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Shifting Our Focus to Preventing Negative Outcomes from Opioids

Preventing negative outcomes from the treatment associated with a workplace injury is just as critical as preventing the injury from happening.
By: | May 18, 2017 • 6 min read

Providing people who want to work, the opportunity to work is not only important to individual families but also the economy. When workers are injured, they may lose that opportunity. Preventing work injuries from happening in the first place is far and away the best way to keep workers from becoming injured workers. When injuries do happen, it is imperative for all involved, to focus on getting workers healthy and back to their lives.

Once an injury has taken place, a lot can happen during the course of treatment that ultimately will lead to positive or negative outcomes. Preventing negative outcomes from the treatment associated with an injury is just as important as preventing the workplace injury in the first place. To prevent injuries we implement and encourage proper training, awareness and safety protocols. Similar protocols should be used to prevent negative outcomes during the course of treatment so injured workers can return to the most productive life possible.

How can we prevent negative outcomes from happening in the course of treatment of an injured worker? If the course of treatment was process mapped, we might find several gaps in care that could affect outcomes. Importantly, a major gap in care for many would relate to the opioid epidemic. The Centers for Disease Control and Prevention (CDC) report that as many as 1 in 4 patients receiving long-term opioid therapy in a primary care setting, struggle with addiction.1 And, “we now know that overdoses from prescription opioids are a driving factor in the 15-year increase in opioid overdose deaths.”2 At their best, opioids are valuable tools in mitigating intense acute pain helping injured workers get through the toughest portions of their pain and onto the road to recovery. At their worst, opioids are an intensely addictive therapy that has led to 91 Americans dying every day from overdoses.2

While recent initiatives such as improving access to care for those addicted to opioids, and expanding access to the life-saving drug naloxone used in opioid overdose are important steps towards addressing the epidemic for those that have already developed a negative outcome, we also need to focus on preventing negative outcomes from happening in the first place. To do this, it has become clear that there needs to be a multifaceted approach that identifies a goal and establishes a methodology to achieve that goal for the injured worker. Process models would challenge us to capitalize on available resources and remove wasted steps to be able to identify, maintain and sustain process improvement towards improving opioid epidemic related problems. The process of treatment within Workers’ Compensation is a team effort among many people who influence the care an injured worker receives and as such an approach that utilizes each team member’s expertise as a resource will be useful.

Stephanie Labonville, PharmD, CPE, BCPS, Director of Clinical Operations

The pharmacist role is an evolving and often underutilized available resource that can be instrumental in a multifaceted approach towards preventing negative outcomes. As experts in medication, pharmacists’ skills and knowledge are valuable resources and they have the ability to contribute to integrated care teams by detecting and resolving or preventing drug related problems, helping to ensure the safe and efficacious use of medicines and providing comprehensive drug information to patients and other health care professionals, thereby reinforcing prevention of negative outcomes.

As an industry, we must focus on our role in appropriate and safe pain management. This focus must take into consideration the CDC’s calling on dispensing pharmacists to be on the front lines of addressing prescription opioid abuse and overdose.3 Dispensing pharmacists as part of a Workers’ Compensation PBM must take this front-line role to a value-added level and develop specific program solutions focused on opioid related problems such as Prescription Drug Monitoring Program (PDMP) reviews and education of injured workers and communication with their physicians regarding high-risk drug combinations, high risk opioid doses and safer alternative treatment regimens.

Some drug combinations can be extremely dangerous. For example, there has been much written about the “holy trinity” of drugs: opioids, benzodiazepines and carisoprodol (Soma) and the serious danger inherent in taking 2 or 3 of these together.4,5 Can we really afford to use a pharmacy or PBM that doesn’t have a standardized approach to this combination or one who does not take action before the combinations of medications are dispensed? We need specific programs that reach out to the patient and prescribing physicians on these specific risky drug combinations prior to their dispensing.

Pharmacists who can access state PDMPs can help identify patients at increased risk of overdose, such as those taking high dosages or obtaining opioids from multiple prescribers. They can then help monitor the patient and their prescriptions allowing for proactive consultation with the injured worker and prescriber prior to dispensing high-risk medications.

In addition to consulting with physicians regarding opioid addiction and high-risk drug combinations, it is important for the pharmacist to be able to alert a prescriber to pertinent legislative rule(s) for their state and their patient’s morphine milligram equivalent (MME) before the pills are dispensed. Choosing a PBM with this capability can be critical to preventing negative outcomes.

As injured workers are educated about what medications may work best for them as well as potential risks of various medications or combinations of medications, they are provided the opportunity to become advocates for themselves. We need to ensure that dispensing pharmacists have experienced insight into pain management within Workers’ Compensation, which they can then use to educate patients. Pharmacists as part of the injured worker’s treatment team can use a variety of ways to educate patients including direct phone calls and subsequent informational pieces that address pain management e.g., “If not opioids, then what?”

Many injured workers are scared that their pain will be unmanageable without opioids. Learning that outcomes and pain management are often improved through the use of tapers, other non -addictive medications, non-drug therapies like; cognitive behavior therapy (CBT), massage, movement therapies, socialization, healthier food and lifestyle decisions, will provide the injured workers the resources and support to get on the road to recovery and return them to what they deserve: the opportunity to return to a productive life. The equipped dispensing pharmacist must be an integral member of the medical treatment team to make that a reality.

We can, as an industry, work towards this goal of keeping workers participating in the workforce and in their life by ensuring that we involve knowledgeable, experienced dispensing pharmacists in the treatment plan of our complex cases before a potentially risky pain medication regimen is determined, prescribed and dispensed.

Let’s help protect our most important national resource: our workers before they become statistics, by focusing on prevention as well as management of this problem.

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This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Specialty Solutions Rx. The editorial staff of Risk & Insurance had no role in its preparation.




Specialty Solutions Rx is a full service workers’ compensation PBM that was designed to proactively and effectively address opioids and other high risk medications.

Black Swan: EMP

Chaos From Above

An electromagnetic pulse event triggered by the detonation of a low-yield nuclear device in Earth’s atmosphere triggers economic and societal chaos.
By: | July 27, 2017 • 9 min read

Scenario

The vessel that seeks to undo America arrives in the teeth of a storm.

The 4,000-ton Indonesian freighter Pandawas Viper sails towards California in December 2017. It is shepherded toward North America by a fierce Pacific winter storm, a so-called “Pineapple Express,” boasting 15-foot waves and winds topping 70 mph.

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Normally, Pandawas Viper carries cargo containers. This time she harbors a much more potent payload.

Unbeknownst to U.S. defense and intelligence officials, the Viper carries a single nuclear weapon, loaded onto a naval surface-to-air missile, or SAM, concealed below deck.

The warhead has an involved history. It was smuggled out of Kyrgyzstan in 1997, eventually finding its way into the hands of Islamic militants in Indonesia that are loosely affiliated with ISIS.

Even for these ambitious and murderous militants, outfitting a freighter with a nuclear device in secrecy and equipping it to sail to North America in the hopes of firing its deadly payload is quite an undertaking.

Close to $2 million in bribes and other considerations are paid out to ensure that the Pandawas Viper sets sail for America unmolested, her cargo a secret held by less than two dozen extremist Islamic soldiers.

The storm is a perfect cover.

Officials along the West Coast busy themselves tracking the storm, doing what they think is the right thing by warning residents about flooding and landslides, and securing ports against storm-related damage.

No one gives a second thought to the freighter flying Indonesian colors making its way toward the Port of Long Beach, as it apparently should be.

It’s only at two in the morning on Sunday, December 22, that an alert Port of San Diego administrator charged with monitoring ocean-going cargo traffic sees something that causes him to do a double take.

GPS tracking information indicates to him that the Pandawas Viper is not heading to Long Beach, as indicated on its digital shipping logs, but is veering toward Baja, Calif.

Were it to keep its present course, it would arrive at Tijuana, Mexico.

The port administrator dutifully notifies the U.S. Coast Guard.

“Indonesian freighter Pandawas Viper off course, possibly storm-related navigational difficulties,” he emails on a secure digital communication channel operated by the port and the Coast Guard.

“Monitor and alert as necessary,” his message, including the ship’s current coordinates, concludes.

In turn, a communications officer in the Coast Guard’s Alameda, Calif. offices dutifully alerts members of the Coast Guard’s Pacific basin security team. She’s done her job but she’s about an hour late.

At 3:15 am Pacific time on December 22, the deck on the Pandawas Viper opens and the naval surface-to-air missile, operated remotely by a militant operative in Jakarta, is let loose.

It’s headed not for Los Angeles or San Diego, but rather Earth’s atmosphere, where it detonates about 50 miles above the surface.

There it interacts with the planet’s atmosphere, ionosphere and magnetic field to produce an electromagnetic pulse, or EMP, which radiates down to Earth, creating additional electric or ground-induced currents.

The operative’s aim is perfect. With a charge of hundreds and in some cases thousands of volts, the GICs cause severe physical damage to all unprotected electronics and transformers. Microchips operate in the range of 1.5 to 5 volts and thus are obliterated by the billions.

As a result, the current created by the blast knocks out 70 percent of the nation’s grid. What began as an overhead flash of light plunges much of the nation into darkness.

The first indication for most people that there is a problem is that their trusty cellphones can do no more than perform calculations, tell them the time or play their favorite tunes.

As minutes turn to hours, however, people realize that they’ve got much bigger concerns on their hands. Critical infrastructure for transportation and communications ceases. Telecommunication breakdowns mean that fire and police services are unreachable.

For the alone, the elderly and the otherwise vulnerable, panic sets in quickly.

Hospital administrators feverishly calculate how long their emergency power supplies can last.

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Supermarkets and other retailers anticipating one of their biggest shopping days of the year on that Monday, December 23, instead wake up to cold homes and chilling prospects.

Grocery stores with their electricity cut off are unable to open and product losses begin to mount. Banks don’t open. Cash machines are inoperable.

In the colder parts of the United States, the race to stay warm is on.  Within a day’s time in some poorer neighborhoods, furniture is broken up and ignited for kindling.

As a result, fires break out, fires that in many cases will not draw a response from firefighting crews due to the communication breakdown.

As days of interruption turn into weeks and months, starvation, rioting and disease take many.

Say good-bye to most of the commercial property/casualty insurance companies that you know. The resulting chaos adds up to more than $1 trillion in economic losses. Property, liability, credit, marine, space and aviation insurers fail in droves.

Assume widespread catastrophic transformer damage, long-term blackouts, lengthy restoration times and chronic shortages. It will take four to 10 years for a full recovery.

The crew which launched the naval surface-to-air missile that resulted in all of this chaos makes a clean getaway. All seven that were aboard the Pandawas Viper make their way to Ensenada, Mexico, about 85 miles south of San Diego via high-speed hovercraft.

Those that bankrolled this deadly trip were Muslim extremists. But this boat crew knows no religion other than gold.

Well-paid by their suppliers, they enjoy several rounds of the finest tequila Ensenada can offer, and a few other diversions, before slipping away to Chile, never to be brought to justice.

Observations

This outcome does not spring from the realm of fiction.

In May, 1999, during the NATO bombing of the former Yugoslavia, high-ranking Russian officials meeting with a U.S. delegation to discuss the Balkans conflict raised the notion of an EMP attack that would paralyze the United States.

That’s according to a report of a commission to assess the threat to the United States from an EMP attack, which was submitted to the U.S. Congress in 2004. But Russia is not alone in this threat or in this capability.

Wes Dupont, vice president and general counsel, Allied World Assurance Company

North Korea also has the capability and the desire, according to experts, and there is speculation that recent rocket launches by that country are dress rehearsals to detonate a nuclear device in our atmosphere and carry out an EMP attack on the United States.

The first defense against such an attack is our missile defense. But some experts believe this country is ill-equipped to defend against this sort of scenario.

“In terms of risk mitigation, if an event like this happens, then that means the best risk mitigation we have has already failed, which would be our military defense systems, because the terrorists have already launched their weapon, and it’s already exploded,” said Wes Dupont, a vice president and general counsel with the Allied World Assurance Company.

The U.S power grid is relatively unprotected against EMP blasts, Dupont said.

And a nuclear blast is the worst that can occur. There isn’t much mitigation that’s been done because many methods are unproven, and it’s expensive, he added.

Lloyd’s and others have studied coronal mass ejections, solar superstorms that would produce a magnetic field that could enter our atmosphere and wipe out our grid.  Scientists believe that an EMP attack would carry a force far greater than any coronal mass ejection that has ever been measured.

An extended blackout, with some facilities taking years to return to full functionality, is a scenario that no society on earth is ready for.

“Traditional scenarios only assume blackouts for a few days and losses seem to be moderate …” wrote executives with Allianz in a 2011 paper outlining risk management options for power blackout risks.

“If an event like this happens, then that means the best risk mitigation we have has already failed … because the terrorists have already launched their weapon, and it’s already exploded.” — Wes Dupont, vice president and general counsel, Allied World Assurance Company

“But if we are considering longer-lasting blackouts, which are most likely from space weather or coordinated cyber or terrorist attacks, the impacts to our society and economy might be significant,” the Allianz executives wrote.

“Critical infrastructure such as communication and transport would be hampered,” the Allianz executives wrote.

“The heating and water supply would stop, and production processes and trading would cease. Emergency services like fire, police or ambulance could not be called due to the breakdown of the telecommunications systems. Hospitals would only be able to work as long as the emergency power supply is supplied with fuel. Financial trading, cash machines and supermarkets in turn would have to close down, which would ultimately cause a catastrophic scenario,” according to Allianz.

It would cost tens of billions to harden utility towers in this country so that they wouldn’t be rendered inoperable by ground-induced currents. That may seem like a lot of money, but it’s really not when we think about the trillion dollars or more in damages that could result from an EMP attack, not to mention the loss of life.

Allianz estimates that when a blackout is underway, financial trading institutions, for example, suffer losses of more than $6 million an hour; telecommunications companies lose about $30,000 per minute, according to the Allianz analysis.

Insurers, of course, would be buffeted should a rogue actor pull off this attack.

Lou Gritzo, vice president and manager of research, FM Global

“Depending on the industries and the locations that are affected, it could really change the marketplace, insurers and reinsurers as well,” said Lou Gritzo, a vice president and manager of research at FM Global.

Gritzo said key practices to defend against this type of event are analyzing supply chains to establish geographically diverse supplier options and having back-up systems for vital operations.

The EMP commission of 2004 argued that the U.S. needs to be vigilant and punish with extreme prejudice rogue entities that are endeavoring to obtain the kind of weapon that could be used in an attack like this.

It also argued that we need to protect our critical infrastructure, carry out research to better understand the effects of such an attack, and create a systematic recovery plan. Understanding the condition of critical infrastructure in the wake of an attack and being able to communicate it will be key, the commission argued.

The commission pointed to a blackout in the Midwest in 2003, in which key system operators did not have an alarm system and had little information on the changing condition of their assets as the blackout unfolded.

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The commission’s point is that we have the resources to defend against this scenario. But we must focus on the gravity of the threat and employ those resources.

Our interconnected society and the steady increase in technology investment only magnify this risk on a weekly basis.

“Our vulnerability is increasing daily as our use of and dependence on electronics continues to grow,” the EMP commission members wrote back in 2004.

But “correction is feasible and well within the nation’s means and resources to accomplish,” the commission study authors wrote. &

Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]