Opioid use continues to be a problem throughout the United States, impacting the health of millions of people and contributing to skyrocketing medical costs. In the context of workers’ compensation claims, employers and insurance carriers should continue to closely monitor claims in which care providers prescribe opioids to treat chronic pain. When it becomes evident that a doctor is prescribing excess opioids or is not properly monitoring the effectiveness of these drugs, it may be time to transfer care to another physician. In South Carolina, employers and insurance carriers benefit from the right to direct medical care under the SC Workers’ Compensation Act. However, there are limitations to this right to direct care, particularly once a treating physician has already been established. As a result, a change in treatment will often require an independent medical evaluation, doctors’ depositions, and ultimately an order from the South Carolina Workers’ Compensation Commission. This can be a somewhat costly and time consuming process, but it is often worth the expense to ensure appropriate care, and to prevent medical costs from spiraling out of control.
In our experience, the SC Commission has been receptive in recent years to requests from employers and insurance carriers to transfer care, particularly where there is compelling evidence of excessive opioid use. We are aided by recently published CDC guidelines, which confirm there is scant evidence to support the effectiveness of opioids to treat chronic pain. The guidelines conclude that “nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred” and that opioids should be considered for chronic pain “only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.”
The guidelines focus on morphine milligram equivalents (MMEs) as a guidepost for determining appropriate long-term care. The CDC’s website https://www.cdc.gov/drugoverdose/prescribing/guideline.html provides a chart to calculate MMEs for commonly prescribed opioids. The guidelines include specific recommendations where total opioid dosage is increased to > 50 MME/day. The guidelines recommend avoiding increasing dosages to > 90 MME/day. Specifically, the guidelines state:
“Before increasing total opioid dosage to ≥50 MME/day, clinicians should reassess whether opioid treatment is meeting the patient’s treatment goals. If a patient’s opioid dosage for all sources of opioids combined reaches or exceeds 50 MME/day, clinicians should implement additional precautions, including increased frequency of follow-up and considering offering naloxone and overdose prevention education to both patients and the patients’ household members. Clinicians should avoid increasing opioid dosages to ≥90 MME/day or should carefully justify a decision to increase dosage to ≥90 MME/day based on individualized assessment of benefits and risks and weighing factors such as diagnosis, incremental benefits for pain and function relative to harms as dosages approach 90 MME/day, other treatments and effectiveness, and recommendations based on consultation with pain specialists. If patients do not experience improvement in pain and function at ≥90 MME/day, or if there are escalating dosage requirements, clinicians should discuss other approaches to pain management with the patient, consider working with patients to taper opioids to a lower dosage or to taper and discontinue opioids, and consider consulting a pain specialist.”
Despite these recommendations, we continue to see the widespread use of opioids to treat chronic pain in workers’ compensation claims, often without careful scrutiny of dosage and effectiveness that the CDC suggests is fundamental to appropriate care and the safety of the patient.
Therefore, employers and insurance carriers should remain vigilant in claims where opioids are involved. Be mindful of total opioid dosage and recognize red flags such as a lack of improvement in the claimant’s pain and function. When there is evidence of a problem, take action as necessary to direct medical treatment as permitted under the SC Workers’ Compensation Act.