Perspective |The Opioid Crisis: Why This Is Our Defining Moment

For every person who dies from opioid overdose, 50 more individuals have an opioid use disorder and 272 misuse prescription opioids in some way. The time to change is now.
By: | October 23, 2018 • 8 min read

Our country is being threatened. And in many ways, the enemy is us. The numbers paint a bleak picture for our priorities as a society as they relate to the opioid crisis. Statistics from the Centers for Disease & Prevention (CDC) report more than 42,000 people died from opioid-related drug overdose in 2016, and provisional data for 2017 currently put overdose fatality rates over 62,000.1

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As clinical leaders in the workers’ compensation space, we bring a unique point of view to this conversation. Managing the care of injured employee populations, where pain and its management are prevalent, we are positioned on the front line of preventive efforts against prescription opioid addiction.

We have seen firsthand the tremendous negative impact that opioids have on the recovery, health and quality of life for the patient. We have critical insight into why this problem is not just about street drugs — that prescription opioids play a definitive role in the larger crisis.

For every fatality counted, there are exponentially more people out there suffering from the impacts of opioids at the individual, family and community levels. For every one person who dies from opioid overdose, 50 more individuals have an opioid use disorder, and 272 misuse prescription opioids in some way.2

Most importantly, we know that change is possible. But it doesn’t happen without a committed effort.

Public Health Approach

The opioid epidemic was declared a national public health emergency in October 2017. A full year later, we are seeing perhaps the first sweeping action on a federal level that rises to the urgency of this declaration, with Congress passing the SUPPORT (Substance Use Disorder Prevention That Promotes Opioid Recovery and Treatment) for Patients and Communities Act.

Silvia Sacalis, PharmD, VP, clinical services, Healthesystems

The legislation — which aims to advance treatment and recovery initiatives, boost abuse prevention efforts, and increase policy and enforcement initiatives — is a good start, albeit a delayed one. And there are still other opportunities for increased effort.

Despite increased allotments to the CDC, NIH and FDA in 2018, these agencies remain the David-versus-Goliath that is the opioid crisis when comparing from a cost perspective. The crisis causes the U.S. an estimated $500 billion per year inclusive of health care, criminal justice and lost productivity costs.2 U.S. opioid sales are projected to hit $18.4 billion annually by 2020.

In 2001, Purdue Pharmaceuticals spent $200 million alone on the promotion of OxyContin — a financial amount nearly twofold what the National Institutes of Health (NIH) have traditionally been allotted in previous years to research opioid use disorder and alternative pain treatments. Stack all of that up to the $500 million directed to the NIH this year, and it’s still like bringing a slingshot to a gunfight.

A continued emphasis on providing financial support to these entities will allow them to better address knowledge gaps and research treatment options for opioid use disorder, as well as new, safer pain therapies, both pharmacological and non-pharmacological. Is this a significant investment? Of course. But here is the more pertinent question: Aren’t our people and our country worth the investment?

A Responsibility for Action

Opioid use disorder — and its related fatalities — is nearly 100 percent preventable. On one hand, the needlessness of this crisis renders it even more tragic. On the other hand, it gives us our best chance at attacking the epidemic head-on with preventive strategies.

Public education: Despite recent high-profile media coverage of opioids, many people remain unaware that the pain medications they are prescribed present serious risk for addiction and other adverse effects. This is not only a significant failure of the prescriber, but there also exists responsibility from a public health perspective.

As a society, we are failing to provide the right context around the opioid crisis in a manner that enables Americans to equate it with other serious health concerns impacting our population. In 2016, the incidence of opioid overdose deaths surpassed the annual number of breast cancer deaths for the first time in history.

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Unlike breast cancer, there are no nationally recognized walks, no advocacy organizations that have become a household name. We don’t pin ribbons to our lapels in support of overcoming this disease that continues to claim more lives year upon year.

A better-informed public makes better-informed patients. And this in turn must be supported by doctors who are willing to engage in dialogue with patients that will shift attitudes and expectations toward pain management — moving away from the “pill for every ill” mindset toward components of treatment emphasized in workers’ compensation populations, such as self-care and non-pharmacologic approaches, in addition to non-opioid medications.

Physician education: The extent of pain management and opioid training most physicians receive is severely inadequate. Pharmaceutical companies have capitalized, filling this void with heavy advertising, detailing and “continuing education” to promote opioid products.

Addressing this enormous gap will take a two-pronged approach: Banning or severely limiting pharmaceutical advertising and rapidly increasing training and education about opioid risks and responsible management.

Education and control measures aren’t enough. As long as opioids are in available in unyielding supply, they will find a way through. Opioids must become a less prevalent and less visible option.

State medical and pharmacy boards play an influential role in modifying, prescribing and dispensing behaviors through practitioner education, stricter board regulations around the dispensing of opioids and other controlled substances with addiction potential, prescribing limitations on dose, quantity and duration, and implementing stronger and more frequent disciplinary actions in response to violations.

Physicians, and the care they provide, would also benefit from increased exposure to the biopsychosocial model — a care model that looks beyond the traditional medical/pharmacologic approach to address the overall physical, mental and emotional health of a patient. These are critical factors when considering that adults with mental health conditions receive 51 percent of total opioid prescriptions in the U.S.3

Dr. Robert Goldberg, chief medical officer, senior vice president, Healthesystems

State regulation: While regulation alone isn’t the solution, it provides important guardrails and controls. The last year has produced a volume of state-based regulation around opioid prescribing, including limits on quantity, dose and duration.

More can be done. Prescribers should be required to check prescription data monitoring programs (PDMPs) prior to prescribing in every state — states with these mandatory rules in place are seeing the impact on prescription rates.

Taking this a step further, interoperability of PDMPs across all 50 states and expanded access to PDMP data to third-party health care entities would help provided much-needed visibility into a patient’s history of controlled substance use. In the workers’ comp space especially, insurance carriers and pharmacy benefit managers (PBMs) play a central role in supporting and upholding opioid prescribing limits through strategic formulary implementation and the tools, alerts and guardrails they set in place to drive adherence to these rules at the claims adjuster, prescriber, pharmacy and patient touch points.

Education and control measures aren’t enough. As long as opioids are available in unyielding supply, they will find a way through. Opioids must become a less prevalent and less visible option. It is incumbent upon federal agencies to tighten controls in their respective areas.

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The FDA is beginning to tighten measures around the development and approval of opioids but in the same breath continues to push new products through. The DEA can play a powerful role by helping to control both prescription and illicit opioid sources, which includes increased enforcement of pill mills, distributors and high-volume dispensing pharmacies and physicians.

Stemming the flow of illicit fentanyl from overseas also becomes a top priority with the explosion of abuse and related fatalities over the last several years. The SUPPORT Act can play a role here, as it will require the U.S. Postal Service to screen packages shipped from abroad, primarily China, a primary source for illicit fentanyl.

The Third Wave

For many, it is too late for primary prevention efforts. More than 11 million people in this country misuse prescription pain medications, and 2.1 suffer from an opioid use disorder.3 Even as we tackle the crisis from the front end, we must clean up the current mess. Measures include:

  • Fully funding treatment of opioid use disorder through workers’ compensation, commercial, Medicaid and Medicare programs, with an emphasis on medication-assisted treatment with buprenorphine, and expansion on the number and geographic distribution of qualified physicians;
  • More effective use of medication contracts, urine drug screens and opioid weaning strategies;
  • Mandatory legislated interoperability of PDMPs to effectively counter abuse and enable routine use for a complete picture of concurrent prescribing and dispensing across all pharmacies and prescribers.

Most importantly, we must be continually critical of ourselves, acknowledging where we are failing — as a health care system, as a government, as a society — and implementing new and better solutions to address these failures.

Ad Astra Per Aspera

Modern U.S. history is marked by moments and movements that have defined the generations in which they have occurred and reshaped the attitudes and policies of our country — for better or for worse. Arguably, the opioid epidemic has become one of the most significant crises in this decade to impact our nation. But we have hope that what will ultimately define us are not the far-reaching and devastating impacts of the crisis itself, but instead the actions we take to overcome it. &


References
1Centers for Disease Control and Prevention. Opioid Overdose. www.cdc.gov/drugoverdose/index.html
2Key substance use and mental health indicators in the United States: results from the 2016 National Survey on Drug Use and Health
3The Council of Economic Advisers. The Underestimated Cost of the Opioid Crisis. November 2017

Dr. Robert Goldberg is chief medical officer and senior vice president with Healthesystems. Silvia Sacalis, PharmD, is vice president, Clinical Services, with Healthesystems. Robert and Silvia can be reached at riskletters@lrp.com.

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 riskletters@lrp.com.