After years of tightening limits, new federal guidelines are giving doctors greater leeway in prescribing opioids.

Unveiled in November by the Centers for Disease Control and Prevention, the voluntary guidelines update more restrictive advice issued in 2016 — advice that triggered a regulatory crackdown on opioids at the state and federal level.

Given the history of opioid abuse in the U.S., insurers and claims administrators in the workers’ compensation arena are closely monitoring the situation. They expect an uptick in opioid prescriptions, particularly for cases of chronic pain. At the same time, they are keeping an eye out for warning signs of addiction and abuse.

“We as clinical professionals do not want to micromanage every single thing in a claim,” said Jennifer Cogbill, senior vice president for GBCARE client services at Gallagher Bassett. “We want to intervene, though, when it becomes clear that there’s a problem.”

Opioids in Review

The new CDC guidelines are the latest chapter in ongoing efforts to strike a balance on opioids, which can be used to treat pain following a workplace injury.

Use of the drugs skyrocketed in the 1990s, leading to a well-documented crisis of abuse, addiction and overdose. Governments and health care providers began to clamp down on opioids in the 2000s.

Although the 2016 guidance was voluntary, many states relied on it to impose mandatory restrictions. Congress passed a law in 2018 that incorporated the guidelines. The Centers for Medicare and Medicaid Services and a number of states followed up with similar regulations.

“That’s really when the providers started to have to really pay attention to it, because then it started to have some potential ramifications,” said Dr. Dan Hunt, medical director for AF Group, a Lansing, Michigan-based holding company whose affiliates provide workers’ comp and other specialty insurance solutions in the U.S.

Opioids and Today’s Prescribing Landscape

Not surprisingly, providers found alternatives to opioids.

Phil Walls, Chief Clinical Officer, myMatrixx

Indeed, on many new workplace injury claims today, opioids are not even in the mix, said Phil Walls, chief clinical officer for myMatrixx.

“They’re going to the emergency room like they may have done in the past, but they’re not necessarily leaving with opioid prescriptions,” said Walls. Trained as a pharmacist, he argued that opioids have never been the best option for pain. Nonsteroidal anti-inflammatory drugs, or NSAIDs, such as ibuprofen, are better, he said.

NSAIDs have side effects on the cardiovascular and gastrointestinal systems, he acknowledged. “But when compared to an opioid, they are much safer in an otherwise healthy adult,” he said.

Fewer people now are misusing prescription opioids, one of the medication’s chief risks. But other problems have cropped up since the 2016 guidance, according to the CDC.

The agency notes that, in some cases, the guidance was misapplied. Some patients, for example, were abruptly cut off from opioids or held to strict time limits. The results were “untreated and undertreated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and suicidal ideation and behavior,” according to the CDC.

Risks Stemming from the New Guidelines

The 2022 guidance aims to address those problems while giving doctors greater flexibility and encouraging them to collaborate with patients.

“We want clinicians and patients to have the information they need to weigh the benefits of different approaches to pain care, with the goal of helping people reduce their pain and improve their quality of life,” Dr. Christopher M. Jones, the acting director of CDC’s National Center for Injury Prevention and Control, said in a statement when the guidelines were released.

Some doctors may have wanted to prescribe opioids before the guidelines changed but held off due to concerns over the legal risks and the potential that insurers would deny coverage, Cogbill said. Others may have accepted that the drugs are dangerous and begun exploring alternative pain treatments.

Either way, insurers and claims administrators are combing prescription data for signs of misuse, such as unusual prescription patterns or deviations from standards of care.

Potential indicators of misuse include the frequency and timing of prescription fills, said Walls. A patient with a 30-day supply of opioids, for example, may try to pick up a new fill on day 25 or 26, Walls said.

“If a patient does that once, it may be a matter of convenience. If he or she attempts it every single time, it’s a pattern,” he said, noting that it could indicate stockpiling or overuse of pills.

In addition, myMatrixx is monitoring for potentially dangerous combinations of drugs, such as opioids prescribed alongside benzodiazepine or gabapentin, an anti-seizure drug that can be used to treat neuropathic pain, Walls said. The combinations increase the risk of overdose.

Rising opioid dosages could be another source of concern, said Hunt, a former surgeon. “That would be certainly a red flag that we would say, ‘Wait a minute, what’s going on here?’ ”

Given the rules and regulations that followed the CDC’s 2016 guidance, Hunt expected little change in the short term to prescribing patterns. Nonetheless, the new guidance could create opportunities for bad actors seeking financial gain, he said. “Those will be the ones that we need to keep an eye on.”

Workers’ Comp and Opioids Today

In workers’ comp today the most common place to find opioid prescriptions are on older claims for people dealing with chronic pain, industry observers said.

On newer claims for chronic pain, providers sometimes prescribe antidepressants or other non-opioid medications, particularly in cases where physical therapy is either not helping or is not an option, Cogbill said.

Under the new guidance, providers may now add opioids to the mix, she added. “In the past, they were not utilized because, essentially, the CDC said opioids are not appropriate for chronic pain, period. So, people were turned away.”

One risk is that opioids once again become the primary answer to long-term pain management, Cogbill said. “We have to be very careful upfront to identify those treatment patterns and intervene to attempt to course-correct away from the opioid as being the answer.”

The alternatives could include physical therapy and assistance that addresses behavioral health concerns, Cogbill said. Gallagher Bassett, for example, employs nurses with behavioral health certification to manage complex claims, such people suffering from unsuccessful back surgeries.

“I believe strongly that we can’t give up on people and their recovery,” she said. “If you just basically ‘abandon’ them to medication, we’re not setting them up for a successful life post-recovery.” &