Opioid Risks

Dead in Bed: The Dangers of Opioids for Inpatients

Among the annual toll in the U.S. opioid epidemic are up to 5,000 hospital inpatients. The drugs they are legally prescribed are creating liability issues for pharmacists as well as physicians.
By: | July 30, 2018 • 5 min read

Fifty years ago, the Rolling Stones sang of ‘Sister Morphine’ and the craving for the next shot of relief. The song has lost none of its relevancy — overprescribing and aggressive marketing of drugs such as Dilaudid, Demoral, OxyContin and Ritalin during the 1990s aggravated an already-serious dependency issue.

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“The idea was to provide very potent, very effective pain relief,” said Kristin McMahon, chief claims officer, North American Specialty, Global Risk Solutions, Liberty Mutual Insurance.

“But the drugs were aimed at elderly patients living out their last days and intended only for a short duration — not for long-term pain relief over an extended period.”

Tackling the problem is no easy task; an estimated 42,000 drug overdose deaths involving opioids were recorded in 2016, five times 1999’s total. While the amount of opioids prescribed in the U.S. peaked eight years ago, it remains at high levels.

There are worrying signs that any progress in this area might be stalling. In March, the Centers for Disease Control and Prevention (CDC) reported that visits to emergency departments for suspected opioid overdoses rose 30 percent between July 2016 and September 2017.

Mike Midgley, vice president, healthcare risk engineering, Swiss Re Corporate Solutions

Contributing to the opioid-related mortality toll is the so-called ‘Dead in Bed’ (DiB) phenomenon, which has garnered less public attention but is well-known within the medical community — particularly among anesthesiologists.

DiB accounts for an estimated 3,000 to 5,000 opioid-related deaths annually, typically of patients in hospital wards rather than intensive care.

Prescribed painkillers while recovering from surgery, many inpatients suffer respiratory failure in their sleep. Although the figure is low in relation to deaths from infections or surgical errors, it’s still a cause for concern. Wide variations across states in the number of cases suggest inconsistent prescribing policies among health care providers.

Health Risk Factors

Silvia Sacalis, vice president of clinical services for the pharmacy benefit company Healthesystems, said the risk factors relating to prescribing opioids for inpatients include several knowns and unknowns. Known risks include patients suffering anxiety, depression and pain disorders, and regular users of alcohol and/or tobacco which pre-dispose individuals to addictive behavior.

Unknown risk factors are more numerous.

“Post-surgery, the patient will often be unconscious and the system shuts down under anesthesia,” said Sacalis.

“Certain parts of the brain don’t receive information needed for them to be able to communicate what they’re experiencing.

“He or she might, say, have low blood pressure or an undiagnosed heart condition. As opioids typically slow the heart rate further, this puts the patient at risk of death.”

“Providers need to pay attention to these prescription standards of care, and risk managers within health care organizations are wise to monitor providers’ prescription patterns.” — Mike Midgley, vice president, healthcare risk engineering, Swiss Re Corporate Solutions

Other unknown risks include:

  • Undiagnosed asthmatic conditions or breathing difficulties, which worsen respiratory depression.
  • Undiagnosed liver or kidney conditions. These organs should metabolise and excrete the drug from the body, but instead they allow it to accumulate.
  • Blockages in the intestine or stomach. Opioids slow metabolism and the way the stomach processes a drug, so any blockage can prove fatal.

“All these potential factors need to be discussed with patients and their medical history studied before an opioid is prescribed,” said Sacalis. “However, physicians are getting better at this.”

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A November 2017 study from the Journal of the American College of Surgeons found that more vigilant prescribing guidelines could reduce the number of opioids prescribed post-operation by up to 40 percent without compromising patients’ pain management needs.

Imposing a Limit on Prescriptions

Mike Midgley, vice president, healthcare risk engineering at Swiss Re Corporate Solutions, said, “The Centers for Disease Control and Prevention recommends when opioids are used for acute pain, the prescribers should order no greater quantity than needed for the expected duration of pain severe enough to require the opioids. Three days or less will often be sufficient.

“So a prescription of, say, two weeks may in many instance fall outside the expected standard of care. This limit could potentially cause concerns for some patients who are accustomed to a prescription exceeding three days,” explained Midgley.

“Providers need to pay attention to these prescription standards of care, and risk managers within health care organizations are wise to monitor providers’ prescription patterns.”

The CDC guideline for prescribing opioids for chronic pain also encourages the use of prescription drug monitoring programs (PDMPs) to inform clinical practice.

“PDMPs in most states require providers to query a database of opioid prescription use for each patient prior to writing a prescription,” added Midgley.

Sacalis said more information sharing between each state’s PDMP would improve their efficacy.

Many insurers have also set goals to lower opioid use. Cigna, for example, announced in 2016 it was targeting a 25 percent cut over three years and recently reported it had already reached that goal. Last fall, the group also said it would withdraw cover for OxyContin, the branded version of the painkiller oxycodone, but not generic alternatives.

“Insurance companies we utilize that are primarily focused on physician exposures have established underwriting guidelines that don’t allow for refill of these types of drugs by their covered providers,” said Steve Kahl, senior managing director for Gallagher Healthcare Practice.

Working to Save Lives

Kahl said many health care risk managers are still trying to identify emerging liabilities, focusing on regulatory and legal requirements related to physician and pharmacy prescribing impacting their organizations.

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“Risk managers are essentially addressing this issue on two fronts: firstly, the management and implementation of best practices for managing and monitoring controlled substances.

“Secondly, they are promoting strategies, tools and policy to minimize patient misuse, and exposures to the organization from patient misuse or harm caused by controlled substances.

McMahon said “the one case rivaling this is the $206 billion tobacco master settlement agreement of 1998, where each company’s contribution reflected their market share.

“We can also expect an opioid-related settlement in billions but deciding how it is divvied up among the market will prove more complicated.” &

Graham Buck is a UK-based writer and has contributed to Risk & Insurance® since 1998. He can be reached at riskletters.com.

More from Risk & Insurance

More from Risk & Insurance

Exclusive | Hank Greenberg on China Trade, Starr’s Rapid Growth and 100th, Spitzer, Schneiderman and More

In a robust and frank conversation, the insurance legend provides unique insights into global trade, his past battles and what the future holds for the industry and his company.
By: | October 12, 2018 • 12 min read

In 1960, Maurice “Hank” Greenberg was hired as a vice president of C.V. Starr & Co. At age 35, he had already accomplished a great deal.

He served his country as part of the Allied Forces that stormed the beaches at Normandy and liberated the Nazi death camps. He fought again during the Korean War, earning a Bronze Star. He held a law degree from New York Law School.

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Now he was ready to make his mark on the business world.

Even C.V. Starr himself — who hired Mr. Greenberg and later hand-picked him as the successor to the company he founded in Shanghai in 1919 — could not have imagined what a mark it would be.

Mr. Greenberg began to build AIG as a Starr subsidiary, then in 1969, he took it public. The company would, at its peak, achieve a market cap of some $180 billion and cement its place as the largest insurance and financial services company in history.

This month, Mr. Greenberg travels to China to celebrate the 100th anniversary of C.V. Starr & Co. That visit occurs at a prickly time in U.S.-Sino relations, as the Trump administration levies tariffs on hundreds of billions of dollars in Chinese goods and China retaliates.

In September, Risk & Insurance® sat down with Mr. Greenberg in his Park Avenue office to hear his thoughts on the centennial of C.V. Starr, the dynamics of U.S. trade relationships with China and the future of the U.S. insurance industry as it faces the challenges of technology development and talent recruitment and retention, among many others. What follows is an edited transcript of that discussion.


R&I: One hundred years is quite an impressive milestone for any company. Celebrating the anniversary in China signifies the importance and longevity of that relationship. Can you tell us more about C.V. Starr’s history with China?

Hank Greenberg: We have a long history in China. I first went there in 1975. There was little there, but I had business throughout Asia, and I stopped there all the time. I’d stop there a couple of times a year and build relationships.

When I first started visiting China, there was only one state-owned insurance company there, PICC (the People’s Insurance Company of China); it was tiny at the time. We helped them to grow.

I also received the first foreign life insurance license in China, for AIA (The American International Assurance Co.). To date, there has been no other foreign life insurance company in China. It took me 20 years of hard work to get that license.

We also introduced an agency system in China. They had none. Their life company employees would get a salary whether they sold something or not. With the agency system of course you get paid a commission if you sell something. Once that agency system was installed, it went on to create more than a million jobs.

R&I: So Starr’s success has meant success for the Chinese insurance industry as well.

Hank Greenberg: That’s partly why we’re going to be celebrating that anniversary there next month. That celebration will occur alongside that of IBLAC (International Business Leaders’ Advisory Council), an international business advisory group that was put together when Zhu Rongji was the mayor of Shanghai [Zhu is since retired from public life]. He asked me to start that to attract foreign companies to invest in Shanghai.

“It turns out that it is harder [for China] to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

Shanghai and China in general were just coming out of the doldrums then; there was a lack of foreign investment. Zhu asked me to chair IBLAC and to help get it started, which I did. I served as chairman of that group for a couple of terms. I am still a part of that board, and it will be celebrating its 30th anniversary along with our 100th anniversary.

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We have a good relationship with China, and we’re candid as you can tell from the op-ed I published in the Wall Street Journal. I’m told that my op-ed was received quite well in China, by both Chinese companies and foreign companies doing business there.

On August 29, Mr. Greenberg published an opinion piece in the WSJ reminding Chinese leaders of the productive history of U.S.-Sino relations and suggesting that Chinese leaders take pragmatic steps to ease trade tensions with the U.S.

R&I: What’s your outlook on current trade relations between the U.S. and China?

Hank Greenberg: As to the current environment, when you are in negotiations, every leader negotiates differently.

President Trump is negotiating based on his well-known approach. What’s different now is that President Xi (Jinping, General Secretary of the Communist Party of China) made himself the emperor. All the past presidents in China before the revolution had two terms. He’s there for life, which makes things much more difficult.

R&I: Sure does. You’ve got a one- or two-term president talking to somebody who can wait it out. It’s definitely unique.

Hank Greenberg: So, clearly a lot of change is going on in China. Some of it is good. But as I said in the op-ed, China needs to be treated like the second largest economy in the world, which it is. And it will be the number one economy in the world in not too many years. That means that you can’t use the same terms of trade that you did 25 or 30 years ago.

They want to have access to our market and other markets. Fine, but you have to have reciprocity, and they have not been very good at that.

R&I: What stands in the way of that happening?

Hank Greenberg: I think there are several substantial challenges. One, their structure makes it very difficult. They have a senior official, a regulator, who runs a division within the government for insurance. He keeps that job as long as he does what leadership wants him to do. He may not be sure what they want him to do.

For example, the president made a speech many months ago saying they are going to open up banking, insurance and a couple of additional sectors to foreign investment; nothing happened.

The reason was that the head of that division got changed. A new administrator came in who was not sure what the president wanted so he did nothing. Time went on and the international community said, “Wait a minute, you promised that you were going to do that and you didn’t do that.”

So the structure is such that it is very difficult. China can’t react as fast as it should. That will change, but it is going to take time.

R&I: That’s interesting, because during the financial crisis in 2008 there was talk that China, given their more centralized authority, could react more quickly, not less quickly.

Hank Greenberg: It turns out that it is harder to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.

R&I: Obviously, you have a very unique perspective and experience in China. For American companies coming to China, what are some of the current challenges?

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Hank Greenberg: Well, they very much want to do business in China. That’s due to the sheer size of the country, at 1.4 billion people. It’s a very big market and not just for insurance companies. It’s a whole range of companies that would like to have access to China as easily as Chinese companies have access to the United States. As I said previously, that has to be resolved.

It’s not going to be easy, because China has a history of not being treated well by other countries. The U.S. has been pretty good in that way. We haven’t taken advantage of China.

R&I: Your op-ed was very enlightening on that topic.

Hank Greenberg: President Xi wants to rebuild the “middle kingdom,” to what China was, a great country. Part of that was his takeover of the South China Sea rock islands during the Obama Administration; we did nothing. It’s a little late now to try and do something. They promised they would never militarize those islands. Then they did. That’s a real problem in Southern Asia. The other countries in that region are not happy about that.

R&I: One thing that has differentiated your company is that it is not a public company, and it is not a mutual company. We think you’re the only large insurance company with that structure at that scale. What advantages does that give you?

Hank Greenberg: Two things. First of all, we’re more than an insurance company. We have the traditional investment unit with the insurance company. Then we have a separate investment unit that we started, which is very successful. So we have a source of income that is diverse. We don’t have to underwrite business that is going to lose a lot of money. Not knowingly anyway.

R&I: And that’s because you are a private company?

Hank Greenberg: Yes. We attract a different type of person in a private company.

R&I: Do you think that enables you to react more quickly?

Hank Greenberg: Absolutely. When we left AIG there were three of us. Myself, Howie Smith and Ed Matthews. Howie used to run the internal financials and Ed Matthews was the investment guy coming out of Morgan Stanley when I was putting AIG together. We started with three people and now we have 3,500 and growing.

“I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

R&I:  You being forced to leave AIG in 2005 really was an injustice, by the way. AIG wouldn’t have been in the position it was in 2008 if you had still been there.

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Hank Greenberg: Absolutely not. We had all the right things in place. We met with the financial services division once a day every day to make sure they stuck to what they were supposed to do. Even Hank Paulson, the Secretary of Treasury, sat on the stand during my trial and said that if I’d been at the company, it would not have imploded the way it did.

R&I: And that fateful decision the AIG board made really affected the course of the country.

Hank Greenberg: So many people lost all of their net worth. The new management was taking on billions of dollars’ worth of risk with no collateral. They had decimated the internal risk management controls. And the government takeover of the company when the financial crisis blew up was grossly unfair.

From the time it went public, AIG’s value had increased from $300 million to $180 billion. Thanks to Eliot Spitzer, it’s now worth a fraction of that. His was a gross misuse of the Martin Act. It gives the Attorney General the power to investigate without probable cause and bring fraud charges without having to prove intent. Only in New York does the law grant the AG that much power.

R&I: It’s especially frustrating when you consider the quality of his own character, and the scandal he was involved in.

In early 2008, Spitzer was caught on a federal wiretap arranging a meeting with a prostitute at a Washington Hotel and resigned shortly thereafter.

Hank Greenberg: Yes. And it’s been successive. Look at Eric Schneiderman. He resigned earlier this year when it came out that he had abused several women. And this was after he came out so strongly against other men accused of the same thing. To me it demonstrates hypocrisy and abuse of power.

Schneiderman followed in Spitzer’s footsteps in leveraging the Martin Act against numerous corporations to generate multi-billion dollar settlements.

R&I: Starr, however, continues to thrive. You said you’re at 3,500 people and still growing. As you continue to expand, how do you deal with the challenge of attracting talent?

Hank Greenberg: We did something last week.

On September 16th, St. John’s University announced the largest gift in its 148-year history. The Starr Foundation donated $15 million to the school, establishing the Maurice R. Greenberg Leadership Initiative at St. John’s School of Risk Management, Insurance and Actuarial Science.

Hank Greenberg: We have recruited from St. John’s for many, many years. These are young people who want to be in the insurance industry. They don’t get into it by accident. They study to become proficient in this and we have recruited some very qualified individuals from that school. But we also recruit from many other universities. On the investment side, outside of the insurance industry, we also recruit from Wall Street.

R&I: We’re very interested in how you and other leaders in this industry view technology and how they’re going to use it.

Hank Greenberg: I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.

R&I: So as the pre-eminent leader of the insurance industry, what do you see in terms of where insurance is now an where it’s going?

Hank Greenberg: The country and the world will always need insurance. That doesn’t mean that what we have today is what we’re going to have 25 years from now.

How quickly the change comes and how far it will go will depend on individual companies and individual countries. Some will be more brave than others. But change will take place, there is no doubt about it.

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More will go on in space, there is no question about that. We’re involved in it right now as an insurance company, and it will get broader.

One of the things you have to worry about is it’s now a nuclear world. It’s a more dangerous world. And again, we have to find some way to deal with that.

So, change is inevitable. You need people who can deal with change.

R&I:  Is there anything else, Mr. Greenberg, you want to comment on?

Hank Greenberg: I think I’ve covered it. &

The R&I Editorial Team can be reached at [email protected]