State News : New Jersey

Pain management has become a major health issue and cost driver in most state workers’ compensation programs with the proliferation of prescription opiates and consequential addictions arising from workers’ compensation injuries.  One of the central problems that practitioners face in file handling and in court is the absence of any clear standards to decide whether opiates are reasonable and necessary.  The Centers for Disease Control and Prevention (CDC) took a significant step forward on March 18, 2016 with the release of the “CDC Guideline for Prescribing Opioids for Chronic Pain.”

The study is available online and any practitioner of workers’ compensation will find its conclusions to have practical applications to the daily problems employers, third party administrators and carriers have with cases involving prolonged use of opiates.  The focus year for the study was 2012.  In that year alone, family doctors and internists wrote 259 million prescriptions for opioid pain medications.  This number does not include the number of prescriptions that pain medicine specialists and other physicians wrote.  The CDC said it was focusing on family physicians because they tend to write about half of all opioid prescriptions.

The Guideline addresses long-term opioid therapy, which is defined as use of opioids on most days for more than three months. Here are some of the key findings in the Guideline:

Concurrent use of opioids and benzodiazepines might put patients at greater risk for potentially fatal overdose

1. Patients who do not experience clinically meaningful pain relief early in treatment (within one month) are unlikely to experience pain relief with longer-term use

2. No evidence shows a long-term benefit of opioids in pain and function versus no opioids for chronic pain with outcomes examined at least one year later
   These observations are particularly relevant to workers’ compensation practitioners, who know intuitively that it does not make sense to continue to prescribe opiates for patients for many months or years when they do not seem to be improving in function or experiencing a diminution in pain.  Even after prolonged use of opiates, many workers’ compensation patients will complain of a pain level of 10 on a scale of 10.  Such prolonged use of opiates often leaves injured workers with even greater problems from dependency and addiction.  

    

   The authors of the Guideline have provided some valuable advice for physicians:

    

• Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient

• Consider non-pharmacologic therapies (PT, weight loss for knee osteoarthritis, Cognitive Behavioral Therapy) to alleviate chronic pain

• NSAIDs, acetaminophen, and some antidepressants may be effective for chronic pain

One theme that permeates the Guideline is that physicians should set a benchmark when they prescribe opiates, and that benchmark should be to achieve both improvement in pain as well as improvement in function.  The Guideline also advises that physicians should not start patients on extended-release opioids.  This would seem like common sense but many physicians leap to prescribe extended release opioids like oxycodone, hydrocodone, and morphine before trying shorter acting opioids.  The lowest possible dosage should be the starting dosage – again, a rule that is often violated in workers’ compensation cases.

Workers’ compensation practitioners can now draw on the CDC Guideline in asking physicians for a treatment plan and specific timelines.   The CDC suggests evaluating benefits and harms with patients within one to four weeks after starting opioid therapy for chronic pain.  The authors suggest that physicians should periodically review the patient’s history of controlled substance prescriptions using the PDMP (Prescription Drug Monitoring Program).  New Jersey is one of the states that utilizes the PDMP.  Our office has found any number of cases where a claimant’s name has been run through the PDMP only to discover that the claimant is already getting multiple prescriptions for the same opiate that the pain medicine physician was about to prescribe.

One comment from the lengthy Guideline that should resonate with workers’ compensation practitioners, employers, third party administrators and carriers is this one:

“Regarding duration of use, patients can experience tolerance and loss of effectiveness of opioids over time.  Patients who do not experience clinically meaningful pain relief early in treatment (i.e., within one month) are unlikely to experience pain relief with longer-term use.”   Most pain medicine physicians appreciate the points made in this Guideline but there are many who seem to be ignoring the sensible conclusions contained in this report.

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John H. Geaney, Esq., is an Executive Committee Member and a Shareholder in Capehart Scatchard's Workers’ Compensation Group.  Mr. Geaney concentrates his practice in the representation of employers, self-insured companies, third-party administrators, and insurance carriers in workers’ compensation, the Americans with Disabilities Act and Family and Medical Leave Act. Should you have any questions or would like more information, please contact Mr. Geaney at 856.914.2063 or by e‑mail at jgeaney@capehart.com.