EXECUTIVE SUMMARY

More people die from drug overdoses than die from car crashes, according to data from the American Society of Addiction Medicine. Opioid dependency has become an epidemic nationwide, leading to a crisis.

  • One problem is that primary care physicians may not realize how long patients have been on their prescribed opioids, or who else is prescribing them.
  • Case managers can assist through education and following up with general practitioners who overprescribe.
  • In workers’ compensation cases involving pain management, case managers can help injured workers recover and avoid opioid dependency.

Opioid addiction resulted in more than 33,000 U.S. overdose deaths in 2015, making drug overdose the No. 1 cause of accidental death in the nation. The overdose death rate has quadrupled since the 1990s, as have sales of prescription painkillers, according to the American Society of Addiction Medicine (ASAM).

“The U.S. population equals 5% of the world population, but we use 80% of opioids in the entire world,” says Kathleen Fraser, MSN, MHA, RN-BC, CCM, CRRN, executive director of the Case Management Society of America (CMSA) in Little Rock, AR.

“There are more overdose opioid deaths than suicides and motor vehicle crashes,” Fraser adds.

Everyone in healthcare has a role to play in stopping the epidemic, but the case management role is especially important: “The case manager knows what to look for and can speak with doctors about alternatives for pain and speak with patients, warning about the addictive nature of opioids,” Fraser says.

Primary care physicians may not realize how long patients have been on their prescribed opioids, or where else they are getting prescriptions. Case managers can help by following up with general practitioners, or working with doctors who overprescribe, Fraser suggests.

“That’s something the case manager brings to the table — being able to educate,” she says. They can educate patients about opioid addiction, and educate physicians about overprescribing and monitoring patients for opioid dependence, she adds.

In workers’ compensation cases involving pain management, case managers are an important part of treating injured workers, helping them recover and helping them avoid opioid dependence and other problems. (See related story about chronic pain and opioid use, in this issue.)

“Because of their clinical backgrounds, nurse case managers play an invaluable role working with physicians,” says Patricia Brookey, MS, CRC, CCM, LRC, senior vice president of managed care services at PMA Companies in Blue Bell, PA.

“They help create optimum outcomes for injured workers with chronic pain by encouraging physicians to consider treatment options other than opioids,” Brookey says.

Case managers also raise awareness of opioid abuse and work with physicians in developing treatment plans.

“We intervene at the outset, and our clinical teams work with physicians to develop a pain management plan customized for the injured worker,” Brookey explains. “If opioids are prescribed by the treating physician, goals and benchmarks for opioid use are established, including an exit strategy.”

Setting goals and an exit strategy are important prior to surgery to help set realistic expectations about postoperative pain management for the injured worker, she adds.

Slowing the nation’s opioid crisis takes a concerted effort by the entire healthcare industry. This is something the Centers for Medicare & Medicaid Services (CMS) recognized with its mandate that Medicare plan sponsors have in place an opioid overutilization program.

Indianapolis-based Anthem launched its Opioid Overutilization Management Program in 2013, following the CMS mandate, says Devanshi Sheri, PharmD, BCGP, a clinical pharmacist who leads the Anthem program.

The program has evolved in the last four years and has successfully reduced opioid claims among at-risk members by 50%.

Sophisticated data-mining to identify at-risk members, combined with a pharmacist-driven case management program, are the key components to the program’s success, Sheri says. (See related story on Anthem’s opioid program, in this issue.)

Workers’ compensation insurers’ pharmaceutical oversight for patients on opioids is a huge assistance to claims adjusters and case management, Fraser notes. Some of the red flags they can identify include opioid prescriptions with higher than typical milligrams, long-acting opioids, and patients who have been on opioids, post-surgery or post diagnosis, longer than necessary, she says.

“You need a partnership with physicians, case managers, pharmacists, and patients to look for the best line of care for patients,” she says.

Opioids might be necessary medication for some patients with acute pain after an injury, surgery, or where there is severe back strain, but patients often need short-acting medication.

In cases of patients with injuries that cause chronic pain, case managers can assist in getting them treatment to alleviate their pain to a tolerable level — without opioids, Fraser says.

In some states, pain relief might involve cannabis. Chronic pain patients also could benefit from massage, acupuncture, TENS units, and heat therapy.

“These are all viable alternatives,” Fraser says. “The goal is not to eliminate opioids completely, but to decrease the amount of opioids taken.”

Case managers can help patients reduce opioid use by working closely with physicians and pharmacists to monitor patients’ prescriptions from all prescribers. For instance, a patient might receive an opioid prescription from a surgeon, and psychotropic medications from another physician. Some combinations could lead to an overdose, and neither doctor knows about the other’s prescriptions, she explains.

“Case management can do medication reconciliation, to make sure everybody is on the same page,” Fraser says.

While electronic medical records are helping prevent this problem, they’re still not integrated across many hospitals, pharmacies, and different systems. “It’s still a huge problem,” she says.

Case managers also can take the lead in educating patients about the dangers of opioids. They can find patient and opioid use information online at the National Institute on Drug Abuse website: http://bit.ly/2uHqU4N.

Also, CMSA provides some education about case management and the opioid epidemic.

“We’re trying to support the effort to stop or reverse the effects of this widespread, out-of-control aspect of the opioid epidemic,” Fraser says.