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

High Net Worth

High Net Worth Clients Live in CAT Zones. Here’s What Their Resiliency Plan Should Include

Having a resiliency plan and practicing it can make all the difference in a disaster.
By: | September 14, 2018 • 7 min read

Packed with state-of-the-art electronics, priceless collections and high-end furnishings, and situated in scenic, often remote locations, the dwellings of high net worth individuals and families pose particular challenges when it comes to disaster resiliency. But help is on the way.

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Armed with loss data, innovative new programs, technological advances, and a growing army of niche service-providers aimed at addressing an astonishingly diverse set of risks, insurers are increasingly determined to not just insure against their high net worth clients’ losses, but to prevent them.

Insurers have long been proactive in risk mitigation, but increasingly, after the recent surge in wildfire and storm losses, insureds are now, too.

“Before, insurance was considered the only step in risk management. Now, our client families realize it is one of the many imperative steps in an effective risk management strategy,” said Laura Sherman, founding partner at Baldwin Krystyn Sherman Partners.

And especially in the high net worth space, preventing that loss is vastly preferable to a payout, for insurers and insureds alike.

“If insurers can preserve even one house that’s 10 or 20 or 40 million dollars … whatever they have spent in a year is money well spent. Plus they’ve saved this important asset for the client,” said Bruce Gendelman, chairman and founder Bruce Gendelman Insurance Services.

High Net Worth Vulnerabilities

Laura Sherman, founding partner, Baldwin Krystyn Sherman Partners

As the number and size of luxury homes built in vulnerable areas has increased, so has the frequency and magnitude of extreme weather events, including hurricanes, harsh cold and winter storms, and wildfires.

“There is a growing desire to inhabit this riskier terrain,” said Jason Metzger, SVP Risk Management, PURE group of insurance companies. “In the western states alone, a little over a million homes are highly vulnerable to wildfires because of their proximity to forests that are fuller of fuel than they have been in years past.”

Such homes are often filled with expensive artwork and collections, from fine wine to rare books to couture to automobiles, each presenting unique challenges. The homes themselves present other vulnerabilities.

“Larger, more sophisticated homes are bristling with more technology than ever,” said Stephen Poux, SVP and head of Risk Management Services and Loss Prevention for AIG’s Private Client Group.

“A lightning strike can trash every electronic in the home.”

Niche Service Providers

A variety of niche service providers are stepping forward to help.

Secure facilities provide hurricane-proof, wildfire-proof off-site storage for artwork, antiques, and all manner of collectibles for seasonal or rotating storage, as well as ahead of impending disasters.

Other companies help manage such collections — a substantial challenge anytime, but especially during a crisis.

“Knowing where it is, is a huge part of mitigating the risk,” said Eric Kahan, founder of Collector Systems, a cloud-based collection management company that allows collectors to monitor their collections during loans to museums, transit between homes, or evacuation to secure storage.

“Before, insurance was considered the only step in risk management. Now, our client families realize it is one of the many imperative steps in an effective risk management strategy.” — Laura Sherman, founding partner, Baldwin Krystyn Sherman Partners

Insurers also employ specialists in-house. AIG employs four art curators who advise clients on how to protect and preserve their art collections.

Perhaps the best known and most striking example of this kind of direct insurer involvement are the fire teams insurers retain or employ to monitor fires and even spray retardant or water on threatened properties.

High-Level Service for High Net Worth

All high net worth carriers have programs that leverage expertise, loss data, and relationships with vendors to help clients avoid and recover from losses, employing the highest levels of customer service to accomplish this as unobtrusively as possible.

“What allows you to do your job best is when you develop that relationship with a client, where it’s the same people that are interacting with them on every front for their risk management,” said Steve Bitterman, chief risk services officer for Vault Insurance.

Site visits are an essential first step, allowing insurers to assess risks, make recommendations to reduce them, and establish plans in the event of a disaster.

“When you’re in a catastrophic situation, it’s high stress, time is of the essence, and people forget things,” said Sherman. “Having a written plan in place is paramount to success.”

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Another important component is knowing who will execute that plan in homes that are often unoccupied.

Domestic staff may lack the knowledge or authority to protect the homeowner’s assets, and during a disaster may be distracted dealing with threats to their own homes and families. Adequate planning includes ensuring that whoever is responsible has the training and authority to execute the plan.

Evaluating New Technology

Insurers use technologies like GPS and satellite imagery to determine which homes are directly threatened by storms or wildfires. They also assess and vet technologies that can be implemented by homeowners, from impact glass to alarm and monitoring systems, to more obscure but potentially more important options.

AIG’s Poux recommends two types of vents that mitigate important, and unexpected risks.

“There’s a fantastic technology called Smart Vent, which allows water to flow in and out of the foundation,” Poux said. “… The weight of water outside a foundation can push a foundation wall in. If you equalize that water inside and out at the same level, you negate that.”

Another wildfire risk — embers getting sucked into the attic — is, according to Poux, “typically the greatest cause of the destruction of homes.” But, he said, “Special ember-resisting venting, like Brandguard Vents, can remove that exposure altogether.”

Building Smart

Many disaster resiliency technologies can be applied at any time, but often the cost is fractional if implemented during initial construction. AIG’s Smart Build is a free program for new or remodeled homes that evolved out of AIG’s construction insurance programs.

Previously available only to homes valued at $5 million and up, Smart Build recently expanded to include homes of $1 million and up. Roughly 100 homes are enrolled, with an average value of $13 million.

“In the high net worth space, sometimes it takes longer potentially to recover, simply because there are limited contractors available to do specialty work.” — Curt Goetsch, head of underwriting, Private Client Group, Ironshore

“We know what goes wrong in high net worth homes,” said Poux, citing AIG’s decades of loss data.

“We’re incenting our client and by proxy their builder, their architects and their broker, to give us a seat at the design table. … That enables us to help tweak the architectural plans in ways that are very easy to do with a pencil, as opposed to after a home is built.”

Poux cites a remote ranch property in Texas.

Curt Goetsch, head of underwriting, Private Client Group, Ironshore

“The client was rebuilding a home but also installing new roads and grading and driveways. … The property was very far from the fire department and there wasn’t any available water on the property.”

Poux’s team was able to recommend underground water storage tanks, something that would have been prohibitively expensive after construction.

“But if the ground is open and you’ve got heavy equipment, it’s a relatively minor additional expense.”

Homes that graduate from the Smart Build program may be eligible for preferred pricing due to their added resilience, Poux said.

Recovery from Loss

A major component of disaster resiliency is still recovery from loss, and preparation is key to the prompt service expected by homeowners paying six- or seven-figure premiums.

Before Irma, PURE sent contact information for pre-assigned claim adjusters to insureds in the storm’s direct path.

“In the high net worth space, sometimes it takes longer potentially to recover, simply because there are limited contractors available to do specialty work,” said Curt Goetsch, head of underwriting for Ironshore’s Private Client Group.

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“If you’ve got custom construction or imported materials in your house, you’re not going to go down the street and just find somebody that can do that kind of work, or has those materials in stock.”

In the wake of disaster, even basic services can be scarce.

“Our claims and risk management departments have to work together in advance of the storm,” said Bitterman, “to have contractors and restoration companies and tarp and board services that are going to respond to our company’s clients, that will commit resources to us.”

And while local agents’ connections can be invaluable, Goetsch sees insurers taking more of that responsibility from the agent, to at least get the claim started.

“When there is a disaster, the agency’s staff may have to deal with personal losses,” Goetsch said. &

Jon McGoran is a novelist and magazine editor based outside of Philadelphia. He can be reached at [email protected]