Your Benefits Plan is Playing Russian Roulette With Opioid Bullets

The silver lining is that solving the opioid crisis goes a long way towards solving the even larger health care dysfunction bankrupting families and communities

The opioid crisis is the largest public health crisis in 100 years -- a self-inflicted wound driven by a dysfunctional health care system. Fortunately, upstream antidotes have been created and proven. It’s time to stop the crisis in its tracks. The illustration to the right conveys what is going on today in the opioid crisis response. In the graphic, those enslaved by opioid overuse disorders are represented by the water on the floor. We certainly need more and better "mops" and "moppers" however you will notice that the sink is running over and the faucet is running full blast. Even today, between 20% and 30% of employees will receive an opioid prescription every year. There's been a modest decline in opioid prescriptions but this remains extraordinarily high -- far higher than other countries. 

Following doctors' orders, far too many people get addicted after just five days. For people who take an opioid for 10 days, almost one in five will still be taking opioids one year later -- in other words, worse odds than playing Russian Roulette. One of the reasons benefits consultants such as David Contorno are ensuring their employers have a modern value-based primary care model in place is that it's one of the important upstream "antidotes" to the crisis. Unfortunately, David has had 22 people overdose and die in his client base -- 20 of the 22 were dependents. No parent should have to bury their child. Fortunately, mothers are protecting their children from this scourge as they get educated on the dangers of opioids which some refer to as "prescription heroin" to point out their danger. 

As you read this, back pain sufferers are getting new non-evidence-based opioid prescriptions or are coming out of non-evidence-based spinal procedures where they'll receive a prescription for 60 or more opioids. At the same time, countless teens are having asymptomatic wisdom teeth removed (something most countries don't do) leaving the dentist with a 60-day supply opioids when ice, Tylenol/Advil, and lots of mint chocolate chip milkshakes would suffice for pain management. A dental prescription is responsible for 31% of first exposure to opioids for teens and there are enough opioid prescriptions written for teens for one out of every five children to have their own prescription.

The following is the portion of a chapter from the latest edition of the CEO's Guide to Restoring the American Dream (free download below) that details the opioid crisis drivers and upstream antidotes:

The Opioid Crisis Isn’t An Anomaly

 For 37 years, Tom L. Shupe, a senior manager at an Oklahoma manufacturer, has been on the frontlines of the challenges facing U.S. manufacturing. He’s full of insight, but most surprising one is that he blames substance abuse—specifically opioids—for most of these challenges. “It’s all addiction issues,” says Shupe. He calls the opioid crisis, which is really an epidemic of addiction, “probably the biggest threat in manufacturing, period.”[i]

Here’s something even more shocking: Employers are unwitting accomplices, enablers, as well as victims of the largest public health crisis since the 1918 flu epidemic. Overwhelmingly, those suffering from opioid overuse disorders are working age or their dependents. Through our health benefits, we have funded a self-inflicted wound – the opioid crisis – that is emblematic of the even broader dysfunction pervasive in our health care system.

Let’s look at just one example. A major challenge of physically demanding, hourly jobs is that if you don’t work, you don’t get paid. Sixty percent of the workforce makes $20 per hour or less[ii] – many of them paid hourly. When an injury occurs, the worker must choose between not working (and not getting paid), or continuing to work despite the pain. Opioids starts as a short-term fix, enabling the worker to stay on the job, but they also slow—and can even prevent—healing. If the worker has the predisposition to addiction, a vicious escalating cycle takes off. Jordan Barbour, Director of Clinical Operations, Psychiatry and Addiction Medicine at Geisinger described the progression they’ve seen hundreds of times. Addiction leads to work issues leading to losing their job and then can spiral to pursuing street drugs, incarceration and getting Hepatitis C – all costing their family and community dearly.

Sidebar: There is a growing trend that equates long term chronic pain patients with people suffering from opioid addictions. There are an array of rare diseases, such as Ehlers–Danlos syndrome, where well-managed opioid regimens can be the appropriate course of treatment. We must be careful that the zeal to address the opioid crisis doesn’t inflict unnecessary suffering those with long term chronic pain. This is where having adequate time to treat patients as individuals is imperative; other countries manage to work with these long term patients without having the opioid crisis that America is dealing with.

Beyond the obvious human toll, there is a financial imperative to solve this crisis. Supporting early identification of addiction, along with access to effective treatment and relapse prevention, doesn’t just help the sick and suffering. It makes great economic sense.

Make no mistake: The opioid crisis is a complicated issue over thirty years in the making. But companies have played a major role in creating and sustaining the crisis. And a vanguard of employers are realizing that they have a major role to play in solving it, recognizing the solutions fall well beyond what the government alone can do. In this, the epidemic is a microcosm and mirror of our failing health system as a whole; ending it will move us meaningfully down the path towards solving the larger crisis.

Primary Drivers

There are 12 primary drivers of the opioid crisis, all of which must be addressed by the country and, specifically, by employers.

1. Undertreated pain leading to a 5th vital sign drives increased opioid prescribing

This concept was initially promoted by the American Pain Society to elevate awareness of pain treatment among health care professionals. The Veteran’s Health Administration made pain a 5th vital sign in 1998, followed by their creation of the “Pain as the 5th Vital Sign Toolkit” in 2000. This made pain equal to things like blood pressure—a number to be managed with medications or lifestyle changes. In 2001, the Joint Commission established standards for pain assessment and treatment in response to the national outcry about widespread undertreatment, putting severe pressure on doctors and nurses to prescribe opioids.

2. Pharmaceutical industry sales and marketing blitz

Pharmaceutical companies capitalized on the other drivers listed here. Through major marketing campaigns,[iii] they got physicians to prescribe opioid products such as OxyContin and Vicodin and in high quantities—even though the evidence[iv] of their efficacy opioids treating long-term, chronic pain is very weak[v], and the evidence that they cause harm in the long term is very strong.[vi] Perhaps no organizations had more ability to flag the growing crisis than pharmacy benefits managers and distributors as they had the complete view of dramatic increases in opioid volume; instead, they let the crisis explode in severity. In contrast to other countries, U.S. physicians stopped prescribing slow and low, one byproduct of which is that huge amounts of opioids readily available in medicine cabinets for people suffering any level of pain—and for teenagers to abuse. Direct-to-consumer advertising also significantly increased patient requests for opioid prescriptions.[vii]

3. Opioids used for non-cancer chronic pain (e.g., back pain)

Eighty percent of people will have lower back pain in their lifetime, making it one of the most common reasons for missing work.[viii] Stress or inappropriate posture, a sedentary lifestyle, and poor workplace ergonomics can all lead to back, neck, and other kinds of musculoskeletal (MSK) pain. The American Academy of Neurology (AAN) told its members that the risks of opioids in the treatment of noncancer chronic pain patients far outweighed the benefits, yet the practice is widespread. The AAN observed that if physicians stopped using the drugs to treat conditions such as fibromyalgia, back pain, and headache, long-term exposure to opioids could decline by as much as 50%.

4. Economic distress

Drug, alcohol, and suicide mortality rates are higher in counties with more economic distress and a larger working class. Many counties with high mortality rates have also seen significant manufacturing employment losses over the past several decades.[ix] For every 1% rise in unemployment, there's a 4% rise in addiction and a 7% increase in emergency department visits.[x] Remember health care costs that can consume as much as 50% of an employee’s total compensation package for people for half the workforce making less than $15 per hour[xi], suppressing wages and holding back job growth.

5. Declining physician reimbursement increases likelihood of prescribing opioids

The current reimbursement structure for physicians in private practice continues to decline, despite an escalation of both operating costs and administrative burden. As patient volume increases, the average amount of time a provider can spend with the patient decreases. As patient interaction time decreases, the probability of writing a prescription increases to less than 10 minutes—and the probability of writing a prescription increases[xii].

These pressures to increase volume make it incredibly challenging for most providers, who typically are not well versed in addiction medicine, to identify and effectively manage patients with chronic pain and potentially undiagnosed substance abuse.

6. Insurers’ refusal to cover validated treatments

Insurance companies’ refusal to cover scientifically validated approaches for pain management such as physical therapy, cognitive behavior therapy, psychological support, or interventional pain procedures also contributed to this crisis. Mental health parity legislation forced insurers hands when it took effect in 2010 but physical therapy and workplace redesign continue to be marginalized despite their proven effects. Even when a physician appeals to an insurance company to approve treatments that may help the patient, several months or even years can go by, especially in worker's compensation cases.[xiii]. By then, the patient may be on escalating doses of opioids just to function as a result of increased tolerance. This results in more anxiety and depression, and can often lead to financial devastation from loss of employment.

7. Health-related state/local budget challenges weaken community resilience

Governments can only raise taxes so much. We’ve seen how out-of-control health care costs have eaten away at the very items that make a community more resistant to public health challenges; every budget item that has been cut could help stem the opioid crisis. One example is mental health funding, a particularly powerful antidote to the opioid crisis. At the local level, funding shortfalls are exacerbated as tax-exempt health systems are often among the largest property owners yet pay no taxes. And yet America’s perverse healthcare incentives reinforce the common view that building hospitals is an economic driver.

8. Mental disorders treated with opioids

According to a recent study, more than half of all opioid prescriptions in the United States annually go to adults with a mental illness, who represent just 16% of the U.S. population.[xiv] It’s important to note that depression and anxiety worsen pain and vice versa. Healthy and effective stress- and life-coping skills, available through a value-based primary care model, can decrease the impact of this pain, and a lack of effective coping skills can leave one vulnerable to experiencing a much greater degree of suffering from pain.

9. Patient satisfaction scores’ influence hospital income

Results from HCAHPS and Press Ganey patient satisfaction surveys that directly impacted hospital income further amped up the pressure. Administrators harangued nurses and doctors to make patients happy by giving them opioids. Data from approximately 52,000 adults was assessed from 2000 to 2007 via the Medical Expenditure Panel Survey. A 26 percent increase in mortality rates was observed in those who were most satisfied[xv]. CMS announced it will remove pain management from its determination of hospital payments beginning in 2018 but that doesn’t undo the damage that has been done.

10. Patients looking for a quick fix

An unfortunate part of American culture is seeking quick fixes. Patients want a pill for instant pain relief and the advertising has conditioned them to expect this. This tendency is exacerbated by doctors looking for a quick fix during their short appointments with patients. The reality is most patients hear more from pharmaceutical companies (16-18 hours of pharma ads per year[xvi]) than from their doctor (typically under 2 hours per year).

With this “instant-fix” conditioning from players across the health care system, many patients aren’t willing to invest time in cognitive behavioral therapy, mindful meditation, or a regular program of physical therapy/exercise. At the same time, we’ve forgotten that some pain is a good indicator of an issue to solve and shouldn’t be instantly numbed.

11. Lack of access to specialists

For many physicians in rural areas, physical therapy and mental health can be limited and pain specialists trained in non-opioid pain management are shockingly rare. Consequently, the only tool in the toolbox has been more pills.

12. Criminals abuse of the system

In many locales, doctors lacking ethics were easier to find than proper pain treatment. Initially “pill mills” disguised as “pain clinics” gave legitimate pain doctors a bad name. Pharmacy benefits managers and pharmacies were more than willing to go along with the game, making billions in the process. The public and private sector purchasers dropped the ball on this by not having opiate prescribing databases in place to catch the bad actors. As prescription opioid availability tightened up, cheap black tar heroin filled the need for individuals suffering from addiction; people addicted to opioid medications are 40 times more likely to get addicted to heroin.[xvii]

Common misconception about physician motivation

Let’s clear up one misunderstanding: Most good doctors, even those who are salaried employees, have no financial incentive to get their patients hooked. The waiting lists to be seen by a pain specialist can take weeks and these doctors aren't going to run out of patients anytime soon, so the vast majority really want their patients to get better. A chronic pain patient who no longer needs pills or experiences pain is the best marketing a doctor could ask for. Most doctors were trying to do the right thing based on what they knew about opioids at the time and what insurers would cover.

A Weight Around Employers’ Necks

Before delving into the antidotes, let’s take a quick look at the damage opioids are wreaking on the American economy in general and employers in particular.

Here’s a good starting point: Opioid overdoses—often taken in conjunction with other central nervous system depressant drugs like benzodiazepines or alcohol—are now the leading cause of death for working age people under 50 years old, surpassing of deaths from guns and car crash.[xviii]

LinkedIn’s Work in Progress podcast looked at the negative impact of the opioid crisis on employers.[xix] There were a couple big takeaways:

●    At a Congressional hearing focused on opioids and their economic consequences, Ohio attorney general Mike DeWine estimated that 40% of job applicants in the state either failed or refused a drug test.[xx] The resulting high rates of unemployment in certain places mean solid middle class jobs can’t be filled. In Congressional testimony earlier in July 2017, Federal Reserve chair Janet Yellen connected opioid use to a decline in the labor participation rate.

●    The issue is amplifying labor shortages in industries like trucking, which has had difficulty for the last six years finding qualified workers. It’s also pushing employers to broaden their job searches, recruiting people from greater distances when positions can’t be filled with local workers. At stake is not just workplace safety and productivity—but whether workplaces need humans at all. Some manufacturers claim opioids are forcing them to automate faster.

Some may find drug testing intrusive, but many jobs—whether in manufacturing or other sectors such as transportation—pose potentially huge consequences from accidents. You may not recall that opioids were to blame for the Staten Island Ferry disaster that killed 11 and injured scores.[xxi] A very big problem for employers is “presenteeism,” where an employee performs sub-optimally, often as a result of impairing pain or medications, especially opioids. Unlike cocaine or heroin, where a confirmatory drug screen results in termination, a “legitimate” prescription for oxycodone and Xanax is a much murkier problem.

The New York Times reported that workers who received high doses of opioid painkillers to treat injuries like back strain stayed out-of-work three times longer than those with similar injuries who took lower doses.[xxii] When disability and medical care payments are combined, the cost of a workplace injury is nine times higher when a strong narcotic like OxyContin is used. The sum of an employee’s medical expenses and lost wage payments is about $13,000., but when he or she is prescribed a short-acting painkiller like Percocet, that cost triples to $39,000—and triples again to $117,000 when a stronger, longer-acting opioid like OxyContin is prescribed.

Insurers’ policies of covering painkillers but not evidence-based physical therapy approaches may “have created a monster,” said Dr. Bernyce M. Peplowski, the medical director of the State Compensation Insurance Fund of California.

It’s Not Just Opioids

Opioids aren’t the only systemic failure. Cathryn Jakobson Ramin devoted an entire book (Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery) to how little evidence informs our back pain industry. And opioids aren’t the only class of medication that is being inappropriately prescribed. Benzodiazepines, or benzos, are a class of depressants that most people know by the brand names Ativan, Klonopin, Valium, and Xanax and. These medications are typically used to treat anxiety, insomnia, and seizures. And they’re being prescribed at alarmingly high rates.

Prescriptions for benzodiazepines more than tripled, and fatal overdoses more than quadrupled between 1996 and 2013[xxiii]. In fact, benzos have been so grossly overused that they among the top-prescribed psychiatric medications[xxiv], but also among the most prescribed medications of any type in the United States. If the opioid crisis wasn't so bad, we'd be seeing coverage of the "benzos crisis" which has roughly the number of overdose deaths as the opioid crisis just 10 years ago.

Like other interventions such as non-evidence-based opioid prescriptions and spinal procedures, benefits of benzos have been oversold. For decades, they’ve been prescribed for anxiety and sleep, but the evidence indicates that they don’t work very well, and they are not intended for long-term use.[xxv]

The Path Forward

While we must be smarter about treating those already afflicted with opioid addictions, we must also turn off the spigot to clean up the mess. The silver lining of the opioid crisis is it shines a light on just how abysmally our health care system has been performing and recognition that health starts at home and in our communities, not hospitals or in a pill.

At the end of Sam Quinones’ gripping book on the opioid crisis, Dreamland, he argues that the sustainable fix is community.

A community that addresses social determinants of health like safe neighborhoods, quality jobs, and a health care system that can treat those afflicted with opioid overuse disorders while preventing others from being drawn into the hell of addiction.

Thus, employers using the opioid crisis as a catalyst to change their approach to health care do their broader community a great service by revitalizing that community. By extension, a growing employer has a better pool of prospective employees to draw on.

You can download the rest of the chapter from my book that includes the upstream antidotes to the crisis. When you download it, you will also be notified when my next book is released that picks up where this chapter leaves off -- those on the list will get a free preview before the book is released in September. If you would like to help educate your community on the upstream fixes to the opioid crisis by bringing a book tour stop to your community, email us at [email protected]. 

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Dave Chase is the co-founder of the Health Rosetta (a LEED-like organization for healthcare), Managing Director of the Quad Aim Fund, Executive Producer of The Big Heist, and author of the book, “CEO's Guide to Restoring the American Dream - How to deliver world class healthcare to your employees at half the cost.” Follow the link to the book below for a free download of the book. Chase's TEDx talk was entitled "Healthcare stole the American Dream -- here's how we take it back." See the Health Rosetta Institute website for how to get involved, resources and how to join others to support its mission.

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