Attorneys Say Workers Need Alternative Treatments as Opioids Continue to Decline

Originally published by WorkCompCentral by Suzanna Speier

The California Workers' Compensation Institute announced that the state’s effort to curb opioid addiction saved $6.5 billion over a 10-year period — a staggering, giant sequoia-scale achievement for the most populous state in the country to boast about, but also a source of concern for attorneys who say their clients struggle to get authorization for alternative pain treatments.

The state already has one of the lowest per capita death rates from an epidemic that has annihilated economies in the nation’s more rural states. According to the National Institute of Drug Abuse, “there were 2,199 overdose deaths involving opioids in California — a rate of 5.3 deaths per 100,000 persons, which is lower than the national rate of 14.6 deaths per 100,000.”

In addition to saving money, California is also bucking the national average by reducing opioid deaths.

CWCI spokesperson Bob Young attributes the dramatic decline in opioid use, reported in a Nov. 12 bulletin, to education, regulatory efforts and treatment guidelines. He also talked about the mandatory Controlled Substance Utilization Review and Evaluation System, or CURES, database that ensures patients can’t go to multiple doctors to obtain more opioids than are being prescribed.

Applicants’ attorney Bret Graham said the CURES database is a good idea. To an injured worker and the family that relies on the worker’s income, however, drastically reducing access to effective pain medication also creates problems that Graham, who has practiced workers’ comp law in California for the last 25 years, said he witnesses firsthand. Graham attributes a decade of regulatory initiatives to growing hardships his clients experience, and it has been getting worse over the last decade.

“They’re cut off without an alternative,” he said. They are “people who have failed surgeries. Or failed multiple surgeries. They’re in severe chronic pain and are left without any medications.”

When asked about alternative modalities to opioids, Graham points out a statutory limit of 24 visits for physical therapy for life. Since the 24-visit cap started in 2004, Graham said he has seen a staggering uptick in suffering due to lack of access to pain management, and he’s emphatic that it coincides with “severe limits on opioids.”

Applicants’ attorney Alan Gurvey, managing partner of Rowen, Gurvey & Win, also questioned the premise of the CWCI report on grounds that the beneficiaries of the study are the insurance corporations, not the patients.

“Opioids are not a subject anyone wants to come out in favor of,” Gurvey said. “A lot of time doctors at the end of the rope prescribe medication, and I’m not saying that’s something we want to be a proponent of.”

But he also said stockholders of insurers are the ultimate beneficiaries of the savings.

Diane Worley, director of policy implementation for the California Applicants’ Attorneys Association, also expressed concern regarding the lack of support for alternative pain management to replace the reduction in opioid use.

“The $6.5 billion savings projected by the CWCI with the reduced use of opioids is significant, and hopefully, will allow for an investment in successful return-to-work programs and not fighting alternative modalities of medical care for workers,” she said of her initial impression of the bulletin.

Alternatives to opioids may include physical therapy or non-opioid medications, items that should be approved within the treatment guidelines, Worley said.

Dr. Steven Feinberg said he believes patients do OK with a moderate dose of opioids, but people are generally better off without them. The Palo Alto-based physiatrist also acknowledged that the state may have gone to extremes in reacting to the overprescribing and is now going to extremes with under prescribing, adding, “A lot of doctors won’t even treat injured workers because of the complications.”

“It’s all about evidence-based medicine,” he said. When used judiciously there is a place for opioids, and Feinberg defines judiciously as “the injured worker has more function, less pain and doesn’t have unmanageable side effects.”

The CWCI study is available here.