“...the treating doctors are reluctant to provide...for multidisciplinary programs that truly can help, especially chronic pain patients with their functional restoration and decreasing pain, since their collective experience has been an automatic denial of all of those modalities of treatment, which, by the way, are typically less expensive approaches to treatment... “It is one thing to look like a hero by saying that the carrier recognizes the need for the replacement of opioid use with alternatives that help patients, and it it’s another thing to actively promote it and authorize these treatments so that the doctors can feel comfortable in referring patients to these treatment programs.” Alan Gurvey
Published by WorkCompCentral as authored by Greg Jones
California’s State Compensation Insurance Fund said it was able to cut in half the number of injured workers receiving opioids over the last four years, thanks in large part to efforts to educate providers about the risks associated with narcotic painkillers.
Dr. Dinesh Govindarao, chief medical officer for State Fund, said Wednesday that reducing opioid prescriptions was a top priority when he came to the carrier in July 2013. He said the carrier settled on a two-pronged approach.
“We had to look at it from the folks that are new injuries and trying to prevent those people from getting on opioids,” he said. “And the other side is we have chronic cases, legacy cases where folks have been on opioids for a long period of time, and we had to figure out strategies to help them in hopefully being able to either wean off opioids, of, if they’re not able to wean, at least reduce the amount of opioids that they’re on from their current dose.”
Gorvindarao said the carrier tightened utilization review rules for network providers by requiring prior approval for any opioid prescription lasting longer than 14 days. Before the change, network doctors were allowed to write an initial prescription for up to 90 days of opioids.
The carrier also closed its pharmacy network — meaning injured workers who had reasonable access to a network pharmacy were required to receive their medications from that pharmacy — so it could monitor where they were receiving their drugs. Additionally, State Fund developed a program that aims to help claimants with chronic pain learn to cope with their condition.
It also created a peer-to-peer program that paired what he called “high-volume prescribers” — doctors prescribing larger dosages of opioids than their colleagues or those who had more patients receiving the drugs — with pain management experts.
Gorvindarao said most doctors don’t receive adequate training on pain management, and the peer-to-peer education was another integral part of the carrier’s success in reducing opioid prescriptions.
He also said State Fund put together a training module to educate providers about safe and appropriate use of opioids that has had a huge impact on prescribing behavior. Surveys of doctors who completed the training classes found several areas where the providers felt they could do better, including focusing more on functional improvements, better communication with patients and using urine drug screening to monitor compliance.
“By far, the most common planned change in practice is to reduce or eliminate the use of opioids,” Gorvindarao said.
Data from a presentation Gorvindarao delivered to State Fund’s board of directors last month appears to show that doctors are following through and making the changes they said they would after completing the training class.
The number of claims with at least one prescription for an opioid fell 50%, to 13,693 in 2017, from 27,369 in 2014.
The number of injured workers with a prescription that exceeded the equivalence of 120 milligrams of morphine fell 81.3%, from 1,458 at the end of 2014, to 237 at the end of 2017. The number of workers receiving a morphine equivalent dosage of more than 80 milligrams fell 78.3%, from 2,681 in 2014, to 582 in 2017. And the number of workers receiving more than the equivalent of 50 milligrams of morphine dropped 77.5%, from 4,934 to 1,112, over the same period.
State Fund also reported the number of injured workers receiving an opioid prescription in the first 30 days after an injury, which decreased 60%, to 1,494 in 2017, from 3,732 in 2014.
And the carrier said it cut in half the percentage of new claims with opioids prescribed in the first 90 days after an injury. In 2014, opioids were prescribed within the first 90 days on 14% of new claims. By 2017, that dropped to 7%.
Gorvindarao said it wouldn’t be appropriate to restrict patients' access to painkillers without providing other options such as chiropractic care or acupuncture. And he said State Fund is working to identify centers of excellence for a functional restoration program as an alternative to using narcotics to manage pain.
Applicants’ attorney Alan Gurvey was skeptical about the suggestion that injured workers are receiving alternative therapies.
Gurvey, managing partner of Rowen, Gurvey & Win in Sherman Oaks, said he has seen “rampant denials” of opioid prescriptions over the past several months but has not seen a proliferation of authorizations for things such as acupuncture, chiropractic care, Pilates or multi-disciplinary approaches to treatment without using medication.
“Perhaps the reason we haven’t seen this, giving State Fund the benefit of the doubt, is that the treating doctors are reluctant to provide (requests for authorization) for multidisciplinary programs that truly can help, especially chronic pain patients with their functional restoration and decreasing pain, since their collective experience has been an automatic denial of all of those modalities of treatment, which, by the way, are typically less expensive approaches to treatment,” Gurvey said. “It is one thing to look like a hero by saying that the carrier recognizes the need for the replacement of opioid use with alternatives that help patients, and it it’s another thing to actively promote it and authorize these treatments so that the doctors can feel comfortable in referring patients to these treatment programs.”
Gurvey said he wholeheartedly supports any carrier that recognizes the need for active treatment without using prescription drugs. And he would like to see widespread authorization for procedures that might help patients avoid opioids in the first place.
“To date, we have seen nothing of the sort,” he said. “Perhaps this is just the beginning of a campaign to educate doctors to start providing RFAs that will be authorized, regardless of mumbo-jumbo in the (Medical Treatment Utilization Schedule), and will be part of a comprehensive, multidisciplinary approach to treating pain.”