High Times: The Opioid Crisis Statistics, Trends, SIGNS, EFFECTS and WC Methods for Combating the Problem Patrick Cronin, CPCU, AIC, AIM, AAI, ARM, CWCP District/Claims Manager – CorVel HealthCare Corporation

Statistics Prescription abuse is the fastest growing drug issue in America In terms of controlling the cost of indemnity claims, prescription opioids are the number one problem Nationally, 55% to 86% of all claimants are receiving opioids for chronic pain relief Evidence based medicine only supports its long term use in very specific cases, most of which involve end- stage cancer treatment

Statistics Overdose deaths (involving opioids) have increased 300% since 1999 2015 – 12.3 overdose deaths in Mississippi per 100,000 people (369) The misuse of prescription pain-killers was responsible for 475,000 ER visits in 2009 Currently, the opioid epidemic kills almost 100 Americans each day (more than motor vehicle accidents)

Current State of Affairs A 2015 survey (51,200 participants) reported 92 million Americans (37.8%) used prescriptions in 2014 In September, Senator Claire MacAskill (MO) released her findings that one Rx company (Insys),”repeatedly employed aggressive and likely illegal techniques to boost prescriptions.” Researchers estimate that the annual economic cost of the U.S. opioid epidemic may be as high as $80 billion per year (excluding the economic value of a lost life).

Current State of Affairs The attorneys general of 41 U.S. states are banding together to investigate the makers and distributors of powerful opioid pain killers Numerous states, including Louisiana, Arizona, Massachusetts and Washington have sued opioid manufacturers for fraudulent marketing schemes and additional state medical costs. Opioid abuse may account for as much as 20% of the decline in the American men’s participation in the labor force

Signs of Potential Opioid Abuse Increased general anxiety and or anxiety attacks Euphoria Improved self-esteem Irritability Utilization of opioids for longer or at a greater amount than intended

Signs of Potential Opioid Abuse Unsuccessful attempts to decrease dosages Abandonment of important activities Increased sensitivity to sensory stimuli Increased heart rate High blood pressure Physical agitation

Effects of Opioid Abuse Fatigue Constipation Breathlessness A sense of elation Nausea Confusion Chest pain Death Difficulty breathing

Rx Impact on WC Expenditures 1990 – Rx accounted for approximately 2% of medical expenditures 2001 – Impact increased by 400% (from 1990) Today – WC Rx accounts for approximately 19% of total medical expenditures

Rx Impact on WC Expenditures Opioids account for approximately 25% of the current Rx spend Opioids account for approximately 35% (or greater) of Rx spend in claims open for three (3) or more years Based on projected Rx utilization (specifically opioids), the cost of MSA calculations are increasing exponentially

Rx Impact on WC Expenditures (continued) Less than proactive pharmacy management increases indemnity payments and impairment ratings The treatment of comorbidities (when coupled to opioid abuse) results in 20-30% of workers’ compensation’s ultimate developed cost

Rx Impact on WC Expenditures (continued) Bottom line – the ship has sailed on Rx’s relatively minor impact on workers’ compensation claim costs In general, employers are unaware of the sizable impact of Rx on their workers’ compensation costs Injured workers prescribed even one (1) opioid had total claim costs 4-5 times greater than claimants with similar claims who didn’t get opioids

Adverse Affects of Opioid Abuse Increased frequency of emergency room visits from overdose Death Addition treatment Comorbidities

Adverse Affects of Opioid Abuse Abuse and misuse of prescription drugs Estimates show that approximately 35% of patients receiving long-term opioid treatment protocols may be addicted Since opioids reduce a patient’s pain by 30%-40%, it is common for opioids to be combined with other, non-opioid analgesics

Potential Tools in the Battle Aggressive Claims Management Generic Equivalents First Fill approval for minor pain meds and anti-inflammatories Make sure MD is conducting routine drug testing

Potential Tools in the Battle Employer/Carrier/TPA Communication Let TPA/Carrier know if employee’s activity level changes Communicate any suspicious behavior to TPA/Carrier Respond to TPA requests for information

Potential Tools in the Battle Return to Work Program Think “Outside the Box” Facilitates faster recovery Fewer doctor visits Less likely to engage an attorney

MS WC Commission Opioid Prescription Guidelines Documentation of efficacy and need for continuation of Rx protocols Random drug screens required at least two (2) times per year Psychological evaluation recommended when more than three (3) months of opioid prescribing is recommended

MS WC Commission Opioid Prescription Guidelines Treatment for Addiction – Required for up to one (1) year EME (Employer’s Medical Evaluation) for treating physicians’ failure to curtail adverse prescribing patterns Administrative Law Judge intervention to curtail/prevent over-use and overly aggressive prescribing patterns

State Intervention - Mississippi Per John Dowdy (Director of MBN), Mississippi is on the verge of a super pandemic, as relates to opioid abuse Many addicts are switching to heroin at $10 per pack, as a prescription opioid runs $65-$85 per pill Fentanyl, which is 50 times stronger than heroin (sold in time release patches – originally for pain associated with cancer related treatment) – Fentanyl is made in China, so the source may be at risk for tampering and combining with other drugs

State Intervention - Mississippi 2016 drug overdose deaths in Mississippi (suspects the number is much higher) Per Marshall Fisher (Commissioner of MDPS), there are more prescriptions for opioids than people in Mississippi

State Intervention - Mississippi So many opioids are prescribed in Mississippi that every man, woman and child could take a pill a day and not run out for 67 days Governor Bryant has formed the Opioid and Heroin Task Force with $3.58M in initial funding

In Summary Be on the look-out for the signs of potential opioid abuse Discuss any concerns with your doctor, HR advisor and TPA This crisis has taken on a sense of urgency at the Local, State and Federal Levels The impact on workers’ compensation costs is being addressed

In Summary Anticipate massive amounts of litigation against the pharmaceutical industry Know the risks of taking opioids and avoid the pitfalls Know that it impacts practically every demographic and socio-economic member of American society