Rising Use of Detox
Chronic pain patients arriving at a detox center in Las Vegas after years of opioid pain medication dependency may be fearful and reluctant, yet hoping for a better life without drugs.
Some patients may be adversarial, pushed there by claims payers’ insistence that continued long-term narcotics consumption is therapeutically inappropriate and probably exacerbating their pain.
Either way, they’ve come for a stay at one of the few programs available nationwide that workers’ comp insurers and case management companies have found stands a good chance of getting high-risk, chronic pain sufferers to rethink their narcotics consumption.
“In the workers’ comp area it’s a tough job getting people off opioids who have chronic pain,” said Dr. Mel Pohl, medical director at the Las Vegas Recovery Center.
“The kinds of stories that are really typical for these patients are that they are on high-dose opioids, well over the danger zone.”
“Detox in a work comp environment is more complex and more challenging because you are not only treating the addiction to alcohol or drugs, but you are also treating chronic pain from a work-related injury that usually has other psychosocial issues,” said Debbie Michel, executive VP and general manager of Liberty Mutual’s national insurance casualty unit.
Workers’ compensation payers are taking greater responsibility for helping injured workers addicted to pain medications that were prescribed to treat workplace injuries. Drug and alcohol detox programs are widely available. But only a precious few combine detox services with pain-management expertise.
There are perhaps six to 15 such programs nationwide that have proven track records for producing positive outcomes and understand the needs of workers’ comp patients, experts said. The scarcity of centers often necessitates flying claimants, and perhaps family members to those treatment facilities, said Sherri Hickey, director of medical management for excess insurer Safety National.
“There are many states where there is really no place to send them to,” Hickey said.
“We have to fly them halfway across the county almost.”
Meanwhile, an ongoing attitude shift is underway among workers’ comp claims payers. More are funding functional restoration programs or biopsychosocial care models, found to work well in combination with detox services.
“If you don’t give them coping mechanisms to deal with the pain — because it is going to stay when the drugs are gone — then you haven’t really provided any benefit for the patient,” said Mark Pew, senior VP at PRIUM, a medical-intervention company.
“You can detox them, absolutely. But chances are good they are going to rebound back to those drugs.”
The services typically found under functional restoration’s umbrella can include cognitive behavioral therapy, biofeedback, yoga, psychological help, hypnosis, physical therapy and vocational-rehab work.
Such offerings provide patients with mental coping mechanisms, whether their pain is generated by psychological, physical, or emotional factors, said Pew.
In addition to physical therapy, the programs may include other exercise-based practices, even gym memberships, for improving physical stamina. That too is a factor in managing pain that will persist once the drugs are eliminated, he said.
Pew has visited addiction and pain management programs nationwide to assess them for claim payers contracting for PRIUM’s services.
“There are a lot of facilities that will detox and send them home,” Hickey said.
If you don’t give them coping mechanisms to deal with the pain — because it is going to stay when the drugs are gone — then you haven’t really provided any benefit for the patient. — Mark Pew, senior VP, PRIUM
“That is not going to fix them. They need psychotherapy. They need cognitive therapy. They need functional [restoration] therapy, to learn how to manage their physical pain with other methods besides the opioids.”
Safety National now sees plenty of “high-risk developmental claims” involving injured workers who have been prescribed opioid pain medications for as long as
five to 10 years, Hickey said.
The long-term consumption commonly causes opioid-induced hyperalgesia, a paradoxical condition whereby the medications cause patients to experience greater pain, Hickey said.
Barnabas Health, an integrated health care delivery system and a 2015 Teddy Award winner, analyzes its workers’ comp claims for early warnings that doctors are prescribing drugs for longer than appropriate durations, said Caryl Russo, senior vice president, corporate care.
When pain-management doctors continue to prescribe the drugs even after assuring Barnabas they will stop doing so, the company transfers the injured worker’s care to other pain management specialists who will wean the patient off the drugs.
But there, too, limited options exist.
“We have identified in the State of New Jersey only two pain medicine physicians that we trust have the ability to help take someone off that pathway … ,” Russo said.
When it comes to detox services, workers’ comp payers have become more open to funding programs that involve psychological care, Hickey said.
“To pay for detox — that was considered outside the realm of the injury,” she said.
“But we have all come to realize that we have to look at the whole person.”
That is not always the case in workers’ comp, said Las Vegas Recovery Center’s Pohl.
“… 80 percent or more of the experience of chronic pain is cognitive or emotional,” he said. “It’s not through physical modalities primarily that people get better. It’s through letting go of their tenacious hold of what pain means to them.”
Overall, workers’ comp claims payers with a nationwide presence face a “cottage industry” of detox and pain management programs with various treatment models, said Darrell Bruga, CEO of LifeTEAM Health, a recovery improvement network.
“There might be similarities to what happens in programs, but there will be fluctuations in the outcomes nd types of services delivered,” he said.
“There is a difference between a functional restoration approach and a chronic pain program that might involve interventions. That is different from a program that is getting people engaged in activities after they have gone through a withdrawal program.”
“We are seeing some very good results from some of the big centers,” Hickey said, while noting that relapse is not unheard of.
About half of patients arriving at the Las Vegas Recovery Center may be adversarial, requiring special skills to assist them, Pohl said. The other half are ready for positive change.
“Even though they have fear and reluctance, they have an intuitive sense that life is going down the tubes and they would be better off without the drugs,” Pohl said.
“People know that. It’s the fear of how to accomplish it that keeps them from acting.”