Limiting The Impact of Opioids

April 2019

By: Francis M. Brady

Outside of “medical marijuana,” the term most often heard recently regarding healthcare in Illinois, and by extension, workers’ compensation practice, is “opioid crisis.” Unlike the alarm over marijuana, where there is no actual experience underlying the sense of foreboding, concerns over opioid usage are founded upon hard data.1

Per the Illinois Department of Public Health (IDPH), opioids are “a class of drugs that include heroin; common prescription pain relievers such as oxycodone and hydrocodone (Vicodin, Percocet, Oxycontin); and, synthetically manufactured analogs such as Fentanyl.” The IDPH warns that “…physical tolerance to opioids can develop in as few as 2-3 days of continuous use...opioids affect respiratory regulation of the brain and an overdose can cause someone to stop breathing…”

On December 4, 2017, IDPH released a “comprehensive opioid data report to provide an epidemiological snapshot of the impact of opioids…” That report stressed that opioid abuse is an urban, suburban, and rural problem. According to IDPH, “opioid overdoses in Illinois have been increasing dramatically in recent years. In 2016, there were 1,946 opioid overdose fatalities…nearly twice the number of fatal motor vehicle accidents and more than one and one-half times the number of all homicides.”

It noted as well that opioid abuse takes a toll beyond overdoses. Neonatal Abstinent Syndrome (NAS) is a condition occurring when a newborn has been prenatally exposed to opioids and experiences withdrawal. Symptoms include tremors, feeding problems and even syndrome. Beyond the symptoms, adverse outcomes consist of low birth weight, breathing difficulties, jaundice, and sepsis.

In an effort to stem the growing tide of opioid abuse, the Illinois General Assembly amended the Illinois Controlled Substances Act to create a Prescription Monitoring Program (PMP). The PMP is a clearinghouse where data on controlled substances prescriptions are collected.

Retail pharmacies dispensing opioids submit information daily to the database as they fill prescriptions. Caregivers licensed to prescribe opioids including not only the pharmacies but also physicians, must register with PMP and can access the database with a user name and password (can register). In fact, when prescribing a new opioid pain- killer, a doctor must try to ascertain the patient’s prescription drug use from PMP and chart the effort.

The PMP and the willingness of prescribers and dispensers to use it have produced results as opioid prescribing activity has been decreasing.2 Between 2013 and 12/4/17, the total number of opioid prescriptions in Illinois decreased by 9.8%. This is consistent with an overall trend nationally toward reduced opioid prescribing in recent years. Nevertheless, opioid prescribing activities remain significantly higher today as compared to the late 1990s.

What can employers and their representatives themselves do to curtail the adverse consequences of opioid overusage. What about trying to predict where the risk of the addiction is the greatest. In a December 2018 study, “Correlates of Opioid Dispensing,” the Workers’ Compensation Research Institute (WCRI) recently did just that. That is, WCRI undertook to project the circumstances in which an opioid is most likely to be prescribed. The study found, for example, that workers employed in mining and construction industries are more likely than workers in other industries to receive opioids for pain. They were also at greater risk for opioid overdose deaths.

Another factor which played a role in opioid prescriptions is an employer’s payroll size. WCRI found “that workers receiving pain medication prescriptions…employed in very small-sized firms were more likely to dispensed opioid prescriptions compared with workers employed in relatively larger firms.” They were also more likely to receive opioids on a chronic basis compared with the workers in a larger firm.

Another risk factor for a higher opioid prescription rate concerned where the worker lived. Workers “residing in urban counties were less likely to receive opioid prescriptions compared with those residing in rural and very rural counties.

Also, pertinent to understanding the incidence of opioid prescription is the type of injury. “A higher proportion of workers who sustain fractures, carpal tunnel, and neurologic spine pain received at least one opioid prescription for pain relief.” And of these, “the likelihood of receiving chronic opioids, high-dose opioids, and longer term opioids was higher for injured workers who sustained neurologic spine pain injuries” Finally, “older patients” seem to receive opioids for pain relief at a higher rate than younger (age 25 and below) workers.

Knowing these risk factors may be of use to underwriters and others charged with setting the parameters, including fees and premiums, of risk management services, and insurance coverages. Indeed, employers themselves might make decisions regarding the course of their businesses having in hand data predicting risk.

More specifically, knowing who is most likely to be prescribed a significant dose of narcotics for pain relief, should inform claims handlers and defense counsel as they take steps to reduce exposure. For example, a construction worker claiming Comp benefits for intractable low back pain may warrant early assignment of a Nurse Case Manager. Likewise, knowledge of the PMP can inform defense tactics. Asking a Section 12 expert to incorporate into his opinions evidence of whether a treater prescribing opioids is registered in the PMP and accessed it prior to prescribing a new opioid may add a valuable dimension to the expert’s opinion.