Damming the River that Feeds the Lake
By Brian Allen
Battling the opioid epidemic is akin to working to drain a lake. In this case the “lake” is the large group of individuals who are dependent on or addicted to opioids. According to the National Survey on Drug Use and Health, in 2016, over 21 million Americans over the age of 12 needed some form of substance abuse treatment, much of that related to opioid abuse. That makes for a pretty significant lake. Draining that lake, or reducing the number of our citizens enslaved by opioids, can only be accomplished by reducing the number of individuals who start taking opioids - essentially damming the river that feeds the lake. Many states have or are taking action by passing legislation that is intended to reduce the prescribing of opioids. Congress is now entering the opioid crisis battle in a big way.
On May 9, 2018, the US House Energy and Commerce Committee marked up 25 opioid-related bills and plans to consider more bills on May 17th. The first round of bills approved cover a broad array of issues related to addressing the opioid crisis that continues to plague our country. Many of the bills are focused on programs to provide services to individuals who are already in the lake of addiction. There are a few bills of interest to the workers’ compensation community that are focused on damming the river, or preventing the use or abuse of opioids.
HR5002 – the Advancing Cutting Edge Research Act, or “ACE Research Act”, expands the authority of the National Institutes of Health to initiate research programs to explore and develop non-opioid treatments of pain.
HR5197 – the Alternatives to Opioids in the Emergency Department Act or “ALTO Act” directs the Secretary of Health and Human Services to conduct a demonstration program to test alternative pain management protocols to limit the use of opioids in emergency departments.
With so much of workers’ compensation care focused on managing pain, success in these first two initiatives could go a long way to providing viable options for reducing the use of opioids among injured workers.
HR5009 – “Jessie’s Law” directs the Secretary of Health and Human Services to develop best practices for including past substance abuse disorders in a patient’s health record to inform providers of the potential risk of relapse should an opioid be prescribed. The law is named for a young Michigan woman who was a heroin addict in recovery and was prescribed an opioid following surgery. The opioid triggered a relapse in her substance abuse that ultimately took her life. Patients consenting to include this information in their health record can inform future treating physicians of a potentially deadly risk. This is especially important in the workers’ compensation system since injured workers frequently are treated by specialists in occupational injuries who may not have the same visibility to the patient’s medical history as the regular, general health care doctor.
HR3528 – the “Every Prescription Conveyed Securely Act” would require e-prescribing for controlled substances in the Medicare Part D program. While not specific to workers’ compensation, if setting a standard of e-prescribing proves to reduce diverted or fraudulent paper prescriptions, it will make it easier for all facets of health care, including workers’ compensation, to begin requiring e-prescribing of opioids and other controlled substances.
States are also continuing their efforts to dam the river. Texas, who led in 2011 with a drug formulary targeting the reduction of the more dangerous long-acting opioids, is pioneering once again with their recently announced Opioids Plan-Based Audit. The Texas Division of Workers’ Compensation audit will focus on opioids prescribed within 10 days of the date of injury, prescribed supplies exceeding 30 days, and will look at claims where there is only one opioid prescriber and claims with multiple opioids prescribers. The opioid prescribing will be evaluated for medical necessity based on prevailing evidence-based guidelines. The Plan-Based Audit conducted a couple of years ago by the Texas DWC yielded some helpful information, resulted in a number of enforcement actions against physicians and prompted changes in the drug formulary rules for prescribing compounded medications.
In appraising many of the opioid prescribing guidelines being instituted across the country, most of them are recommendations without any real oversight or enforcement mechanisms built into the proposals. The Texas DWC Plan-Based Audit is first, and foremost, a targeted evaluation of opioid prescribing practices that will help shape future opioid prescribing policy in the Texas workers’ compensation system. Any enforcement yielded will be driven by the findings of the audit. Such enforcement, while not the primary reason for the audit, will also help shape prescribing behavior amongst providers.
Recent reports indicate that opioid prescribing in the workers’ compensation systems in many states is beginning to move downward. We have partially dammed the river but more needs to be done. Concerted effort, creativity and accountability are needed to fully span the gorge and reduce opioid prescribing to an appropriate trickle. The efforts of Congress and the various states to reduce prescribing and to seek treatment alternatives, coupled with accountability efforts like those in Texas, will, in time, give us a real shot at draining the lake of dependence and addiction.
==============================================
By: Brian Allen, Vice President of Government Affairs at Mitchell
As the Vice President of Government Affairs at Mitchell, a workers’ compensation pharmacy benefit manager, Brian is in the unique position to see firsthand how a drug formulary impacts injured workers as it is implemented and managed over time. In every state where a formulary has been approved and activated, Brian has seen a reduction in the use of opioids and other dangerous medications
Battling the opioid epidemic is akin to working to drain a lake. In this case the “lake” is the large group of individuals who are dependent on or addicted to opioids. According to the National Survey on Drug Use and Health, in 2016, over 21 million Americans over the age of 12 needed some form of substance abuse treatment, much of that related to opioid abuse. That makes for a pretty significant lake. Draining that lake, or reducing the number of our citizens enslaved by opioids, can only be accomplished by reducing the number of individuals who start taking opioids - essentially damming the river that feeds the lake. Many states have or are taking action by passing legislation that is intended to reduce the prescribing of opioids. Congress is now entering the opioid crisis battle in a big way.
On May 9, 2018, the US House Energy and Commerce Committee marked up 25 opioid-related bills and plans to consider more bills on May 17th. The first round of bills approved cover a broad array of issues related to addressing the opioid crisis that continues to plague our country. Many of the bills are focused on programs to provide services to individuals who are already in the lake of addiction. There are a few bills of interest to the workers’ compensation community that are focused on damming the river, or preventing the use or abuse of opioids.
HR5002 – the Advancing Cutting Edge Research Act, or “ACE Research Act”, expands the authority of the National Institutes of Health to initiate research programs to explore and develop non-opioid treatments of pain.
HR5197 – the Alternatives to Opioids in the Emergency Department Act or “ALTO Act” directs the Secretary of Health and Human Services to conduct a demonstration program to test alternative pain management protocols to limit the use of opioids in emergency departments.
With so much of workers’ compensation care focused on managing pain, success in these first two initiatives could go a long way to providing viable options for reducing the use of opioids among injured workers.
HR5009 – “Jessie’s Law” directs the Secretary of Health and Human Services to develop best practices for including past substance abuse disorders in a patient’s health record to inform providers of the potential risk of relapse should an opioid be prescribed. The law is named for a young Michigan woman who was a heroin addict in recovery and was prescribed an opioid following surgery. The opioid triggered a relapse in her substance abuse that ultimately took her life. Patients consenting to include this information in their health record can inform future treating physicians of a potentially deadly risk. This is especially important in the workers’ compensation system since injured workers frequently are treated by specialists in occupational injuries who may not have the same visibility to the patient’s medical history as the regular, general health care doctor.
HR3528 – the “Every Prescription Conveyed Securely Act” would require e-prescribing for controlled substances in the Medicare Part D program. While not specific to workers’ compensation, if setting a standard of e-prescribing proves to reduce diverted or fraudulent paper prescriptions, it will make it easier for all facets of health care, including workers’ compensation, to begin requiring e-prescribing of opioids and other controlled substances.
States are also continuing their efforts to dam the river. Texas, who led in 2011 with a drug formulary targeting the reduction of the more dangerous long-acting opioids, is pioneering once again with their recently announced Opioids Plan-Based Audit. The Texas Division of Workers’ Compensation audit will focus on opioids prescribed within 10 days of the date of injury, prescribed supplies exceeding 30 days, and will look at claims where there is only one opioid prescriber and claims with multiple opioids prescribers. The opioid prescribing will be evaluated for medical necessity based on prevailing evidence-based guidelines. The Plan-Based Audit conducted a couple of years ago by the Texas DWC yielded some helpful information, resulted in a number of enforcement actions against physicians and prompted changes in the drug formulary rules for prescribing compounded medications.
In appraising many of the opioid prescribing guidelines being instituted across the country, most of them are recommendations without any real oversight or enforcement mechanisms built into the proposals. The Texas DWC Plan-Based Audit is first, and foremost, a targeted evaluation of opioid prescribing practices that will help shape future opioid prescribing policy in the Texas workers’ compensation system. Any enforcement yielded will be driven by the findings of the audit. Such enforcement, while not the primary reason for the audit, will also help shape prescribing behavior amongst providers.
Recent reports indicate that opioid prescribing in the workers’ compensation systems in many states is beginning to move downward. We have partially dammed the river but more needs to be done. Concerted effort, creativity and accountability are needed to fully span the gorge and reduce opioid prescribing to an appropriate trickle. The efforts of Congress and the various states to reduce prescribing and to seek treatment alternatives, coupled with accountability efforts like those in Texas, will, in time, give us a real shot at draining the lake of dependence and addiction.
==============================================
By: Brian Allen, Vice President of Government Affairs at Mitchell
As the Vice President of Government Affairs at Mitchell, a workers’ compensation pharmacy benefit manager, Brian is in the unique position to see firsthand how a drug formulary impacts injured workers as it is implemented and managed over time. In every state where a formulary has been approved and activated, Brian has seen a reduction in the use of opioids and other dangerous medications
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