Prescription Opioids as Barrier to Recovery in Workers Compensation

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1 Prescription Opioids as Barrier to Recovery in Workers Compensation CMSA Conference Presentation June 2013 Barbara DeGray, RN-BC, CRRN Aimee Uhrig, RN, CCM To empower individuals and organizations to attain and sustain health and productivity

2 Objectives 1. Participants will be able to identify trends in regards to the increase in prescription opioids in healthcare and within the workers compensation environment with the resulting effects of increased disability and expense. 2. Participants will be able to identify and describe the collaborative strategies utilized within the workers compensation environment by the nurse case manager and workers compensation team to overcome the barrier to recovery caused by increased prescription opioids. 3. Participants will be able to apply clinical knowledge of pain management techniques and communication techniques to support the injured worker s recovery to prevent, reduce or overcome disability caused by prescription opioids. 2

3 Nurse Case Managers in workers' comp are dedicated to PREVENT MINIMIZE OVERCOME an employee s disability

4 Pondering Paradox Pain management medications that are meant to improve recovery can lead to increasing disability Opioid use beyond the acute phase of injury can impair function Opioid use can itself become a barrier to recovery Opioid use can in itself increase the pain experience Dependency and addiction are not desired outcomes by anyone on the workers' comp team, especially the patient 4

5 Is there an opioid problem in workers compensation? AUDIENCE PARTICIPATION Case Managers say 5

6 Workers comp industry says Duration for claims with prescribed opioid pain medication is clearly higher than for claims without opioids prescribed. National Council on Compensation Insurance, NCCI: Workers Compensation Temporary Total Disability Indemnity Benefit Duration 2012 Update In some cases, the use of opioids for work-related injuries may actually increase the likelihood of disability. Receiving more than a one week supply of opioids or two or more opioid prescriptions soon after an injury doubles a worker s risk of disability at one year post injury, compared with workers who do not received opioids. Washington State Department of Labor and Industries deline pdf 6

7 Nation says CDC: Centers for Disease Control and Prevention has classified prescription drug abuse as an epidemic CDC: Opioid-related Overdose Deaths Are a National Epidemic Deaths-Are-a-National-Epidemic FDA: Food and Drug Administration is extremely concerned about the inappropriate use of opioids, which has reached epidemic proportions in the U.S., becoming a major public health challenge. blogs.fda.gov/fdavoice/index.php/2013/03/fda-joinswith-health-professional-organizations-inencouraging-prescribers-to-seek-training-to-safelyprescribe-opioid-pain-medicines/ Office of National Drug Control Policy: Prescription drug abuse is the Nation s fastest-growing drug problem. 7

8 Prevalence of Hydrocodone Food & Drug Administration, FDA By number of prescriptions sold ittee/ucm pdf Source: IMS Health 8

9 Physicians say The American College of Occupational and Environmental Medicine, ACOEM: Overuse of opioid therapy to treat chronic pain conditions is becoming epidemic in the United States Journal of Clinical Psychiatry: A National Epidemic of Unintentional Prescription Opioid Overdose Deaths 9

10 Employees say i need my percs for my back but am scared that its killing me(the pills.) HELP! Got injured about a year ago and have been poppin' pills ever since. They work for the pain but now I'm addicted. No one understands- including myself. So soooo...low when I run out! I just want my life back. Website blogs and discussion groups 10

11 they spoke. they listened. they responded. Make a habit of two things: to help; or at least to do no harm Hippocrates 11

12 Nation responds EPIDEMIC: RESPONDING TO AMERICA S PRESCRIPTION DRUG ABUSE CRISIS Office of National Drug Control Policy, ONDCP The 2011 Prescription Drug Abuse Prevention Plan expands upon the Obama Administration's National Drug Control Strategy. Four major areas to reduce prescription drug abuse EDUCATION Educate parents, youth, and patients about dangers. Require prescribers to receive education on use, proper storage and disposal MONITORING Implement prescription drug monitoring programs (PDMPs) in every state to reduce doctor shopping and diversion, with sharing across states.. DISPOSAL: Develop responsible prescription drug disposal ENFORCEMENT Provide law enforcement with the tools necessary to eliminate improper prescribing practices and stop pill mills 12

13 Workers Comp Industry Responds IAIABC, International Association of Industrial Accident Boards & Commission: National guidance for states for enacting legislation Washington state: Opioid Dosing Guideline Insurance companies, third party administrators and self-insured employers: network requirements, peer reviews, case management oversight, utilization review committees 13

14 Washington State website resources FREE Patient Assessment Tools - Please feel free to print and use in your practice. Below are documents and tools that are found in the 2010 Opioid Dosing Guideline for Chronic Non-Cancer Pain. While the guideline contains other useful tools, we feel these are the most valuable and efficient. These documents are all in the public domain and are recommended as the best free practical, publically available tools. Activity Diary (122 KB PDF) Patient activity diary sample to help track goals and progress Opioid Risk Tool (65 KB PDF) Screening tool for past and current substance abuse Opioid Treatment Agreement (51 KB PDF) Doctor/patient agreement samples DSHS Chronic Pain Agreement (18 KB PDF) Doctor/patient agreement samples Alcohol Abuse Screening (14 KB PDF) Audit Questionnaire: Screening for alcohol misuse CAGE-AID - Overview (30 KB PDF) The CAGE-AID is a conjoint questionnaire where the focus has been expanded from alcohol alone to include alcohol and other drugs CAGE-AID - Questionnaire (27 KB PDF) The CAGE-AID Questionnaire is to be used in conjunction with the CAGE- AID Overview PHQ-9 - Overview (45 KB PDF) The PHQ-9 is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression PHQ-9 - Questionnaire (226 KB PDF) The PHQ-9 Questionnaire is to be used in conjunction with the PHQ-9 Overview Opioid Dosing Calculator (33 KB XLS) Calculate the total daily morphine equivalent dose (MED) for prescribed opioids 14

15 Health Care Industry Responds Structured Pain Management Plans Dosage guidelines Contracts with employees Drug testing at appointments One primary prescriber for opioids REMS:Risk Evaluation and Mitigation Strategy (REMS) for Extended- Release and Long-Acting Opioids: Required education and monitoring MED, Morphine Equivalency Dosage, facilitates comparisons 15

16 Morphine Equivalents Total opioid dose can be converted into morphine units This is called the Morphine Equivalent Dose (MED) Above 120mg MED per day is considered the high dose threshold Risks substantially increase at doses at or above 100 mg Specialty consultation is recommended Assessing the effectiveness of opioid therapy should include tracking and documenting both functional improvement and pain relief 16

17 Role of Case Management PREVENT progression from acute to chronic use of opioids MINIMIZE need for opioids OVERCOME dependency and addiction

18 Definition of Case Management The Case Management Society of America (CMSA) definition of Case Management is as follows: Case Management is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes. 18

19 Case # 1 PREVENT MINIMIZE OVERCOME Mike, 52 yr old security employee, sustained severe ankle strain 3 weeks ago. E.R. ordered Hydrocodone, Flexeril, crutches, and off work instructions until seen by ortho. Ortho added ankle splint, PT and instruction for ice & elevation and remain off work 1 week and then return to work with restrictions. Modified duty was not available. At 3 weeks, post injury, Mike remains off work and continues with Hydrocodone 3-4 times a day and attends PT 3 x week. Question: Appropriate case management interventions, at this time, may include: 1. Review with employee, side effects of Hydrocodone and potential for dependency, expectations of recovery and alternate methods of pain reduction. 2. Review records and verify if any history of risk factors for dependency or addiction 3. Contact employer and require offer of modified duty work 4. Write to treating physician and reference industry standards for opioid use related to acute injury 5. Be accepting that some people just can t tolerate pain and opioids are needed until at MMI with full duty release to work. 19

20 Prevention of Dependency and Addiction Primary goal in workers comp case management regarding use of opioids is to help employee AVOID dependency and addiction Education is key Stay in contact with employee Clarify expectations of anticipated pain Plan action if previous history, such as, attendance at AA or NA groups Facilitate access to alternate methods for managing pain Communicate with prescribing physician with oversight of proper use of medical standards and opioid prescribing. Utilize physician networks when possible. Obtain assistance with monitoring from Pharmacy Programs. Obtain reviews, second opinions and IME s. Whenever possible, avoid transition from acute to chronic 20

21 Common Employee Barriers to Recovery due to Opioids Impaired function Impaired mental and emotional capacity * Uncontrolled pain Acceptance of need based upon continued prescribing by treating physician Dependency Addiction Inability to work Mistrust of intentions of case manager, claims and employer Diversion 21

22 Impaired mental and emotional capacity * PAIN and DISABILITY may be linked to Depression Catastrophic thinking Fear of further pain or injury Feelings of perceived injustice Pain and disability factors enhanced by long term use of opioids PGAP, McGill University 22

23 Common Health Care Provider Barriers to Time constraints Recovery due to Opioids Limited education or understanding of opioids Sympathy for patient Authorization process Limitations of traditional drug rehab not customized for prescription addiction and underlying pain Paperwork Financial gain with possible diversion Mistrust of intention of claims management Legal concerns Frustration 23

24 Common Employer Barriers to Recovery due to Opioids Time constraints Limited education or understanding of opioids Human resource or operations constraints Mistrust Frustration Personal experiences 24

25 Common Claims Barriers to Recovery due to Opioids Time constraints Limited education or understanding of opioids Paperwork Litigation Mistrust Frustration Personal experiences 25

26 Common Case Manager Barriers to Recovery due to Opioids Time constraints Limited education or understanding of opioids Documentation Litigation Mistrust Frustration Personal experiences Desire to fix everything for everyone 26

27 Overcome Barriers Assessment is essential in understanding if an opioid problem even exist or has potential for developing Assessment is essential in understanding factors each member brings to the case: employee, employer, provider, claims plus effects of other life factors Planning involves extensive consideration as to potential interventions based upon assessment and case manager s knowledge of opioids and drug rehab with clarity of short and long term goals Implementing actions of facilitation, education and communication often requires persistence and extensive collaboration in accessing appropriate services. Monitoring, re-assessing and documentation keeps the case moving toward resolution 27

28 It s not whether you get knocked down, it s whether you get up. Vince Lombardi 28

29 Case Manager s knowledge and role as educator To educate others, need to educate self Understand the barriers Know the facts about opioids Obtain information about pain management treatments Understand methods for effective communication and relationship building Recognize and accept limitations of case management interventions 29

30 Case Management Strategies Transition to Chronic Use Case manager may be able to influence referral to good pain management specialist Subacute to chronic transition point MED > 120 Need for opioid management plan beyond scope of primary care practice Set expectations for having a plan that addresses function Employer should anticipate need to observe, assess and document alertness vs. impairment in return-towork planning 30

31 Short Acting and Long Acting Variations in durations for long acting based upon medication and patient response, can vary from 8 to 72 hours. No 2 patients are identical Tailoring Chronic Pain Treatment to the Patient: Long-Acting, Short-Acting, and Rapid-Onset Opioids Charles Argoff, MD,

32 Case #2 MINIMIZE PREVENT OVERCOME Tina is a 43 yr old laundry worker who injured her neck 4 years ago leading to 2 cervical surgeries. She has worked sedentary work intermittently since DOI and is currently off work since 2 nd surgery 7 months ago. Tina s attorney has declined offer of case management contact with employee and treating physician. Medical records are available through claims and billing. Current diagnoses include s/p cervical fusion, chronic pain, depression. Tina continues with long acting, Opana. Records indicate intermittent PT with reference to aquatic therapy but no indication that implemented. Records don t seem to indicate opioid dependence or addiction behavior. QUESTION: Appropriate CM interventions, at this time, may include: 1. Communicate, in writing, with attorney requesting follow-up of aquatic therapy. 2. Facilitate referral to aquatic therapy through claims process. 3. Communicate, in writing, with attorney requesting sharing of REMS with treating physician and reinforcement that limited duty is available at same employer. 4. Collaborate with claims to consider second opinion or IME to address medical necessity of opioid with request to consider alternate medication and/or appropriate treatment plan for chronic pain and depression. 5. Educate employer and claims on opioid guidelines in chronic pain and depression 32

33 Case management techniques to overcome opioid barriers ASSESSMENT Identify existence of opioid SIDE EFFECTS Anticipate DEPENDENCE with continued use Identify whether improved FUNCTION is clearly demonstrated Consider that HIGH DOSES may be causing increased pain Clarify physical and psychological diagnoses Determine if additional diagnostic procedures are indicated Include all members of team: patient and family, physicians, other health care providers, claims agents, employers, and self, as case manager 33

34 Case management techniques to overcome opioid barriers IMPLEMENTATION Facilitate patient access to alternative methods of pain management and treatment of physical and psychological condition(s) Implement structured monitoring of utilization, Pharmacy Benefit Manager, PBM Coordinate objective measurements of function, such as, functional capacity evaluations, ACPA Quality of Life Scale Facilitate access to detoxification, drug rehabilitation and support services Refer or provide vocational services to obtain or retain employment Maintain professional detachment and objectivity 34

35 Common: Opioid Side Effects Nausea, vomiting, constipation Until body adjusts sedation, drowsiness Physical dependence, tolerance Less common: Delayed emptying of the stomach Hormonal dysfunction (including sexual problems) Increasingly recognized: Hyperalgesia 35

36 Opioid-Induced Hyperalgesia Changes in neurologic response caused by overexposure to opioids resulting in INCREASED PAIN Paradoxical response with increased opioid dose, the pain increases Suspect when opioid s effect seems to wane without evidence of the injury or illness worsening, especially symptoms like burning, tingling, or increased sensitivity to touch Clinically complex and difficult to diagnose 36

37 Pain and Opioid Dose in Opioid Induced Hyperalgesia And so on Pain increases more so doctor ups the opioid dose again Pain still not better, in fact is worse, so doctor increases the opioid dose again Increased pain reported so increased pain medication dose is prescribed 37

38 Function Opioid guidelines say that opioids may be continued for chronic non-cancer pain as long as: No troublesome side effects There is documented evidence of improved function No evidence of aberrant behavior 38

39 Case # 3 PREVENT MINIMIZE OVERCOME Case: Jack is 26 yr old who injured his back 3 yrs ago. Has worked intermittently since DOI but now off work for past 6 months due to his inability to progress past sedentary work. He has been prescribed opioids since DOI with increasing dosage levels and now takes Norco, 2 x day as long acting and Percocet 2-3 a day as short acting. His speech is often slurred during conversations and he demonstrates memory impairment. He has gained 40 pounds since DOI. Current diagnoses are Chronic Back Pain, Depression, Narcotic Dependency. He expresses desire to get off these drugs and mentioned Livestrong website. He is not yet at MMI. QUESTION: Appropriate CM interventions, at this time, may include: 1. Communicate with treating physician as to consideration of hyperalgesia and referral to detox and residential rehab program 2. Arrange IME to address medical necessity of continued opioids 3. Communicate with employee regarding expectations of increased function with timeframes with employee input as to impact of opioids 4. Utilize steps referenced on Livestrong to move toward detox 5. Facilitate vocational services to identify sedentary work with new employer 39

40 Impact on Function A good scale is that developed by the American Chronic Pain Association (ACPA) 40

41 ACPA Quality of Life Scale NON-FUNCTIONING 0 Stay in bed all day. Feel hopeless and helpless about life. 1 Stay in bed at least half the day. Have no contact with outside world. 2 Get out of bed but don t get dressed. Stay at home all day. 3 Get dressed in the morning. 4 Do simple chores around the house. Minimal activities outside of home two days a week. 5 Struggle but fulfill daily home responsibilities. No outside activity. Not able to work/volunteer. 6 Work/volunteer limited hours. Take part in limited social activities on weekends. 7 Work/volunteer for a few hours daily. Can be active at least five hours a day. Can make plans to do simple activities on weekends. 8 Work/volunteer for at least six hours daily. Have energy to make plans for one evening social activity during the week. Active on weekends. 9 Work/volunteer/be active eight hours daily. Take part in family life. Outside social activities limited. 10 Go to work/volunteer each day. Normal daily activities each day. Have a social life outside of work. Take an active part in family life. NORMAL QUALITY OF LIFE 41

42 Signs of potential aberrant behavior Non-adherence with other aspects of medical or mental health treatment plan Non-adherence with requests from claims or employer Drug-seeking behavior Signs of diversion Demonstrated poor coping mechanisms leading to interpersonal problems with family, friends and work associates 42

43 Diversion Opioids following pattern of Methadone 43

44 Physical Dependence Physical dependence is an expected response to chronic exposure to opioids. Withdrawal symptoms when drug is abruptly reduced or stopped. Often accompanied by tolerance, or the need to take higher doses of a medication to get the same effect. 44

45 Addiction Addiction is marked by compulsive drug seeking and use despite sometimes devastating consequences 45

46 Divide each difficulty into as many parts is feasible and necessary to resolve it. Rene Descartes 46

47 Case Management Techniques for Dependency and Addiction Avoid case manager frustration Divide your time, resources and energy into addressing each barrier while continuing to focus on the identified short and long term goals. 47

48 Case Management Techniques for Dependency and Addiction When assessment leads to determination of dependency and addiction, recovery often stalls until dependency and addiction are resolved. Case management interventions in other aspects of the employee s recovery can become less effective. Facilitation of non-opioid related services should continue with clarification of realistic short and long term goals and anticipated prolonged duration to meet goals. 48

49 Planning: employee agrees Collaborate with medical team as to preferred actions Consider gradual weaning vs detox For detox, in-patient safer and more effective Detox requires follow-up drug rehab Detox and drug rehab may take multiple attempts. Stay persistent. Continued monitoring to avoid relapse Identify potential support groups, in-person, telephonic or web based. 49

50 Planning: employee in denial Attempt to maintain contact with employee. Remain objective and non-judgmental Communication skills are KEY Focus on function If employee declines contact, focus on prescribing physician. Start with sharing standards. Obtain peer reviews and IME s. Share written standards with reviewers. Be persistent. You are still helping employee to overcome disability. Seek denial of further payment based upon medical necessity and guidelines. Continue to offer drug rehab services. 50

51 Advocacy for Options & Services Once started, it is sometimes hard for patients and their treating doctors to stop opioids Within a few months of starting, if it looks like the patient will need to stay on opioids, doctors should be starting to develop an opioid management plan 51

52 Substance Abuse Treatment Considerations Keep in mind that in almost all cases, opioid dependence was result of taking medication AS PRESCRIBED Terms addiction and addict can interfere with treatment acceptance Need programs that include pain management protocols (e.g. behavioral therapy, exercise, etc.) Access dependent on authorization and billing 52

53 Case # 4 MINIMIZE PREVENT OVERCOME Ana is 49 yrs old and previously worked as registered nurse with the VHA. She has been off work for 5 years following multiple back surgeries, including complications due to nerve damage during one of the surgeries. She continues with numbness in the left leg, requiring use of cane and occasionally a walker. She utilizes an internal nerve stimulation implant and attends pool therapy 3 times a week. She currently takes Nucynta (long acting) and Vicodin (short acting) for shooting pains that she reports in both legs. Extensive diagnostic studies have demonstrated no clinical reasons for shooting pains. Ana presents as addicted to opioids but denies need to reduce her use. QUESTION: Appropriate CM interventions, at this time, may include: 1. Communicate with employee regarding expectations of return-to-work 2. Review with employee options of volunteer work at 2 hours a day with goal to progress to 4 hours a day of paid employment 3. Collaborate with claims to consider authorization of residential program 4. Communicate with treating physician requesting referral to detox and rehab 5. Arrange IME to address medical necessity of continued opioids 53

54 Communication & Collaboration Direct contact with employee: supportive, nonjudgmental, professional Indirect: remain respectful and goal oriented Function focused Goal setting, short and long term, with time expectations Application of strong communication techniques with all members of the team, including employee case manager serves as role model Professional detachment and objectivity 54

55 Productive employment Productive employment remains focus of goal of recovery Involve vocational services during drug rehab with overlapping interventions Establish vocational goals with time tables Address need for opioid free life to return or remain at work Assist claims with documentation if settlement or non-work resolution anticipated 55

56 Documentation Clear objectives as related to employee: To reduce level of opioid use. To eliminate need for opioid use. To increase functional level to return to work, or progress to regular duty. To complete detoxification and drug rehab program. Assign expectations of completion dates. Level of employee s engagement in process with objective behavioral observations. If employee not engaged, involvement of alternate methods of resolution, including claims and employer actions. Progression to resolution 56

57 Not an easy task Continue to learn resources and facilities in your service area and nationally within WC plans Understand the regulations and apply to each case Remember that no 2 cases are totally alike Plan carefully and stay focused on the objectives of each case Obtain support from colleagues to remain objective and optimistic Celebrate successful resolutions. Attitudes are changing! Outcomes will follow. 57

58 Be Gentle with Yourself and Others It s a tough world out there, let s make it a bit more gentle for everyone

59 Nurse Case Managers in workers' comp are dedicated to PREVENT MINIMIZE OVERCOME an employee s disability

60 Acknowledgement Appreciation of support and permission for use of professional materials in preparation for this presentation as provided by Marianne Cloeren, MD, MPH. Board Certified Occupational Medicine and Internal Medicine 60

61 Contact Information Barbara DeGray, RN-BC, CRRN, MBA phone: Aimee Uhrig, RN, CCM, BSN phone:

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