Alternatives to Opioids

5 Ways to Help Injured Workers Avoid Opioid Misuse

To improve the odds of injured workers recovering from injuries without opioids, employers have tools and strategies at their disposal.
By: | August 20, 2018 • 7 min read

While opioid medications have taken Public Enemy No. 1 status in the last few years, they do have their place. Opiates make sense for patients with cancer-related pain, traumatic injuries like burns and amputations, invasive surgeries and certain other conditions. That said, an enormous spectrum of conditions are still being unnecessarily treated with opioids.

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Both the health care industry and the workers’ comp industry are working to turn that around. Employers can join in the effort by giving injured workers the support they need to recover without opioids. Here are five ways employers can help.

1) Educate Your Workforce

Most people tend to simply accept whatever prescription the doctor writes without questioning it. Despite widespread public attention on opioids, some people still may not grasp the havoc that opioids can wreak on the body. There are plenty of addicted patients who likely never would have agree to take them had they understood what they were ingesting.

Employers can help their workforce become better educated health-care consumers. Include myths and facts about opioids in your rotation of safety and workers’ comp training topics. Make sure workers understand opioids are known to cause all manner of discomfort from itchiness to nausea and constipation — even respiratory depression.

Mark Pew, senior VP, Product Development & Marketing, Preferred Medical

Some people quickly develop a tolerance to the drug, meaning they require ever high doses to manage pain. Worse, some actually experience an increased sensitivity to pain, and wind up taking yet more opioids in an attempt to manage the increased pain. This can result in not only addiction, but respiratory failure and death.

Educating workers on the alternatives to opioids should also be a part of the equation, said Mark Pew, senior VP, Product Development & Marketing for Preferred Medical.

“It’s important for them to understand the benefits versus the risks of opioids. But they also need to know that there are other things at their disposal – things that they can do for themselves or ask their doctor for.”

Those things include deep diaphragmic breathing, mindfulness, yoga, massage therapy, dry needling, acupuncture, cognitive behavioral therapy and more, said Pew. If necessary, short-term NSAIDS or Gabapentin might be a consideration in some cases.

2) Manage Expectations

There’s a world of difference between managed pain and zero pain. The bottom line is that injuries hurt, and so do surgeries. Managing the pain to a tolerable level is a reasonable goal. Eliminating the pain probably isn’t, not at first. Pain is a normal part of the healing process, and it improves over time. “Pain-free” is a mindset that took hold in the US at the height of the opioid marketing push. Turning that mindset around is a challenge.

In a pain relief video posted to YouTube, Dutch hand surgeon Teun Teunis noted, “In the U.S., if you break your ankle and have surgery, you take one of the strongest opioids available. In the Netherlands, you take acetaminophen, a non-opioid pain reliever, just as in most other countries. And pain intensity and satisfaction with pain relief are no different. It seems that when a Dutch person breaks their ankle and needs surgery to repair it, they think, ‘This is going to hurt.’ But in the United States, we think, ‘Why am I hurting?’ ”

For non-complex injuries and minor surgeries, it’s often possible to manage with non-opioid analgesics like acetaminophen, ibuprofen or a staggered combination of the two. If pain is disrupting sleep, patients can supplement with a low dose of an opioid medication at night for a day or two.

One thing injured workers should avoid — especially in the early stages of an injury or immediately after minor surgery — is letting the pain build up. They should be taking non-opioid analgesics at the recommended intervals, or at the first sign of discomfort. Waiting too long can allow the pain to become unbearable, and convince patients to use the supply of opioids they left the ER or the surgery center with.

3) Increase Resiliency with Wellness

The body’s natural healing abilities can be greatly enhanced by a person’s overall health and wellness. Employers can be proactive by cultivating a robust wellness culture. Fit and healthy workers are better able to avoid prolonged pain after an injury.

“It’s important for them to understand the benefits versus the risks of opioids. But they also need to know that there are other things at their disposal – things that they can do for themselves or ask their doctor for.” — Mark Pew, senior VP, Product Development & Marketing, Preferred Medical

Habits such as smoking and inactivity and comorbidities such as obesity can have a dramatic effect on pain severity and duration. As pain drags on, people lose patience with feeling pain and may turn to opioids to make it finally stop.

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A healthy diet, good muscle tone, well managed blood pressure and good stress-management skills are all goals that employers can help their people work toward, said Pew.

“From a wellness standpoint, you can set the standards,” said Pew. That might mean swapping out soda for vitamin water or candy for protein bars in the vending machines. It might mean providing standing desks, or advocating for walking meetings, or reminding workers to get up and walk around every hour. It might mean bringing a nutritionist in to teach people how to cook with less oil and less sodium.

“You can convey this attitude and let it permeate [through the organization],” said Pew. “It sends a subtle message that the best way to deal with life’s curveballs is to develop some resiliency.

“We need to focus on the whole person so when the injury occurs, they’re more fit psychologically, emotionally and physically, so that the injury isn’t catastrophic, and they’re not out of work as long.”

4) Have a Robust Return-to-Work Program

Employers may not be thinking of it in these terms, but a strong return-to-work program is an excellent pain-management tool. It sounds simplistic, but simply having something else to focus on is a technique that works.

“Of course you don’t want to ask them to do more than they’re capable of, but getting them back into the work environment is so important,” said Pew.

He recalled that two years ago at the National Workers’ Compensation and Disability Conference®, Marcos Iglesias, one of his clinical mentors and now the medical director for Broadspire, “made this comment that stuck with me — that ‘worklessness is a comorbidity.’

“The inability to do work is just as bad as hypertension, smoking, or kidney disease.” Said Pew.

“It’s because the sense of value, the sense of accomplishment, the sense of collaboration that you get from working, you can’t get from sitting at home feeling sorry for yourself, watching TV commercials about drugs and about personal injury attorneys — both of whom are turning you into a victim.”

During recovery, a worker might be able to do a modified version of his or her existing job or it may be a slightly different job. Whatever the case, it’s important that the work be meaningful.

“Partial duty shouldn’t be something so insignificant and so mind-numbing that it’s worse than sitting at home,” said Pew, noting that companies with limited light duty options sometimes choose to send workers to non-profit facilities during their recovery.

“Even though they may not be at their regular work, they’re doing good someplace, they’re not just sitting home in the dark basement feeling sorry for themselves” and thinking about their pain, he said.

5) Work with Treating Physicians

Engaging directly with treating physicians is a good strategy for ensuring that workers aren’t being prescribed opiate medications unnecessarily. But an employer or payer’s ability to engage with treating physicians may be limited depending on the state.

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“Connecticut has ex parte rules that you absolutely positively cannot speak to [an injured workers’] physician, and the physician is purely the choice of the injured worker,” said Pew. “While in states like Georgia, the employer selects the panel of physicians and workers have to [utilize] those physicians. In Texas and California, employers can create networks of physicians and there are benefits for employees  who use that network.”

If employers are able to select their physician panel, it’s important to select doctors who are experienced and who understand the nuances of occupational health, said Pew, and to ensure that their sole focus is return to work and return to function.

“Fill your network with doctors who are very competent, who follow evidence-based medicine, and that have demonstrated proof, over time, that they deliver people back to work and back to function quickly — but not so quickly that they reinjure themselves,” he said.

Employers who can’t influence clinician selection may still be able to help injured workers avoid opioid pitfalls by providing case managers or nurse triage providers who are closely aligned with the company’s philosophy on selecting opioid alternatives whenever possible. &

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]

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 and 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]