Reducing Narcotics Abuse in Workers Compensation

As the cost of prescriptions, including narcotic medications, directly impacts the cost of a workers compensation claim, insurers are looking for ways to quickly get control of cases of misuse and abuse. One of the most efficient ways to manage narcotic use in a claimant population is to partner with a pharmacy benefit manager (PBM). A PBM can clearly define a strategy for proactively and effectively monitoring narcotics. These plans and strategies help payors ensure injured worker safety and reduce expenses.

The Workers Compensation Narcotics Quandary

Narcotics, also referenced as opioids or opiates, have a long history of being used to therapeutically treat pain resulting from on-the-job injuries. They are often prescribed to alleviate pain after an injury first occurs, when other drugs are ineffective for acute pain and in chronic pain cases.

And, while narcotics are considered safe and effective if used properly, they have the potential for leading to addiction and abuse if not monitored and controlled. Misuse and abuse of narcotics represent three areas of particular concern for workers compensation insurers including:

1. Potential for serious health risks.
2. Higher percentage of medical expenses as claims age.
3. Risk of litigation.

Potential for Serious Health Risks

The United States Food and Drug Administration (FDA) has recognized serious risks associated with narcotics use including respiratory depression, central nervous system depression, addiction, and death. Some of these risks are associated with improper dosing, indication, patient selection, abuse, and addiction. As a result of these adverse events, the FDA has begun to take serious steps to monitor whether the benefits of narcotic medications outweigh the risks associated with short- and long-term usage.⁴

These steps include an FDA-led panel developing Risk Evaluation and Mitigation Strategy (REMS) for long-acting narcotics. The purpose of REMS is to ensure that prescribers are educated regarding the proper use of narcotics and that benefits outweigh risks associated with:

1. Abuse.
2. Misuse.
3. Overdose, both accidental and intentional.

Narcotics, including methadone tablets, fentanyl patches and extended-release medications containing morphine, oxymorphone, and oxycodone are among the medications effected by the REMS requirement. Narcotics on the FDA’s list are provided in a table at the end of this article.⁵

Recently, the FDA proposed plans to further address the increasing misuse and abuse of narcotics specifically related to extended-release (ER) and immediate-release (IR) opioid analgesics. While a panel committee agreed the goals of the REMS are appropriate, the individual components of the REMS are insufficient to address the misuse and abuse of ER opioid analgesics. It was agreed that these particular REMS plans be tabled until there is a stronger proposal in place.⁶

Higher Percentage of Medical Expenses as Claims Age

While narcotics account for more than a quarter of workers compensation medication spending, even more troubling is the allocation of that spending. In a recent study released by the National Council on Compensation Insurance, narcotics’ total share of medication expenses increases as claims age – from 15 percent in year one to as much as 35 percent in the fifth year of service.⁷

The role narcotics play in total workers compensation claims expenses has not gone unnoticed by state workers compensation funds. For example, the Arizona State Compensation Fund noted they were easily able to pinpoint over-prescribing of narcotics as a key source of inflated medical costs.⁸

What’s more, the longer an injured worker is on narcotics, the longer the delay in the injured worker’s ability to return to work in a timely fashion. There is also an increased likelihood the payor will need to pay for rehabilitation programs for addiction.

Risk of Litigation

Narcotic abuse poses serious legal risks for workers compensation payors. While much of the litigation to date has been targeted against physicians and pharmacies, there are many experts who believe workers compensation payors will be next. This is because payors have access to data showing patterns of abuse and misuse and may have the duty to warn injured workers and prescribers in cases involving potential misuse.⁹

Workers compensation payors who choose not to take proactive measures to monitor utilization or communicate with physicians could face lawsuits for negligence. This is especially critical in cases where one or more narcotics are prescribed for more than six months at a time.

With respect to paying questionable claims, many payors have done so rather than face the expense and time of litigation. Morally, this poses a key question for insurers. Is it acceptable for insurers to settle fraudulent claims or does it position them as aiding and abetting the perpetrator? This could change if payors become defendants in lawsuits related to narcotic abuse.

References

1. “2010 Workers Compensation Drug Spend Analysis.” Progressive Medical, April 2010.
2. “Risk Evaluation and Mitigation Strategies for Certain Opioid Drugs; Notice of Public Meeting,” Federal Register, Volume 74, Number 74; Notices, Pages 17967-17970, Department of Health & Human Services, Food and Drug Administration, Docket No: FDA-2—0-N-0143.
3. “Trends in Emergency Department Visits Involving Nonmedical Use of Narcotic Pain Relievers,” Substance Abuse and Mental Health Services Administration and Centers for Disease Control, http://www.cdc.gov/mmwr(/mmwr/).
4. Gardiner Harris, “FDA to Place New Limits on Prescriptions of Narcotics,” New York Times, February 9, 2009.
5. “Opioids Products Chart,” U.S. Food and Drug Administration, http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm163654.htm.
6. “Opioid Drugs and Risk Evaluation and Mitigation Strategies (REMS),” U.S. Food and Drug Administration, http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm163647.htm.
7. Barry Lipton, Chris Laws and Linda Li, “Narcotics in Workers Compensation,” NCCI Research Brief, December 2009 p.5.
8. “Sky High Out of Control Drug Costs A Threat,” State Compensation Fund of Arizona.
9. “Prescription for Peril,” December 2007, Coalition Against Insurance Fraud, p. 43.

About Progressive Medical
Progressive Medical offers cost management services and programs to the workers compensation industry. By combining its clinical expertise with access to an expansive network of pharmacies, home health care services and medical equipment and supplies, the company enables its clients to manage costs while providing quality care to injured workers. Learn more at Progressive Medical or call 866.939.5365. http://www.workcomptransformation.com/narcotics-quandary/

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