proof” establishes a pretty high bar to hurdle for some injuries; for example, a back injury: “It also would require a worker to provide the employer with medical proof that an injury or illness is a direct result of the job if the worker’s claim is contested.”
Dirty Business – Is workers’ comp dirty? Some people seem to think so and Dave DePaolo considers whether there’s more to the frequent use of the term than coincidence. See Work Comp and Dirt – Do They Have to be Synonymous?
Florida drug warsTampa Bay Times says that drugstores are the new focus of painkiller investigations. From the article: “The U.S. Drug Enforcement Administration says that in 2009 no Walgreens retail pharmacies were listed among the DEA’s top 100 Florida purchasers of oxycodone — a key ingredient in OxyContin, Percocet and Percodan. / By 2011, 38 Walgreens made the list. By February, the total reached 53 of the top 100. So says a warrant filed last week in U.S. District Court for the Middle District of Florida. / In Fort Myers, the DEA says one Walgreens pharmacy sold more than 2.1 million oxycodone pills in 2011. That’s more than 22 times the oxycodone sales at the same pharmacy two years earlier.”
Healthcare’s 1%Who are the chronically costly? The costliest 1% of patients consume one-fifth of all health care spending in the U.S., according to federal data. Doug Trapp of amednews digs into the data to profile the most costly patients and where so much of the medical spend goes.
From the courts – Fred Hosier of SafetyNewsAlert has an interesting post about whether workers comp will be on the hook for prescribed drug’s side effects. He cites a case related to a West Palm Beach police officer who has filed for additional workers’ comp benefits for the treatment of his gynecomastia, an excess growth of breast tissue, a side effect of medication he was prescribed to treat a work-related injury. Initially denied, an appeals court has reopened his claim for review by an expert medical advisor.
Occupational Medicine – It’s been a bit since we visited the American College of Occupational and Environmental Medicine (ACOEM) site. ACOEM offers up a few new guides, and a revision of an older guide – Fatigue Risk Management in the Workplace (PDF), Guidance to Prevent Occupational Noise-Induced Hearing Loss and Guidance for the Chronic Use of Opioids.
Affordable Care Act – At Health Care Policy and Marketplace Review, Bob Laszewski looks at what individual health insurance might cost if the court strikes the mandate down and still requires insurers to cover everyone. Hint: a lot.
Briefly….