Workers' Comp

Paying for Detox

The opioid epidemic is addressed by detoxification programs.
By: | August 4, 2014 • 8 min read

Helping patients addicted or dependent on the very medications that were designed to ease their pain is driving workers’ comp claims payers in some cases to fund tapering and detoxification programs.

Study results in recent years have boosted that initiative by identifying multidisciplinary treatment approaches as offering an improved chance for success.

The treatment approaches call for weaning patients off of pain medications while also addressing a range of complex issues contributing to addiction and dependency, experts said.

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Success, though, is frustratingly hard to come by, so payers have been cautious, or even reluctant to fund detox treatments — although more are doing so, they added.

Recidivism is common, even after someone successfully completes a good detoxification treatment program and appears to be winning the struggle to turn their life around. Experts said it can take several attempts or “episodes of care” to wean someone off narcotics. Long-term support is often necessary.

“The success rate is poor enough that it becomes difficult to feel that even the best programs by reputation are delivering,” said Dr. Dwight Robertson, national medical director in Glendale, Calif., for EMPLOYERS, a workers’ compensation insurer.

“Where we have a case that just goes on and on and we are trying to intervene … it can be very frustrating because the patient may not be ready to change.” — Dr. Dwight Robertson, chief medical officer for EMPLOYERS

“It is so tough that you often have a lot of cases you send to the best programs, it costs you a lot of money, and you still don’t get success. But having said that, you can’t just sit back and do nothing.”

Payers have several reasons for helping workers struggling with addiction or drug dependency, including the drugs’ direct costs, the expense of treating drug side effects, a desire to cut their ongoing liability by closing complex claims, and a sincere goal of helping workers recover, said Dr. Steven M. Moskowitz, senior medical director for Walnut Creek, Calif.-based Paradigm Outcomes, a catastrophic care management company.

But several hurdles often frustrate attempts to help, especially if the overuse or abuse of addictive prescription narcotics has escalated over time without eliminating the chronic pain responsible for prescribing opioids in the first place.

The hurdles include a dependent or addicted worker’s refusal to seek help, especially when their judgment is clouded by an intense desire for drugs that someone else is paying for; caregivers who might understand detoxification but not chronic pain issues or vice versa; and a range of personal or psychosocial problems such as mental health complications or a claimant’s troubled home environment.

To help overcome those hurdles, more payers are working to identify detox treatment and tapering programs nationwide that they expect will provide the best chance of success, said Mark Pew, senior VP of product development for PRIUM, a workers’ comp medical management company.

In addition to the cost of the programs, they are paying for travel and other expenses necessary to get addicted or drug-dependent claimants into treatment.

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Yet, with treatment programs ramping up marketing efforts to push their services, and recidivism a very common problem, worker’s comp payers are also cautious about selecting treatment programs and patients who might benefit.

“They are not doing it willy-nilly and they are not doing it generously,” Moskowitz said of workers’ comp payers funding detox treatments.

“They are doing it cautiously, as they should, because everyone now is [selling detox services]. It’s a lot of money. It’s an expensive resource.”
In cases where they feel the patient’s treating physician lacks the expertise necessary to address severe pain or treat addiction, insurers, excess insurers and TPAs are funding detoxification treatments.

That’s doubly true when patients have a documented history of consuming multiple medications, including narcotics, in high doses, Pew said.

Dependency Versus Addiction

With addicts, the withdrawal and the lengths to which an injured worker will go to get drugs are extreme.

True addiction manifests itself in aggressive drug-seeking behavior, such as visiting multiple prescribers or claiming the loss of a prescription to obtain early refills.

“Basically you are out of control in terms of your utilization and you are doing whatever you can to get as much of the drug as quickly as possible,” said Dr. Robert Goldberg, chief medical officer for Healthesystems, a workers’ comp pharmacy and ancillary benefits management company in Tampa, Fla.

Among workers’ comp claimants, full-scale addiction is less common than psychological or physical dependence. However, dependent cases may also require detoxification or tapering assistance, Goldberg said.

Dr. Robert Goldberg, chief medical officer for Healthesystems

Dr. Robert Goldberg, chief medical officer for Healthesystems

Detoxification describes the process of helping individuals safely withdraw from substance use, and may involve gradually tapering dose amounts or prescribing alternative drugs to minimize withdrawal symptoms.

“An injured worker’s treating physician that has the proper experience should be capable of addressing simpler cases and helping patients taper off drugs,” Goldberg said.

“A more complicated situation [includes patients with] co-morbidities, a lot of psychosocial factors, higher doses, and longer term dependency,” Goldberg added.

“That is where you have to decide if you need a more formal detox program, either inpatient or outpatient. That is where you are stepping up the game and the intensity of treatment and the cost.”

Reluctance to Seek Treatment

Complicating matters is that workers’ comp payers can’t force a claimant to seek treatment for drug dependency or addiction. In addition, reluctance to seek treatment is typical, so payers must act quickly when a patient indicates a willingness to seek help.

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“Where we have a case that just goes on and on and we are trying to intervene … it can be very frustrating because the patient may not be ready to change,” EMPLOYERS’ Robertson said.

“Yet we have to be ready for that moment when maybe they soften up and say they do want to change their life. We have to be ready to evaluate them at that moment and say, ‘Is a true detox program needed?’ ”

There are several opioid detoxification program settings.  Selecting one can depend on a claimant’s specific needs and the severity of the problem, experts said.

Settings include hospital-based detoxification with 24-hour service, non-hospital detoxification programs with 24-hour service, intensive ambulatory outpatient services and ambulatory detoxification, said Dr. Adam L. Seidner, national medical director for The Travelers Cos. Inc.

“Our nurses help ensure that the services and facility match the required detoxification needed,” Seidner said.

“Multiple service types may be involved. The worker needing detoxification may need to start in the hospital and progress to an ambulatory facility.”

A patient who desires to leave drugs behind and has a supportive home environment may succeed with outpatient care, Paradigm’s Moskowitz said. Others may need the added structure provided by an inpatient program, he added.

The decision whether to use an outpatient or inpatient facility may also depend on a worker’s mind-set. If they don’t consider themselves addicted or dependent, they may object to an inpatient program and only accept outpatient assistance.
Regardless of the care level, though, failure is always possible despite a program’s reputation, Robertson said.

“Sometimes the intervention in a hospital — and there are some great hospital programs — can be most impacting and work best,” Robertson said.

“But you may appear to have a good result then you send the patient home and they go right back into the same set of complex issues that created the problem to begin with.”

That is why experts said a process that only weans patients off medications often is inadequate. They advocate a multidisciplinary approach that includes help with addiction, functional restoration and addressing psychosocial issues that can lead to relapses.

Detox and Chronic Pain Management

Some programs are capable of helping address chronic pain, but not addiction and detoxification, while others excel at helping with the latter but not pain, Moskowitz said.

“We have found the best luck identifying a handful of good programs around the country that are really good at pain management as well as detoxification,” Moskowitz said.

“Most of these cases that have the substance problems also [complain of pain stemming from work injuries]. So you have to address the rehab of the underlying pain diagnosis. In addition, they need to get somebody to change their mind-set to cooperate with coming off the medication.”

To succeed, experts said, payers may also have to fund mental health treatment such as cognitive behavioral therapy that helps patients learn coping skills and managing psychosocial conditions.

“If you don’t do it properly,” Pew said, “you can spend $15,000, $20,000, $25,000 for a functional restoration or chronic pain management program and then they relapse two or three months later because you didn’t deal with how they cope with pain or manage their condition and change their lifestyle.”

But Robin Orchard, president and owner of Orchard Medical Consulting, a case management company that provides detox services in Phoenix, said that simultaneous detox and chronic pain management programs are often not necessary.

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She has seen an increase in claimants seeking detoxification help since workers’ comp payers have learned about the pitfalls of opioid prescribing and curtailed their spending on the medications.

Many of those claimants are psychologically dependent on opioids and have benefited from detox treatment alone, she said.

Once off the drugs, they find that it was their opioid dependence that was helping to drive their pain.

“What we are seeing is when people are off of narcotics, they are not experiencing pain,” Orchard said.

“The overwhelming fear that the pain might occur once they are off the narcotics is what is driving them” to continue using the drugs, she said.

Roberto Ceniceros is senior editor at Risk & Insurance® and chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at [email protected] Read more of his columns and features.

More from Risk & Insurance

More from Risk & Insurance

2017 RIMS

RIMS Conference Opens in Birthplace of Insurance in US

Carriers continue their vital role of helping insureds mitigate risks and promote safety.
By: | April 21, 2017 • 4 min read

As RIMS begins its annual conference in Philadelphia, it’s worth remembering that the City of Brotherly Love is not just the birthplace of liberty, but it is the birthplace of insurance in the United States as well.

In 1751, Benjamin Franklin and members of Philadelphia’s first volunteer fire brigade conceived of an insurance company, eventually named The Philadelphia Contributionship for the Insurance of Houses from Loss by Fire.

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For the first time in America — but certainly not for the last time – insurers became instrumental in protecting businesses by requiring safety inspections before agreeing to issue policies.

“That included fire brigades and the knowledge that a brick house was less susceptible to fire than a wood house,” said Martin Frappolli, director of knowledge resources at The Institutes.

It also included good hygiene habits, such as not placing oily rags next to a furnace and having a trap door to the roof to help the fire brigade fight roof and chimney blazes.

Businesses with high risk of fire, such as apothecary shops and brewers, were either denied policies or insured at significantly higher rates, according to the Independence Hall Association.

Robert Hartwig, co-director, Center of Risk and Uncertainty Management at the Darla Moore School of Business, University of South Carolina

Before that, fire was generally “not considered an insurable risk because it was so common and so destructive,” Frappolli said.

“Over the years, we have developed a lot of really good hygiene habits regarding the risk of fire and a lot of those were prompted by the insurance considerations,” he said. “There are parallels in a lot of other areas.”

Insurance companies were instrumental in the creation of Underwriters Laboratories (UL), which helps create standards for electrical devices, and the Insurance Institute for Highway Safety, which works to improve the safety of vehicles and highways, said Robert Hartwig, co-director, Center of Risk and Uncertainty Management at the Darla Moore School of Business at the University of South Carolina and former president of the Insurance Information Institute.

Insurers have also been active through the years in strengthening building codes and promoting wiser land use and zoning rules, he said.

When shipping was the predominant mode of commercial transport, insurers were active in ports, making sure vessels were seaworthy, captains were experienced and cargoes were stored safety, particularly since it was the common, but hazardous, practice to transport oil in barrels, Hartwig said.

Some underwriters refused to insure ships that carried oil, he said.

When commercial enterprises engaged in hazardous activities and were charged more for insurance, “insurers were sending a message about risk,” he said.

In the industrial area, the common risk of boiler and machinery explosions led insurers to insist on inspections. “The idea was to prevent an accident from occurring,” Hartwig said. Insurers of the day – and some like FM Global and Hartford Steam Boiler continue to exist today — “took a very active and early role in prevention and risk management.”

Whenever insurance gets involved in business, the emphasis on safety, loss control and risk mitigation takes on a higher priority, Frappolli said.

“It’s a really good example of how consideration for insurance has driven the nature of what needs to be insured and leads to better and safer habits,” he said.

Workers’ compensation insurance prompted the same response, he said. When workers’ compensation laws were passed in the early 1900s, employee injuries were frequent and costly, especially in factories and for other physical types of work.

Because insurers wanted to reduce losses and employers wanted reduced insurance premiums, safety procedures were introduced.

“Employers knew insurance would cost a lot more if they didn’t do the things necessary to reduce employee injury,” Frappolli said.

Martin J. Frappolli, senior director of knowledge resources, The Institutes

Cyber risk, he said, is another example where insurance companies are helping employers reduce their risk of loss by increasing cyber hygiene.

Cyber risk is immature now, Frappolli said, but it’s similar in some ways to boiler and machinery explosions. “That was once horribly damaging, unpredictable and expensive,” he said. “With prompting from risk management and insurance, people were educated about it and learned how to mitigate that risk.

“Insurance is just one tool in the toolbox. A true risk manager appreciates and cares about mitigating the risk and not just securing a lower insurance rate.

“Someone looking at managing risk for the long term will take a longer view, and as a byproduct, that will lead to lower insurance rates.”

Whenever technology has evolved, Hartwig said, insurance has been instrumental in increasing safety, whether it was when railroads eclipsed sailing ships for commerce, or when trucking and aviation took precedence.

The risks of terrorism and cyber attacks have led insurance companies and brokers to partner with outside companies with expertise in prevention and reduction of potential losses, he said. That knowledge is transmitted to insureds, who are provided insurance coverage that results in financial resources even when the risk management methods fail to prevent a cyber attack.

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This year’s RIMS Conference in Philadelphia shares with risk managers much of the knowledge that has been developed on so many critical exposures. Interestingly enough, the opening reception is at The Franklin Institute, which celebrates some of Ben Franklin’s innovations.

But in-depth sessions on a variety of industry sectors as well as presentations on emerging risks, cyber risk management, risk finance, technology and claims management, as well as other issues of concern help risk managers prepare their organizations to face continuing disruption, and take advantage of successful mitigation techniques.

“This is just the next iteration of the insurance world,” Hartwig said. “The insurance industry constantly reinvents itself. It is always on the cutting edge of insuring new and different risks and that will never change.” &

Anne Freedman is managing editor of Risk & Insurance. She can be reached at [email protected]