The opioid crisis in America is frequently in the news and should be. Opioids have caused an enormous cost increase for workers’ compensation employers and insurers. Some cases are impossible to settle because a Medicare Set Aside trust (“MSA”) is required, and the cost of the MSA is $500,000 or more due primarily to the projections of opioid medications for the remainder of the claimant’s life. The Center for Disease Control (“CDC”) recently issued guidelines for prescribing opioids for chronic pain. A copy of those guidelines is attached. The CDC is attempting to effect an enormous change in how opioids are used.
Here are the high points: “Opioids are not first line or retained therapy for chronic pain.” Although opioids can be appropriate for acute pain immediately after an injury, “clinicians should prescribe the lowest effective dose of immediate release opioids and prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. According to the guidelines, three days or less will often be sufficient; more than seven days will rarely be needed.
The other guidelines discuss the need for frequent drug screens, and discontinuing opioids after a few weeks, if there is no meaningful improvement in pain and function. Physicians should also review a patient’s history, if any, for the use of any addictive narcotic medications or drugs. Before prescribing medications, doctors should go online to use state prescription drug databases.
According to these guidelines, opioids are for acute pain immediately after a severe injury or trauma, or end of life care. Opioids are not for treatment of long term chronic pain.
Remember: these guidelines are only suggestions and do not have the force of law. Many doctors will continue to prescribe opioids and maintain that they are useful for the treatment of chronic pain. At a minimum, those doctors should be getting frequent urine drug screens from their patients, with confirmation testing of the drug screens. Doctors should also assess if the opioids are reducing pain and improving function.
Pre-employment and random drug screens should include testing for opioids as well as any drug screens done immediately after an injury. Remember that someone that has just suffered a severe injury may have opioids in his or her system from medications immediately given after the injury. The confirmation drug testing can distinguish between the presence of opioids which have been in a person’s system for several days versus opioids taken within the past few hours.
RECOMMENDATIONS FOR NEW CLAIMS
With new claims, try to keep claimants off opioids after the first three to seven days. If an authorized treating physician insists on prescribing opioids for more than three to seven days, it is appropriate to forward the CDC guidelines to the treating physician, ask whether he or she intends to perform frequent drug screens, and whether the doctor will assess the benefits of the treatment within one to four weeks. As you know, many doctors simply start prescribing opioids and likely have the expectation that the patient will be on opioids for months or years. Even if opioids are tried as a treatment for chronic pain, they should not be continued if there is no improvement in pain and function within the first few weeks or months. Even if the patient insists that the pain is reduced from the opioids, the doctor should also be checking or clinical and objective signs of improved function. Subjective reports from the patient that the opioids are helping should not be sufficient to warrant continuing prescriptions. Although doctors are not required to follow the CDC guidelines, the guidelines provide a reasonable basis for questioning doctors who seem to offer little more than chronic use of opioids.
Doctors who do not use opioids have to provide other treatment options. This treatment will likely take the form of physical therapy, work hardening conditioning, or injections. Another opinion is psychological treatment specifically designed to help a patient cope with pain. There has been, and likely will continue to be, reluctance to include psychological counseling for pre-existing as part of a pain management program. This treatment must be specifically designed to help an injured patient learn to live with chronic pain and/or disabilities rather than a “blank check” to treat unrelated conditions.
RECOMMENDATIONS FOR PATIENTS ALREADY TAKING OPIOIDS
For patients who have been on opioids for years, the solution is not to simply stop authorizing the medications. Patient cannot go “cold turkey.” Some patients will be difficult to wean from opioids. There are several strategies which may be successful. Get a second opinion with a physician who is known to wean patients from opioids and who offers treatment options other than pills. Peer review or utilization review could be an option. Insist the patient be required to undergo frequent drug screens. According to the guidelines, if the opioids are not helping, the solution is not to increase the dosage. The solution is to try another form of treatment. Also, make sure the doctor responds appropriately to inconsistent drug screen results.
Other options include filing a motion for a change in authorized treating physician or asking the treating physician if he or she will consider switching a patient with opioid use disorder to medications such as Buprenorphine, Methadone, or Naloxone.
The over prescription of opioids will likely continue to be a problem. Fortunately, the CDC guidelines, and the studies and research upon which these guidelines are based, can help give employer/insurers a reasonable basis to prevent opioid addiction and to argue for weaning some chronic opioid users from these medications. If you have any specific questions about opioids, please do not hesitate to contact Drew Eckl & Farnham.