Federal agencies say that dangerous misuse of opioids is getting worse. Informed workers’ comp professionals tell me that the situation is probably improving.

They are both right. Here’s why.

The Food and Drug Administration’s deputy commissioner Robert Califf said the other day that “things are getting worse, not better, with the epidemic of opioid misuse, abuse and dependence.” He was most likely using as his primary benchmark the rate of opioid-related deaths, which has been rising. That rate was 9 per 100,000 in 2003; in 2014, it was 15.

Ten years ago, opioid-related deaths were concentrated in counties in West Virginia and eastern Kentucky. The problem spread. In 2014, West Virginia had a rate of 32 per 100,000, while Kentucky, Ohio, Tennessee, Oklahoma, New Mexico, Utah and Nevada had rates of 20 or over.

The New York Times reported on January 19 that the trend is now similar to that of the H.I.V. epidemic in the late 1980s and early 1990s, according the C.D.C.’s chief of mortality statistics.

The rural nature of most of these high-rate states reflects one dimension of the problem. In a large urban state like California, the death rate has always been at or below the national average (8.7% in 2003 and 11.1% in 2014). Another dimension is that, from the start some 15 or so years ago, the deaths have been concentrated among young and middle-aged white male adults. This demographic, between 25 and 44, has a death rate now of over 40 per 100,000 – close to three times the national average.

Work injuries may well be the portal through which opioid abuse spreads among the adult population. The first reported opioid-related death in the country was of an injured worker, in Washington state. The failure of about every workers’ comp state agency other than Washington to investigate injured worker deaths due to prescribed opioids is shameful. This black mark matches the past failure of state workers’ comp systems to properly accept disease claims by atomic weapon production workers. That led to federalization of these claims under the Clinton Administration.

However, the workers’ comp industry has on balance acted responsibly. While states kept a crypt-like silence on these deaths, they did introduce an array of formal controls. Claims payers with their pharmacy benefit management partners began to address the problem earnestly. These responses began to reinforce one another starting around 2010. I summarize them in my 2015 report, "We’re Beating Back Opioids: Now What?"

In late January, I polled 14 individuals, all holding top positions in claims or medical management. They work mostly for claims payers and PBMs and have multi-state responsibilities. I asked what is going on in managing opioid abuse.

One responder’s comment on industry trends captures a consensus among the respondents that the problem in workers’ comp is either stable or, more likely, improving. This respondent noted:

• PBMs have evolved from a model of simply repricing drugs/paper bills to offering sophisticated clinical programs that control utilization.
   
• There are more abuse-deterrent opioid options now available.
   
• Prescribing decisions are more intelligent. Opioids claimant utilization and prescription count have decreased.
   
• More education to claimants and the prescribing community, and constant updating of ODG/ACOEM/state treatment guidelines, is having an impact.

A cautiously positive mindset prevails among these experts. Half of them said that payers and vendors have significantly improved their practices. Close to half said that most major states have significantly improved their practices (the others were mostly unsure). Close to 60% thought that most prescribing physicians today are more informed.

Some 70% said that national groups other than those influenced by Pharma have “helped.” About half thought states have helped. More, however, said that state medical societies were unhelpful than were helpful. I have heard before that state medical societies are perceived by some as resisting useful measures such as mandatory training.

I asked for predictions of what the future will bring. One responded, “A focus on fixing the mess. More drug formularies in more states. More $'s for PDMPs [prescription drug monitoring programs] then mandate access. More death benefit claims.”

Another respondent weighed in as follows: “I see continuing awareness of the problem and potential risk of wanting 'quick' solutions to the problem either through liability settlement (let the patient manage the problem on his/her own), new service offerings to taper the addiction, law enforcement prosecuting opioid-related deaths due to social pressure. Best in breed insurers will target prevention and manage existing liability risks.”

We are indeed better off now than we were five years ago. The quality of the industry’s response to this epidemic has improved even while opioid-related deaths nationwide continue to rise. What remains unclear is whether our industry can achieve much more success without parallel public safety advances throughout society.

Further Reading:

1. FDA News Release: “Califf, FDA top officials call for sweeping review of agency opioids policies.” February 4, 2016
2. Centers for Disease Control Data Visualization: http://blogs.cdc.gov/nchs-data-visualization/drug-poisoning-mortality/