Work Comp Insurers Find Doctors Willing to Bend When Asked to Curb Opioid Use

Workers’ compensation insurers are reporting dramatic reductions in opioid use by injured workers. In some cases, all it took was asking doctors to stop renewing prescriptions.

A peer-reviewed study by Mitchell International and Utah’s WCF Mutual Insurance Co. found that the number of opioids prescribed to claimants dropped by 56 percent in the 18 months after the carrier started flagging prescriptions that lasted longer than 14 days. WCF rejected or modified most of the opioid prescriptions that were requested after kicking off the intervention program, but there wasn’t much pushback from physicians, said Dr. Mitch Freeman, a pharmacist and clinical officer for Mitchell.

Freeman said in most cases, doctors modified their treatment plans after claim reviewers reminded them about American College of Environmental and Occupational Medicine guidelines.

“The physicians were not aware. They just didn’t realize what they were writing,” Freeman said. “They had been writing ‘one or two tablets every four to six hours as needed for pain.’ They’ve been doing that for decades.”

Dr. Dwight Robertson, medical director for Employers Insurance Co., said he had a similar experience when he implemented a policy in 2017 that requires claims managers to intervene in every claim where opioids were used for more than 30 days. Robertson said the carrier had long used utilization review to flag inappropriate prescriptions, but the new policy requires claims managers to go further by scheduling peer-to-peer discussions to talk about the patient’s opioid use and nothing else.

“My problem with utilization review is UR rarely ends up having a discussion, ‘Why is this patient still on the drug after 30 days?'” Robertson said. “I turned it upside down. It was a succinct discussion that appears to have had a dramatic effect.”

Robertson said when the program started, Employers flagged approximately 150 new claims where opioids had been in use for more than 30 days. He said the carrier whittled away at that number by reminding doctors that the goal is to end opioid use. Now, Employers has not as single new claim where the patient has continued opioid use longer than 30 days, he said.

Robertson said Employers continues to have “scores” of legacy claims involving claimants who are long-term habitual users, but it hasn’t created any new long-term opioid users because it has persuaded physicians to get their patients off of the drugs.

“The key to me was we needed to end up with zero,” he said.

Downward trend

Researchers have chronicled a long-term decline in the use of opioids by workers’ compensation patients across the United States over the past decade, which generally coincides with growing public awareness of the dangers of addiction. Many policymakers became concerned that state workers’ compensation systems were one of the gateways to chronic opioid abuse and imposed measures such as drug formularies and treatment guidelines to curb abuse.

The Workers’ Compensation Research Institute reported in July that opioid use declined by 10 percent to more than 20 percent in 27 states that it studied from 2012 to 2018. The report found that injured workers turned to other pain relievers, but that did not fully offset the reduction in opioid use, meaning there was a net reduction for all pain relievers paid by workers’ compensation.

The California Workers’ Compensation Institute — whose home state pays 20 percent of the total U.S. workers’ compensation premium — documented a 50% decline in the average number of opioids prescriptions to injured workers from 2008 to 2016, said Rena David, senior vice president of research for CWCI.

David said in 2008, 52% of California workers’ comp claimants had been prescribed an opioid within two years of injury. Now, opioids are prescribed in only 33% of claims. She said CWCI also measured a 45% reduction in the average potency of opioids from 2008 to 2016, measured by morphine equivalent dosages.

David said CWCI has seen a corresponding improvement in the amount of time that injured workers remain on temporary disability and improvements in claim closure rates. She said she can’t give specific numbers, but expects to publish the results of a study next week.

David said California’s implementation of evidence-based treatment guidelines are part of the reason, but physician awareness is also a factor.

“For most doctors, if they are made aware of the problem, they will usually respond,” David said. “I think education helps.”

Holding the line

In Utah, opioids were prescribed to one third of the state’s adults in 2014, according to the state Department of Health. It had the seventh-highest rate of opioid overdoses among the 50 states. Many of the state’s opioid users got their first pill after filing a workers’ compensation claim.

WCF, which writes 50% of the state’s workers’ comp premium, decided in was time to educate doctors. Starting on March 1, 2017, WCF started denying prescriptions of opioids with more than a 50 mg of morphine equivalent dose and kept initial prescriptions to a 14-day supply. American College of Environmental and Occupational Medicine guidelines state that usually no more than three days of opioid use is sufficient, but WCF decided to use a 14-day limit to avoid too severe a disruption to current practices.

The program required a review of any continued use of opioids Mitchell — the pharmacy benefit manager — after the initial supply ran out. Mitchell used a decision logic table created by ACOEM to determine if opioid therapy should continue. Treating physicians were required to show that the patient had reduced function because of pain, suffered a “severe disorder” warranting opioid treatment, and could show an objective improvement of both symptoms and functionality after the initial trial of opioid therapy.

WCF required Mitchell to make a decision about whether continued opioid use was merited within four hours. If the review could not be completed by then, the prescriptions were automatically approved, but dosages were limited to 50 mg of MED.

The study published in the occupational medicine journal explains the results by comparing opioid usage statistics from 18 months before the intervention program launched to 18 months after.

The results: Even though the number of claims increased by 9% during that time due to employment growth in Utah, the total number of prescriptions across all claims declined 30.8%, from 18,665 to 12,909. The total number of claims with any prescription fell from 22.8% of claims to 17.1% of claims. There was a reduction of 56.4% reduction in the number of opioids prescribed.

Freeman, the clinical director, said nothing in Utah’s workers’ compensation scheme says that WCF had a right to deny opioid prescriptions, or that it was required to authorize them. He said strict enforcement of the guidelines potentially could have increased legal costs by stirring up litigation before the Workers’ Compensation Board.

That didn’t happen.

“Having discussions with the physicians — walking them through the guidelines — it actually had a significant change in their prescriptions, instead of fighting it out before the board about what each injured worker should receive.”

“The study points out how much can be accomplished just by monitoring what is filled and doing outreach,” Freeman said.