Five Factors Contribute to Persistent Opioid Use for Worker's Compensation Patients
Occupational Health Concern:
Persistent opioid use is a recognized national public health epidemic with both significant economic costs and tragic health outcomes. In the specialized medical field of occupational health, employees injured on the job are covered under regulatory mandated employer-sponsored workers compensation coverages for medical and disability benefits. According to a 2018 JAMA Network Open article published in October 2018, injured workers compensation patients were found to have an approximately 30% higher risk of persistent opioid use 90 days after the date of the initial injury. The study identified 5 statistically relevant risk factors that could be used to predict persistent opioid misuse in this unique patient population.
This timely JAMA study spotlights the compelling economic rational of addressing excessive opioid use in injured workers compensation patients. Persistent opioid use increases the cost of individual patient medical treatment and leads to continued loss of worker productivity. In the long term, persistent opioid use can lead to addiction and a high risk of a fatal overdose.
The JAMA study was retrospective in nature based on 9, 596 workers compensation cases for the largest state of Maryland workers compensation carrier Chesapeake Employers’ Insurance Company from the historic period from 2008 to 2016. A steady increase of opioid prescriptions per injured worker cases has been documented since 2003. Of the claimants who filled at least one opioid prescription during their treatment period, 28.6% of these patients were noted to still be filling opioid prescriptions at 90 days past the initial injury date. The study quoted a corresponding 6% surgical patient persistent opioid level as published by the Center for Disease Control and Prevention.
The 90-day definition of persistent opioid usage standard was noted to be consistent with other recent opioid epidemic medical publications. In addition, almost 10% of the study population was still filling opioid prescriptions one year after the injury. Fortunately, the study did find that 77% of the of the almost 10,000 patients in the study had no record of filled opioid prescriptions linked to workers compensation pharmacy claims.
Claimant ages ranged from 18 to 65 years of age. The average patient age was 43 years old and the population was 65% male. The study did not include patients that died directly from their injury nor did they measure any claimants that died at later time due to a drug overdose. This study also notes that workers compensation claimants are a protected patient entity who are regulatory protected from encountering any out of pocket patient costs for the injury care. Therefore, no financial deterrents exist to deter the patients from filling any pharmacy prescriptions.
Five Key Predictive Patient Characteristics:
The JAMA study recommends diligent tracking of five prognostic factors to assist in the identification and prevention of excessive opioid usage.
1. Participants aged 60 years or older
The number of years with the current employer, manual labor job industries, and temporary employment status were all noted as related increasing subfactors.
2. Crush and open Wound Injuries
The type and severity of the injury were tracked through the ICD-9 diagnosis codes. More complex injuries require longer clinical rehabilitation treatments to return the worker to a pre-injury status when compared to soft tissue or contusion injuries.
3. Strain or sprain injuries
These general diagnoses are not considered to be serious injuries and hence are often treated with non-addictive anti-inflammatories.
4. Annual preinjury income of more than $60,000
This factor was contrary to the researcher’s hypothesis and counter-intuitive to other public perceptions of the opioid crisis.
5. Concomitant diagnoses for chronic pain
Accompanying secondary diagnoses for chronic pain such as migraines, joint pain and fibromyalgia were 3 times more likely to be still filling opioid prescription 90 past the injury date along with statistically significant association in the 1-year category. The study authors noted that they were unable to determine with the available data if the injured worker had been previously diagnosed pre-injury with chronic pain by another healthcare provider or if the chronic pain commenced after the injury.
The authors note that during the majority of patient data collection timespan of 2008 through 2016 the U.S. Healthcare industry was employing the less specific ICD-9 diagnosis codes. As of October 2015, the U.S. healthcare system upgraded to the more granular ICD-10 diagnosis codes which are more descriptive of the etiology (cause or source) of a medical condition and address initial vs. subsequent treatments.
The study bases their quantity of opioids on claims paid to pharmacy dispensers. However, just because the injured worker obtained the narcotics does not mean he/she consumed any or all of them. Unfortunately, the intended recipient of the opioids could possibly sell the drugs on the street for profit.
The researchers also stated their concern over their inability to measure the level of the worker’s motivation to return to work, the intent of an injured workers legal representation, and the possibility that more opioids were obtained by the injured worker to further the appearance of a permanent disability status within the current state of Maryland’s workers compensation laws. Workers designated as permanent partially disabled were significantly more likely to qualify for persistent opioid usage compared to medical claims only workers in the study.
The authors emphasized that these 5 predictive factors are not meant to be an exhaustive list of all possible co-factors. They were limited in their investigation due to the narrow scope of the routine databases kept on workers compensation beneficiaries at the workers’ compensation carriers. The authors theorized that more robust access to patient data could illuminate additional cofactors in this potentially high-risk patient population.
Conclusion and Action Plan:
The JAMA study authors summarize their conclusions with the following statement. “The findings suggest workers compensation claimants have a high proportion of persistent opioid use. Interventions to lower persistent opioid use among this population should target patients with the identified factors, and since persistent opioid use does not correlate well with injury severity consideration should be given to not initiating opioid use for nonsevere injuries.”
In order to fight the current opioid epidemic, we must accurately measure and track negative data trends with serious population health implications such as persistent opioid usage in order to process improve our healthcare delivery system. The action plan should include diligently guarding against new persistent opioid users plus creating affordable and social stigma-free treatment options to rehabilitate existing misusers.
Conexia solutions can assist this endeavor by assisting the medical audit team spotlight actionable data for the clinical providers. For example, the implementation of alerts in a platform information system dashboard aimed at identifying and tracking the five prognostic risk factors could suggest alternative treatments to avoid persistent opioid use among this population. The same alerts also help detect aspects related to: multiple medications in covered patients (5 or more concurrent medications), drug interactions, quantities, costs and suppliers.