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2 “Life is ten percent what happens to you and ninety percent how you respond to it.” Lou Holtz 2

3 Deaths from prescription opioid painkillers have reached epidemic levels in the past decade.

4 Opioid analgesics are now responsible for more deaths than: the number of deaths from suicide, motor vehicle crashes, cocaine and heroin overdoses combined! 4

5 Persons with pharmaceutical opioid-related substance use disorders are disproportionally: Caucasian Female Middle-age Residents of rural communities Yet more men than women die of overdoses from prescription painkillers.

6 A disturbing trend has been caused by a whole host of factors: A philosophical shift in physician attitudes toward the treatment of pain. The Joint Commission on the Accreditation of Healthcare Organizations core principles state that “patients have a right to pain assessment and management and a patient’s self-report is the most reliable indicator of pain.” 6

7 While this attitudinal shift may be positive for chronic pain sufferers, regulatory systems must be designed to effectively monitor these powerful prescriptions. 7

8 Improving the way prescription painkillers are prescribed can reduce the number of people who misuse, abuse or overdose from these powerful drugs, while making sure patients have access to safe, effective treatment. 8

9 Opioid analgesics, such as oxycodone, hydrocodone, and methadone, were involved in approximately 75% of pharmaceutical overdose deaths. 9

10 . According to the Center for Disease Control, “Appropriate screening, identification, and clinical management by health care providers are essential parts of both behavioral health and chronic pain management.” 10

11 Some people obtain prescriptions from multiple prescribers by "doctor shopping." Pinning down just where the problem lies is a task which is arguably as tough as correcting the problem of opioid abuse itself. 11

12 T here needs to be better mechanisms to hold prescribers accountable, enable the use of drug monitoring and testing, and monitor pain management clinics. 12

13 The most surprising thing is that the payer community has been consistently paying for these drugs but has shown little concern for curbing the abuse. While the responsibility doesn’t lie with payers alone, it is now critical that workers’ compensation stakeholders come together to stop these inappropriate prescribing patterns. 13

14 Workers’ compensation stakeholders must confront the inappropriate use of narcotics in the system. Injured workers are suffering and employers are paying for the unintended consequences of these drugs.

15 According to The New York Times, the cost of workers’ compensation claims sky rocket when injured employees start using narcotics. The average lost time workers’ compensation claim in the U.S. without the use of opioids cost $13,000. When an employee is prescribed a short-acting opioid like Percocet, the average lost time claim cost triples to $39,000. When an employee is prescribed a long-acting opioid like oxycontin, the average lost time claim costs explodes to $117,000, an increase of 900% over the average lost time work comp claim without the use of any opioids. 15

16 Nonmedical use of prescription painkillers costs health insurers up to $72.5 billion annually in direct health care costs. Over half a million emergency department visits in 2012 were due to people misusing or abusing prescription painkillers.

17 Research indicates : Temporary Disability payments are 3.5 times more with opioid prescriptions. There is a 322% greater likelihood for litigation. According to National Council on Compensation Insurance, Inc. (NCCI), approximately 38% of pharmacy costs in Workers’ Compensation are for opioids and opioid combinations, amounting to over $1.5 Billion. Contributing to over $100 Billion in lost productivity, medical costs and disability payments. 17

18 “Alone we can do so little; together we can do so much.” Helen Keller

19 Improved utilization of statewide databases that track opioid prescriptions, ferreting out and punishing overprescribing doctors, dealing with the growing number of pain management clinics and stricter controls in management of provider networks are among the solutions a number of states have adopted or are considering to tackle this multifaceted problem 19

20 Opioids usually result in a change of motivation within the injured employee. The employee’s focus of recovery from the injury is replaced with a focus on obtaining more of the opioid. The long term use of opioids results in a sub- conscious (or sometimes even a conscious), desire not to recover from the injury but to stay off work to use the opioid. 20

21 NO STATES ARE IMMUNE TO THIS EPIDEMIC! Louisiana and New York had the highest utilization of opioids on a long term basis. In California, 3 percent of the state’s doctors prescribe 55 percent of the opioids.

22 Many states report problems with "pill mills" where doctors prescribe large quantities of painkillers to people who don’t need them medically. They usually go to pill mills so that they can obtain drugs and resell them on the street. 22

23 Georgia just passed a “pill mill” bill that would license and regulate pain management clinics and now require the owner of such an establishment to be a doctor. States like Kentucky, Ohio, Tennessee, West Virginia, Texas, Louisiana, Mississippi and Florida have passed similar legislation.

24 . In Ohio, pharmacists must record Opioid prescriptions in the online Ohio Automated Rx Reporting System (OARRS). These new guidelines encourage prescribers to use the data in OARRS so that they will know how much pain medication a patient already is receiving, perhaps from multiple prescribers. The guidelines also strongly advise prescribers to talk with their patients about managing their chronic pain, the risks of an unintentional overdose from their prescription pain medication, the potential for pain medication abuse, and secure storage of their pain medications, to prevent misuse by others.

25 In Approximately 20 states the doctor can both prescribe and sell the drug to the injured employee, tripling the overall claim cost In Illinois a single Vicodin pill will cost an average of 53 cents at a pharmacy, yet sold by the doctor prescribing, the Vicodin pill sold for $1.44. Roughly a third of the prescriptions written in Illinois were for drugs dispensed by the physicians. The spread was even greater in Connecticut, where the single Vicodin pill sold by pharmacies averaged 37 cents, but $1.43 when sold by the doctor prescribing the pill. This is not a best practice as it bypasses the pharmacist oversight.

26 PRESCRIPTION DRUG MONITORING PROGRAM Maryland’s PDMP will make prescription information available, upon authorized request, to law enforcement agencies, health professional licensing boards and four units of DHMH5 to support investigations into improper professional practice, prescription fraud and illegal CDS diversion.

27 COLLABORATION IN MARYLAND The Advisory Board on Prescription Drug Monitoring; the Boards of Physicians, Nursing and Pharmacy; the University of Maryland, School of Pharmacy; the Governor’s Office of Crime Control & Prevention (GOCCP); Chesapeake Regional Information System for Our Patients (CRISP); and other DHMH agencies and professional organizations, ADAA will provide PDMP training and education on issues related to prescription drug abuse and overdose to an array of stakeholders, including healthcare providers, law enforcement, public health professionals and the general public.

28 Maryland Medical Assistance (MA), in both the Fee-For-Service Program (FFS) and Managed Care Organizations (MCO), currently employs procedures to identify and remedy activities of both recipients and providers that could contribute to the misuse of pharmaceutical opioids. Although these programs have been developed primarily for the purpose of quality assurance, cost containment and fraud detection, they will be utilized as a component of strategies to reduce opioid overdose. These programs include a corrective care management program and prospective drug utilization review.

29 Although heroin-related overdoses declined in Maryland from 2007 to 2011, the state witnessed a significant rise in overdoses related to pharmaceutical opioid analgesics during this period. Early data from 2012 suggests resurgence in heroin-related overdoses concurrent with the first reduction in pharmaceutical opioid-related overdoses in years.

30 “ Doctors who have been convicted of behaving like street drug dealers, or who lost their licenses due to similar findings, will need to apply not just to the Board of Medical Examiners, but also to the Director of Consumer Affairs, if they want to practice again. They will need to demonstrate that they can be trusted with the responsibility they once abdicated.”

31 THE ROLE OF CASE MANAGEMENT? The case management process is carried out within the ethical and legal realm of a case manager’s scope of practice, using critical thinking and evidence-based knowledge. If we want to preserve the ethical ethos of case management, case managers must know the ethical standards which they are held and comply with them. 31

32 “ The ethics of excellence are grounded in action-what you actually do, rather than what you say you believe. Talk, as the saying goes, is cheap.” Price Pritchett 32

33 STANDARDS OF PRACTICE Empowering the client to problem-solve by exploring options of care, when available, and alternative plans, when necessary, to achieve desired outcomes. Encouraging the appropriate use of health care services and strives to improve quality of care and maintain cost effectiveness on a case- by-case basis. Assisting the client in the safe transitioning of care to the next most appropriate level. Striving to promote client self-advocacy and self-determination. Advocating for both the client, employer and the payer to facilitate positive outcomes for the client, the health care team, and the payer. 33

34 Prescription monitoring and nurse case managers can combat the problem. If a nurse case manager is not already assigned to a lost time claim, the issuance of a prescription to the injured employee for any narcotic should be an automatic trigger to assign that claim to the nurse case manager.

35 If a nurse case manager is already assigned to the claim, the nurse should discuss with the treating physician the use of short-acting opioids rather than long-acting opioids. Careful monitoring of the opioid use by both the pharmacy benefit management company and the nurse case manager is essential to holding down the cost of the claim and preventing opioid addiction.

36 “Be the thermostat, not just the thermometer” Dr. Martin Luther King

37 WEBSITE RESOURCES WorkCompWire, http://www.workcompwire.com Centers for Disease Control and Prevention, http://www.cdc.gov Managing Opioid Use in Workers’ Compensation, http://www.scripnet.com Amaxx Risk Solutions, Inc, Insurance Journal, http://www.insurancejournal.com Workers Compensation Research Institute, 37

38 How do you keep your passion for Case Management when our patients, their families, bosses, physicians, employers, adjusters, etc, etc, etc…. can drain the passion completely out of you? 38

39 “The pessimist may be right in the long run, but the optimist has a better time during the trip.” Anonymous 39

40 Hang in there! Keep your sense of humor! Be kind! Have fun! 40

41 “We are all here for a spell; get all the good laughs you can.” Will Rogers




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