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By Scott McConnell
Internal Audit Manager
Kentucky Employers' Mutual Insurance
Opioid (narcotic) medications are a significant issue for AASCIF funds because they are frequently prescribed for claimants, and the potential for abuse is significant.
If your fund's experience is similar to that of KEMI, one-third of the prescriptions provided to claimants in terms of cost, quantity and frequency are for opioids. While pain management and the use of opioids will always be a significant factor in claim management, efforts must be made to assure they are prescribed and used responsibly. We must understand what behaviors both physicians and claimants should demonstrate. By doing this, we will increase our chances of reducing fraud, abuse and related claim costs.
This article addresses three primary subjects as they relate to opioid prescriptions--pain, opioid use, and expectations of physicians. Exceptions to these guidelines will occur, and information presented may be more applicable to situations where longterm opioid use is anticipated.
Pain management
More complex than simply having medication prescribed, pain management involves:
•Understanding the different types of pain that can occur.
•Assessing pain.
•Providing the correct drug and dosage for the type of pain diagnosed.
•Establishing treatment goals.
•Gauging treatment effectiveness.
Of particular importance in understanding the effectiveness of pain management is recognizing strategies physicians should demonstrate with respect to patient management.
Pain can be classified into the following three types:
•Somatic pain arises in skin, bone and muscle.
•Visceral pain involves the visceral organs.
•Neuropathic pain results from injury to nerves.
Pain can be further classified as acute or chronic. Acute pain is sharp and intense and is associated with observable physical and autonomic changes. Chronic pain is characterized as being constant and unrelieved. Autonomic changes are not usually observed in chronic pain patients.
Another descriptive term important to understand is breakthrough pain. Breakthrough pain occurs when medication doses are insufficient to control the pain and it "breaks through." Breakthrough pain may come on suddenly or gradually and may be brief or prolonged.
Because not all pain conditions are treated the same way, understanding the type of pain being experienced is the first step in successful pain management. Treatment approaches should be individualized to the patient, and drug selections should be tailored to the type of pain diagnosed.
Prior to the issuance of medication, a detailed assessment of the claimant's condition must be performed and documented by the treating physician. One of the main problems in assessing patients with pain is that pain is an experience, not an objective finding. A physical examination and laboratory tests often do not provide the information necessary to gauge pain severity and assess outcomes. Therefore, pain is generally assessed indirectly by questioning the pain has impacted the patient's life.
The following is an assessment format that should be demonstrated in gauging the severity of pain and in determining the degree of disability:
•Understanding exacerbating factors that to this point have affected the claimant's ability to cope with the pain.
•Understanding the patient's emotional state and to what degree the claimant is preoccupied mentally with the symptoms being experienced.
•Understanding functional status at home and at work.
•Understanding the degree to which analgesic medications are utilized.
Establishing treatment goals is also important in the management of pain because they can have a direct impact on the type of pain medication prescribed. It is essential for the physician and patient to collaborate in developing goals to guide treatment and the means to assess progress. As these goals are established, the physician's treatment plan should also address side effects of medication, maximizing the patient's quality of life, and minimizing the possibility for abuse or dependency.
Use of opioids for pain management
All types of pain can be treated with opioids, but they should not necessarily be the first therapy utilized for pain management, nor are they recommended as the only treatment.
Whenever possible, opioids should be used as part of a comprehensive treatment plan involving other non-opioid medications and modalities. Non-opioid drugs affect different neurological pathways and receptors to alter pain perception.
However, in some cases, opioids alone are the best method of treatment as the dosages can be increased without the worry of exceeding maximum daily dosages of nonopioids like acetaminophen.
The amount and frequency of opioid treatment are individualized according to each patient's need for pain control. There is no maximum dosage for single ingredient opioid therapies as long as pain is present. Factors that limit the use of opioids are the occurrence of adverse reactions.
Because pain is a subjective experience, there is a great degree of subjectivity in prescribing opioids. Physicians should adhere to some reasoned methodology to determine correct dosing. The goal is not to minimize the dose of opioid, but rather to determine the correct dosage to provide adequate pain relief with a minimum of side effects. Initially there must be frequent contact between clinician and patient so that dosage adjustments can be made.
Ideally, when opioid therapy is commenced, the necessary dose is established by using short-acting drugs taken every three to four hours. As a rule, it is best to begin treatment with a low test dose to avoid serious side effects. Should these arise, an alternative opioid may be tried. If initial dosing is ineffective, opioid strengths may be increased as necessary and as tolerated. Once pain relief has been achieved, the relevant dose may be repeated at four- to six-hour intervals.
If a claimant is in continuous pain and has responded well to short-acting opioids, longacting sustained release drugs can be utilized. The initial daily dose should be roughly equivalent to the average daily amount of short-acting opioid that provided relief. Most patients taking long-acting opioids should be supplied with a fast-acting rescue opioid to treat breakthrough pain. Whenever possible, the rescue dose should be the same opioid as the long-acting one.
Appropriate drug selection is important. Both adverse and beneficial effects must be evaluated in the context of an individual patient's current physical condition. Choosing the right opioid for a patient can be a matter of guesswork because patient reactions in terms of drug effectiveness and side effects can vary. It would not be unusual for a patient to be prescribed trial doses of two or three opioids before achieving satisfactory pain relief without intolerable side effects. Drug therapy should be tailored to the patient versus the patient being tailored to the drug.
Short-term, immediate-release opioids have durations from four to six hours, and many are combination products containing other medications such as acetaminophen. Short-term opioids are typically recommended for use in acute pain, for intermittent pain conditions, for use in chronic pain during dose analysis, and for use in chronic pain as a supplemental agent for breakthrough pain.
Sustained-release opioids provide 8 to 12 hours of pain relief and have a distinct advantage over short-term combination products. Long-acting formulation requires less frequent dosing and provides a smoother blood level so that there is more consistent pain relief and less euphoric effect.
Another possible advantage is that total daily dosing of opioids may be lower when sustained-release opioids are used. Recent advances in pain management theory suggest that if the sustained-release opioid is correctly dosed on a schedule, breakthrough medication is typically only necessary one or two times daily. By negating the need for breakthrough pain medication, total dosing is reduced.
Expectations for opioid therapy
Opioids should provide improvement in activities of daily living if pain impairs these activities. Most adverse side effects of opioids resolve on their own as tolerance to the drug grows with continued use.
Whether tolerance develops to the painrelieving effects of opioids is a matter of controversy. Most of the data on opioid tolerance and physical dependence involves people who were not in pain. Studies of patients with chronic pain taking opioids for a long time indicate that once the dose required for pain relief is established, it generally remains stable unless: the underlying disease progresses, there is an increase in physical activity, or a deterioration in psychological status, such as depression.
There are negative side effects associated with the use of opioids, the most prominent being the potential for drug dependence and addiction. Physical dependency on opioids is an expected occurrence in all individuals if they are continually used. However, physical dependence has nothing to do with addiction. It simply means that a habituated user will experience certain physical symptoms if the drug is stopped abruptly. For opioids, these withdrawal symptoms include anxiety, irritability, goose bumps, salivation, nausea and vomiting, abdominal cramps, and insomnia.
One of the important facts differentiating addiction from dependency is that addiction constricts one's life, whereas appropriate drug use will enhance it. A patient's level of functioning will be a clear indication of this. If they are using the drug for other than pain relief, their loss of control will become apparent soon enough.
A patient who is addicted to drugs will show some of the following signs:
•Medication is not taken as prescribed.
•Frequent requests for early refills. Patient seeks prescriptions from different doctors and has them filled at multiple pharmacies.
•Patient visits different emergency rooms to obtain opioid drugs.
•Requesting specific medications.
•Resisting changes in therapy repeatedly despite adverse drug effects.
•Hoarding drugs during periods of reduced symptoms.
•Complaining aggressively about the need for more medicine.
•Demonstrating functional deterioration related to drug use.
By establishing expectations of physicians that prescribe opioids, we further enhance our claim management guidelines and increase the odds of identifying fraudulent behavior, and placing the injured worker at MMI.
The following is a list of strategies physicians should demonstrate in the management of their patients if opioids are prescribed beyond short-term needs:
•A thorough patient history is obtained and physical examination is performed. A specific diagnosis and pathological process as to what is causing pain should be documented. Family history of alcoholism and other addictions should be questioned.
•Examination notes should be specific and detailed as to patient observations. Explanations as to why opioid analgesics will be helpful, what alternatives have been considered, and how the patient will be followed over time should be provided.
•An understanding on behalf of the injured worker should be documented indicating an understanding of the treatment proposed.
•Referral to specialist in the field of pain management by the primary care practitioner if the use of opioids continues for a prolonged period of time.
•If the use of opioids is necessary for a prolonged period, long-lasting opioids should be prescribed to achieve consistent pain management.
•Patients receiving opioid analgesics should be seen on a regular basis. Open-ended prescriptions with refills should not be provided.
•Reductions in daily dosages of opioids should occasionally be tried to determine the minimum dose necessary to maintain function and useful activities of daily living.
•A urine drug screen should be ordered if warranted by the injured worker's behavior.
Author Scott McConnell can be reached at smcconnell@kemi.com or (859) 425-7800.
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