Winter 2020/2021

Moving Forward: How Should Opioid Guidance Continue to Evolve?

Fast Focus

With prescription opioid utilization decreasing, groups like the American Medical
Association want to ease restrictions on opioid prescriptions to help patients facing
chronic pain. However, the COVID-19 pandemic raises new risks that impact opioid
use, making it uncertain how opioid policy should move forward.
Over the last several years, prescription opioid utilization has decreased across healthcare and in workers’ comp, giving many people hope that the epidemic responsible for nearly 450,000 deaths since 19991 could soon be a thing of the past.

Decreases in Opioid Utilization

According to the Centers for Disease Control and Prevention (CDC), opioid prescribing has been decreasing since 2012.2 Studies have found:

Annual opioid prescribing fell 19% from 2006-20172

Opioid prescriptions decreased 23% from 2012-20172

Daily MME per opioid prescription dropped 24% from 2006-20173

MME per injured worker fell 30% or more in 17 states4

But while a 2019 industry survey revealed that workers’ comp leaders may view opioids as less of a top program challenge, chronic pain is still considered a top industry concern.5 And with chronic pain, there will continue to be a legitimate medical need for opioid medications in certain scenarios.

Opioids, even at reduced levels of utilization, still require ongoing vigilance and reassessment, both on an individual claim basis, and on a big picture level, to ensure patient safety and manage associated costs.

But how should we navigate the use of opioids going forward? Some groups are calling for reforms that loosen opioid restrictions to better assist patients with pain management, while others call for further scrutiny, citing the impacts of the COVID-19 pandemic.

Calls for Reform: The American Medical Association

The American Medical Association (AMA) took the position that the U.S. no longer has a prescription opioid epidemic, but rather an overdose epidemic driven by heroin and illicit synthetic opioids.6

This claim is backed by CDC data which indicates that prescription opioid overdoses now make up a small part of overall opioid overdoses,1 and it is why the AMA believes that current prescription opioid policy needs to change.

The AMA posits that various entities have adopted CDC guidelines as hard policies, leading to excessive opioid restrictions that have created stigma around pain management.6

This has supposedly led to the denial of care for patients who could benefit from opioid prescriptions that exceed CDC thresholds. The AMA believes that now is the time to shift to a more holistic, patient-centric mode of care beyond hard policies and prescription limits.

What Steps Does the AMA Want to Take?

The AMA wants healthcare workers, policy makers, and other stakeholders to develop a new opioid model that acknowledges patient individuality.7 While more discussion is necessary to establish and achieve such a model, the AMA offered various suggestions.

What follows is a brief summation of some of their more notable recommendations.

An Increased Focus on Mental Health

The AMA is advocating for greater assessment, referrals, and treatment for co-existing mental health disorders within opioid-using populations, as well as meaningful oversight and enforcement of state and federal mental health and substance use disorder parity laws.7

Mental health has a particularly crucial role in workers’ comp, as issues such as anxiety, depression, catastrophizing (assuming the worst), and fear avoidance can be detrimental to recovering from workplace injuries.

HOW MENTAL HEALTH
IMPACTS RECOVERY

Depression is the foremost inhibitor of restored function in injured worker patients with minor injuries8

Psychosocial factors can be more detrimental to claims outcomes than physiologic factors in patients following surgery for occupational hand injury9

Fear avoidance can lead to higher pain and disability levels and lower return-to-work rates10

Understanding That Opioid Dosing Should Be Unique

The AMA takes the stance that the CDC opioid guideline’s dosage and quantity limitations have been adopted too strictly by state legislatures, national pharmacy chains, federal agencies, and various healthcare companies.6

Stepping outside the AMA’s positions, opioid dosing should not be a one-size-fits-all matter. Individual patients will have varying tolerances to opioid medications. According to the AMA, a patient’s initial opioid prescription may require adjustments to better address the severity of pain, but such adjustments – which require additional or replacement prescriptions – may be interpreted as doctor-shopping behavior.7

72% of pain medicine specialists said that they – or their patients – have been required to reduce the quantity or dose of medication prescribed11

Furthermore, the AMA notes that reports from prescription drug monitoring programs (PDMPs) sometimes require interpretation. Physicians who specialize in pain management are more likely to prescribe opioids, and at higher strengths, than a general practitioner. However, without this context, prescriptions may be flagged as suspicious.

While PDMPs are incredibly valuable in managing opioid therapy – some studies have shown that PDMPs have reduced doctor-shopping behavior by 80%12 – misinterpretations of legitimately complex opioid histories can delay care for the patient, leaving them in serious pain that is detrimental to their recovery and wellbeing.

Addressing Barriers to Non-Opioid Treatment

While patients can often benefit from non-opioid pain therapies, the AMA believes there has been no concomitant increase in access to or affordability of evidence-based non-opioid alternatives.6

Despite a general desire to direct patients away from opioids, there are significant barriers to alternative treatments.

ADMINISTRATIVE BURDENS

92% of pain specialists report facing authorization roadblocks for non-opioid pain care11

62% of pain medicine specialists said that they have had to hire additional staff to handle the prior authorization requirements11

Improving Access to Treatment for Opioid Use Disorder

In addition to general reform to opioid policy, the AMA also wants to improve patient access to treatment for opioid use disorder (OUD) among patients with pain.7

Over 2 million Americans have untreated substance use disorder, and 50,000 healthcare professionals were newly certified to prescribe buprenorphine (a drug that helps treat OUD) since 2017.7

While there is clearly a strong need for OUD treatment, the AMA claims that inappropriate administrative burdens and other barriers delay or deny care for FDA-approved medications used as part of medication-assisted treatment for OUD.

This is particularly relevant to workers’ comp, as a study from the Journal of Occupational and Environmental Medicine (JOEM) found that providing access to OUD drug therapy leads to significant cost savings among injured worker populations.13

Calls for Additional Concern: COVID-19 Impacts

While the AMA makes many points on the need for opioid reform, the COVID-19 pandemic has severely disrupted many aspects of healthcare, which in turn can impact opioid use.

Mental Health

There is no shortage of stressors that the COVID-19 pandemic has placed upon individuals; isolation from social distancing, disruption in family and support systems, stress over the virus itself, financial worries, employment concerns, general uncertainty, and more.

Mental health concerns such as catastrophizing, anxiety, and depression put individuals at a higher risk for prescription opioid misuse.14 Furthermore, psychiatric drugs prescribed for the treatment of mental health disorders often react negatively with opioid medications, which can endanger patients.

NOTABLE TRENDS

Antidepressants saw a 9.2% increase in utilization during the pandemic, while antianxiety drugs saw a 10.2% increase in utilization15

In March, anxiety medication prescriptions increased by 2 million compared to 201916

51.4% of opioids – or 60 million prescriptions – in the U.S. are prescribed to adults with mental health conditions17

Among Americans with mental health disorders, 18.7% use prescription opioids17

Furthermore, for those who have previously suffered from substance abuse, the stress of the pandemic could potentially trigger a relapse. Quest Diagnostics, an organization that manages millions of workplace drug tests for employers, reported that positive drug tests are at a 16-year high, likely due in part to pandemic-related stressors.18

If patients are abusing any type of substance, adding opioids to the mix will not provide a benefit that exceeds the risk.

Healthcare Changes and Disruptions

Prior to the pandemic, state and federal governments, in addition to various private entities, were still in the process of initiating opioid policy initiatives meant to keep the momentum going against the opioid epidemic.

However, planned initiatives across the country have been put on hold for the time being as stakeholders focus on pandemic-related concerns.

For example, the National Health Institute (NIH) paused a $900 million project meant to improve the understanding of pain, pain therapy, and treatment for OUD.19 Meanwhile in New York State, an initiative to help spur opioid weaning in legacy claims was delayed.

Furthermore, regulatory changes stemming from the pandemic have created easier access to prescription drugs. Though these efforts are applauded for maintaining continuity of care while reducing potential viral exposure, this has limited traditional clinical oversight in certain cases.

In some scenarios, controlled substances can be prescribed via telehealth, opioids can be prescribed from out of state, and early refills can give patients access to more opioids.

COVID-19 and Opioids

Considering the worst-case scenario, if a patient were to develop COVID-19 while taking opioids, the results could be disastrous.

COVID-19 can cause acute respiratory distress syndrome (ARDS), a buildup of fluids in the lung that reduces oxygen to the bloodstream. Even mild cases of COVID-19 make breathing difficult.

Opioid medications, even when used as directed, come with the risk of respiratory depression (slow and ineffective breathing). Combining a drug and disease that both debilitate breathing can put patients in serious danger.

Considering how much of a risk COVID-19 is right now, with over 250,000 deaths in the U.S.,20 opioid use now comes with escalated risks.

Extra Precaution: FDA Recommends Co-prescribing
Naloxone with Opioids

An additional call for concern surrounding opioid use comes from the FDA, which now recommends providers co-prescribe naloxone – the opioid overdose reversal drug – with all opioid prescriptions, as well as with all OUD medications.21

New language reflecting these recommendations will be added to drug labels to reduce the risk of death from opioid overdose. While these recommendations can potentially save lives, there are two important claim-related points to note:

Patients may assume having a naloxone medication will act as a safety net against opioid overdose, allowing them to use opioids more liberally.

This is not the case, as oftentimes naloxone may only temporarily reverse an opioid overdose. Emergency medical services are still required because the naloxone prescribed may not be enough to completely counteract the opioids a patient ingested.

Patients with high levels of opioids in the body may wake up from an overdose, but once the naloxone runs its course, remaining opioids in the body could restart an overdose. It is therefore important to discuss these concerns with patients.

Adding a naloxone prescription to every claim with an opioid prescription could significantly increase pharmacy costs on an opioid claim.

Oftentimes, naloxone is only necessary for high-dose opioid prescriptions. Low-dose opioid prescriptions may only require naloxone co-prescriptions in special circumstances, such as with chronic opioid therapy, certain comorbidities, when special medications are concurrently being used, etc.

However, initial naloxone costs should not deter a co-prescription, as preventing overdoses and subsequent complications not only helps patients but saves costs in the long run.

Fine Tuning for a Better Model of Care

While the opioid epidemic has improved, it is not yet over.

Continued vigilance and appropriate clinical interventions are still necessary to maintain the progress made and to continue reducing opioid overdose deaths. This is particularly important in the COVID-19 era, as additional risks emerge due to the ripple effects of the pandemic.

There will always be mitigating circumstances where patient-specific care considerations require exemptions from established guidelines. Going forward, care recommendations must continuously be fine-tuned as new risks emerge in order to best guide therapy.

KEY CONSIDERATIONS FOR FINE TUNING OPIOID THERAPY

Non-pharmaceutical and non-opioid pain relief must be considered first whenever possible; opioids should only be initiated when these modalities fail, or when pain is severe
Mental health must be considered when prescribing opioids
Mixing opioids and psychiatric medications is not safe
Barriers to non-opioid care must be addressed if patients cannot be allowed to use opioids
Greater utilization of medication assisted therapy (MAT) for OUD is still needed and benefits not only patients, but payers as well
Opioid dosing should use guidelines as a starting point, not an ending point; opioid dosing should factor in a patient’s unique opioid tolerance, comorbidities, other medications, care history, and a wide variety of other factors

References

  1. Opioid data analysis and resources. Centers for Disease Control and Prevention. Page last reviewed March 19, 2020. https://www.cdc.gov/drugoverdose/data/analysis.html
  2. Prescribing practices: changes in opioid prescribing practices. Centers for Disease Control and Prevention. Last updated Aug 12, 2019. https://www.cdc.gov/drugoverdose/data/prescribing/prescribing-practices.html
  3. 2018 Annual surveillance report of drug-related risks and outcomes – United States. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Aug 31, 2018. https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf
  4. Wang D, Thumula V, Liu TC. Interstate variations in dispensing of opioids, 5th edition. WCRI. July 31, 2019. https://www.wcrinet.org/reports/interstate-variations-in-dispensing-of-opioids-5th-edition
  5. 2020 Workers’ comp industry insights survey. Healthesystems. 2020. https://www.healthesystems.com/CompSurvey2020
  6. Docket No. CDC-2020-0029 – American Medical Association letter to Centers for Disease Control and Prevention. American Medical Association. June 16, 2020. https://searchlf.ama-assn.org/undefined/documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2F2020-6-16-Letter-to-Dowell-re-Opioid-Rx-Guideline.pdf
  7. Opioid task force 2020 progress report: physicians’ progress toward ending the nation’s drug overdose and death epidemic. American Medical Association. July 2020. https://end-overdose-epidemic.org/wp-content/uploads/2020/07/AMA-Opioid-Task-Force-2020-Progress-Report.pdf
  8. Richmond TS, Amsterdam JD, Guo W, et al. The effect of post-injury depression on return to pre-injury function: a prospective cohort study. Psychol Med. 2009;39:1709-20.
  9. Roesler ML, Glendon AI, O’Callaghan FV. Recovering from traumatic occupational hand injury following surgery: a biopsychosocial perspective. J Occup Rehabil. 2013;23:536-46.
  10. Wertli MM, Rasmussen-Barr E, Held U, et al. Fear-avoidance beliefs – a moderator of treatment efficacy in patients with low back pain: a systematic review. Spine J. 2014;14:2658-78.
  11. Second annual survey of pain medicine specialists highlights continued plight of patients with pain, and barriers to providing multidisciplinary, non-opioid care. American Board of Pain Medicine. 2019. http://abpm.org/uploads/files/abpm%20survey%202019-v3.pdf
  12. Ali MM, Dowd WN, Classen T, et al. Prescription drug monitoring programs, nonmedical use of prescription drugs, and heroin use: Evidence from the National Survey of Drug Use and Health. Addict Behav. June 2017; 69: 65-77. https://pubmed.ncbi.nlm.nih.gov/28152391/
  13. Opioid use disorder and employee work presenteeism, absences, and health care costs. Journal of Occupational and Environmental Medicine. May 2020. https://journals.lww.com/joem/Abstract/2020/05000/Opioid_Use_Disorder_and_Employee_Work.4.aspx
  14. Arteta J, Cobos B, Hu Y, et al. Evaluation of how depression and anxiety mediate the relationship between pain catastrophizing and prescription opioid misuse in a chronic pain population. Pain Med. Feb 2016. doi: 10.1111/pme.12886.
  15. Petersen A. More people are taking drugs for anxiety and insomnia, and doctors are worried. Wall Street Journal. May 25, 2020. https://www.wsj.com/articles/more-people-are-taking-drugs-for-anxiety-and-insomnia-and-doctors-are-worried-11590411600
  16. Shifts in healthcare demand, delivery, and care during the COVID-19 era: tracking the impact in the United States. IQVIA. April 2020. https://www.iqvia.com/insights/the-iqvia-institute/covid-19/shifts-in-healthcare-demand-delivery-and-care-during-the-covid-19-era
  17. Davis MA, Lin LA, Liue H, et al. Prescription opioid use among adults with mental health disorders in the United States. J Am Board Fam Med. 2017;30:407-17. doi: 10.3122/jabfm.2017.04.170112
  18. Workforce drug testing positivity climbed to highest rate in 16 years, new Quest Diagnostics drug testing index analysis finds. Quest Diagnostics. Aug 25, 2020. https://newsroom.questdiagnostics.com/2020-08-25-Workforce-Drug-Testing-Positivity-Climbed-to-Highest-Rate-in-16-Years-New-Quest-Diagnostics-Drug-Testing-Index-TM-Analysis-Finds
  19. Coping with the Collision of Public Health Crises: COVID-19 and Substance Use Disorders. NIH Director's Blog with Dr. Volkow, April 21, 2020. https://directorsblog.nih.gov/2020/04/21/coping-with-the-collision-of-public-health-crises-covid-19-and-substance-use-disorders/
  20. CDC COVID data tracker - maps, charts, and data provided by the CDC. Centers for Disease Control and Prevention. Nov 13, 2020. https://covid.cdc.gov/covid-data-tracker/
  21. FDA recommends health care professionals discuss naloxone with all patients when prescribing opioid pain relievers or medicines to treat opioid use disorder. FDA. July 23, 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-recommends-health-care-professionals-discuss-naloxone-all-patients-when-prescribing-opioid-pain

RxInformer

Since 2010, the semi-annual RxInformer clinical journal has been a trusted source of timely information and guidance for workers’ comp payers on how best to manage the care of injured worker claimants and plan for the challenges that lay ahead. The publication is an important part of Healthesystems’ proactive approach to advocating for quality care of injured workers while managing the costs associated with treatment.