Event Details
The discussion of alternatives to opioids continues as the workers’ compensation industry works to find ways to treat and manage pain. This podcast, recorded live at our annual mPower Conference, explores different options for alternatives to opioids, from new clinical options to non-pharmaceutical therapy. Dr. Mitch Freeman, Pharm.D., Chief Clinical Officer at Mitchell, and Helen Froehlich, Vice President of Case Management at Genex Services, provide insights.
What are some challenges and considerations that come with managing pain?
With any claim, the management of pain can come with several considerations. Dr. Freeman underlines that pain, unlike blood pressure, for instance, is very subjective. In recent years, those studying pain have come to understand that pain is not simply a biological function; there are also psychological and social components that need to be considered when treating an injured worker. He says that previous understandings were that no one should be in any pain, but now we understand that pain is something to be managed rather than completely eliminated. Freeman also points out that there is difficulty in finding the appropriate pain treatment since everyone reacts to treatment differently and there are so many different approaches that one can take. Helen Froehlich continues by saying that, in case management, it is very important to understand the patient and what factors outside the injury are affecting how that person feels pain as well as what pain means at that moment to that specific patient. Since self-reporting pain is not tangible or measurable, Froehlich says that it’s very important that case managers articulate the question in a way that helps better understand how the person is interpreting their pain. Importantly, Froehlich says, the pain is very real to the patients and we must work to better understand that pain.
What is the current landscape in relation to opioids?
Freeman says that we have made a lot of progress in the industry in reigning in the overprescribing of opioids. A number of factors have contributed to improved outcomes, including treatment guidelines (CDC, ODG, ACOEM) and clear recommendations around the use of opioids in the workers’ compensation industry. State limits have also been effective in guiding treating physicians in prescribing. Freeman points out that although there has been success in limiting the number of opioids prescribed to new claims, there are still many claimants taking high doses of opioids, and those will be the issues the industry will need to address next.
Since it is so subjective, how do we measure pain?
In order to make pain somewhat more measurable, Froehlich says that the key is education—both for the injured worker and case manager. From the case manager perspective, it’s important to get to know the injured worker well and understand how they interpret pain. She says that case managers can often help learn the patterns of the injured worker by having them document their medication routine, then they can identify what is or is not working. From the patient’s perspective, it is important to help them understand their body better and what the pain measurements mean. Two different people might be on a similar drug regimen, but they interpret their pain completely differently. Helping the person who is feeling high measures of pain despite their drug therapy understand why they are feeling the way they are and how to help that pain without higher doses of opioids is key.
What are clinical alternatives to opioids (both currently and in the future)?
Freeman says that current alternatives include NSAIDs, which are effective but not addicting, though there are some side effects associated with long-term use. Freeman also says that gabapentinoids (ex: Lyrica) have been talked about a lot recently as a potential alternative. However, these drugs are approved for neuropathic pain, which is not necessarily appropriate for someone who is newly injured. There are also potential risks with gabapentinoids, such as their ability to potentiate opioid risks such as euphoria and depressed breathing. Medical marijuana is also discussed a lot in the industry as a potential future alternative. Freeman points out that we still do not know enough about medical marijuana to know for certain that it will be an effective alternative to opioids. Although anecdotes suggest that the drug is effective at treating pain, there are still no FDA-approved clinical studies. These studies would help us understand several things, including whether the drugs are safe for long-term use and what doses are appropriate for injuries.
What are some non-pharmaceutical pain management strategies?
Among different pain management strategies are physical medicine (physical therapy, home exercise programs, etc.), passive therapies (cold/hot treatments, electrical treatments) and other treatments such as epidurals. Froehlich also highlights cognitive behavior therapy (CBT), which the literature shows to be promising in helping certain individuals cope with pain.
What are some concerns with these alternative therapies?
From a non-pharmaceutical perspective, Froehlich says that two of the main concerns are whether these treatments will be authorized and whether the treatments will work. She emphasizes, however, that even if a certain treatment does not work, it is not necessarily a negative. By trying different therapies, the case management team can help the injured worker identify the therapy that will work. Clinically, there is risk with any drug, Freeman says. Therefore, it is important to follow treatment guidelines. He also says that when there is a lot of buzz around a certain drug, misunderstandings can develop. For instance, gabapentinoids are now thought by many to be good for treating any type of pain, even though they have been approved mainly for neuropathic pain. This has led to an increase in the prescribing of Lyrica in the workers’ compensation industry, which has increased costs. Freeman says now that generic pregabalin is available, costs have decreased. With medical marijuana, a similar issue could occur. Freeman expects that if drug companies begin to manufacture medical marijuana, it will be very expensive. For instance, Epidiolex (approved for very limited use in epilepsy cases) costs around $1,800 per month.
What are best practices in treating pain?
For both panelists, a holistic view of the claim is vital. Freeman says that in order to help a claim progress well and help the injured worker get back to health, three components must be in line:
- Visibility—The PBM must be able to see all prescriptions, whether in or outside the network, from paper bill or otherwise.
- Guideline Enforcement—In order to have control over a claim, you should be able to enforce treatment guidelines early in a claim.
- Intervention—When appropriate, intervention should be available and easy to enforce.
Froehlich continues by saying that, since there’s no one silver bullet, there must be an overall managed case looking at the entire life of the injured worker. She says that if there are puzzle pieces missing in the case, the case manager could miss a non-pharmaceutical option that could be helpful for the injured worker.
How do you make sure the injured worker is receiving the best care when dealing with pain?
Froehlich says that understanding the injured worker and evaluating the best ways to provide care are vital to ensure the injured worker is receiving the best care. She underlines that options such as CBT should not be ruled out and that helping the injured worker understand their pain will help them get back on the road to recovery. Freeman highlights the importance of following treatment guidelines in managing the clinical aspect of a claim and ensuring the injured worker is receiving good care. He points out that many claims start like any other, but then escalate without warning. It’s important to monitor these claims and, when an issue arises, to provide guidance to the claims staff for proper intervention.
Audience Q&A
The audience asked a few questions at the end of the panel, covering topics from CBD creams to opioid metabolizing. Here are a few highlights: Audience: Is CBD cream a consideration? Freeman: Anecdotally, CBD cream is considered effective at treating pain, but there aren’t FDA-approved studies to back this up. A recent bill lifted the ban on CBD that is purified from hemp, so the product is widely available. It will be interesting to see how drug manufacturers, if they have the opportunity to create medical marijuana products, will differentiate—that may mean changing one molecule and patenting a slightly different drug. Audience: What types of patients would CBT treatment be good for? Froehlich: CBT can be expensive, but it is good to consider for certain patients, such as those with addictive personalities (whether that is to drugs or other things), with depression, or who are emotionally sensitive. Froehlich says this can be identified by speaking with the employer, who often knows their employee’s personality very well. Audience: How do you identify whether someone’s “4” pain rating is different from another person’s “4”? Froehlich: It is very important to get to know the person and to give them examples of what each pain number represents so they can better report out their pain. Informing the claims adjuster, case manager and others of what the scales mean is important as well. Audience: People react to medications differently—do you take that into account when assessing risk? Freeman: Medications can metabolize differently for different people, so it often does not matter if two people are the same size and weight and taking the same dose. There is genetic testing available that can determine what level of metabolizer a person is, but this testing should be considered on a case-by-case basis since it can be very expensive. Additionally, since opioids are regulated based on pain and not by how a person metabolizes, the testing is not necessarily helpful. For more information on case management, visit Genex Services.