The Rough Notes Company Inc.

Integrated Behavioral Health creates opioid abuse treatment program for workers comp claimants who become addicted to medication following an injury

Who remembers the old Viagra commercial that started with “This is Bob,” followed by an upbeat whistling tune? If you do recall, please whistle that tune while reading this introduction.

This is Bob. Bob works as a machine operator at a factory. One day Bob suffers a serious injury on the job; he receives workers compensation benefits and is prescribed painkillers to ease the pain. Two months later, Bob is ready to return to work. He still takes the painkillers for his chronic pain. One year later, Bob is back in full force at work and still taking his prescribed medication, more than what he was originally prescribed. Bob is addicted to his prescribed painkillers. Now what?

It’s called the opioid crisis for a reason; you can stop whistling now if you were. According to the information on Surgeongeneral.gov:

• 44% of Americans claim to personally know someone addicted to prescription painkillers
• 78 Americans die daily from an opioid overdose
• In 2014, more than 10 million Americans reported using opioids for non-medical purposes

“One thing that’s been noticed for probably a decade or more is the increase in prescription of opioid medications by physicians,” says Paul Keith, MD, medical director at Integrated Behavioral Health. “The problem is that these physicians are prescribing opioids, but are not addressing the etiology of the pain. So the patient comes in for a quick visit every so often to get their prescription refilled, and they continue taking it.”

Keith says there are two paths at this point. “One is the patient who has a predisposition to substance abuse. Once they start taking opioids, they usually get some sort of euphoric effect from it; it reduces the stresses from their everyday life and they don’t want to stop. They start supplementing what’s prescribed by picking up drugs on the street.

“The others are people who are maintained on their opioids by their physician, again without the etiology of the pain being addressed. They find out they don’t feel so good if they don’t take their medication, and they develop physical tolerance. They start increasing the dose that doctors might not prescribe, and pretty soon they’re heavily addicted to high doses of opioids.”

Statistics from the Surgeon General’s Report on Alcohol, Drugs, and Health from November 2016 show that only about 10% of people with a substance abuse disorder receive any type of specialty treatment. Over 40% of people with a substance abuse disorder also have a mental health condition, and fewer than half—48%—receive treatment for either. But the most disturbing stat is that 40% of individuals who know they have a problem are not ready to quit.

Due to the crisis facing the country—the United States leads opioid use globally—stricter regulations have begun to take effect.

“As the use of opioids has increased among the population in general and among medical patients, various state regulators are responding to the crisis by limiting the number of prescriptions that physicians can write for opioids,” says Sam Mayhugh, Ph.D., founder, director and chief clinical officer at Integrated Behavioral Health. “Before, they could write for maybe 30 days at a time, but now there are some that can only write for seven days or three prescriptions. For someone who has been on a workers comp claim for an extended period of time and is taking opioids, this is aggravating the situation even more.”

Integrated Behavioral Health

What can be done to help wean opioid users when they become addicted? This is where Integrated Behavioral Health (IBH) comes in.

“For 29 years, IBH has managed behavioral health benefits, inpatient/outpatient, EAP, and disability,” says Mayhugh. “Our products were integrated into a multi-stage workers comp opioid treatment program. It’s not known widely, but we’re starting to get some traction and even finding some judges who are mandating treatment for workers comp claimants. We use doctoral-level case care managers who help patients with building resilience, stress management, and pain management.”

Stage one involves a carrier contacting IBH and presenting a case involving a patient.

“We then go into an assessment and evaluation, where we take a look at what happened on the date of injury and just prior to that, and what’s been happening with the medications and the claimant’s history,” Mayhugh says. “We pull the data together and establish an engagement program. We engage with the claimant and their family, if appropriate, explaining what’s available to them and the benefits of going through a multi-dimensional treatment program, as compared to just a regular refilling of prescriptions.

“We go through a period where the medications are being reduced and our personnel are consulting, coaching, and providing training through educational materials and web programs. As we improve functionality with rehab, we look at what the claimant might need for occasional outpatient support in the community.”

“The assessment, the initial detoxification, the follow-up, and the structured substance abuse program would last eight to 12 weeks,” adds Keith. “Once they complete the acute part of the program and they’re going on to maintenance, they will stay involved with our care manager for another 12 months.”

Adds Mayhugh: “If it’s a Medicare claimant, we provide 24-month follow-up. At any stage, if the claimant refuses or doesn’t cooperate, the carrier pays, but it’s related to what was delivered, not a flat payment up front. It’s reasonable for the carriers because not all of the patients will cooperate.”

But those who stick with the program are showing positive results.

“What you see in the treatment world of addiction is that patients often start off with detox and some sort of rehabilitation program, and then they get lost in the follow-up,” says Mayhugh. “It’s important that they continue with ongoing monitoring and contact that keeps them engaged in the recovery process.”

“I’ve been involved in treatment at facilities for several decades, and they usually have cooker-cutter programs that have very little individualization in the treatment for a given patient,” adds Keith. “Everyone gets the same program. What often don’t get addressed in those kinds of programs are the personal issues of the individual. Many programs try to address it, but the therapists involved with individual treatment are typically trained primarily in substance abuse and are not psychotherapists who can deal with other kinds of life issues.

“Our program is providing a lot more individual therapy to address  the stresses that everybody has in their life and help them develop more successful coping skills. The patients are less depressed and anxious, and therefore they’re less motivated to see drugs as a solution to their problems. The engagement program helps them develop an understanding about the problems that they’re individually dealing with. You get a much better outcome.”

As previously mentioned, the IBH program is designed to work well with workers comp claimants.

“We have a network of providers for substance abuse treatment, and we take a different approach with the workers comp claimant programs,” says Mayhugh. “We select providers who are experienced and do quality work, and we put together an addendum to our agreement with them. The addendum asks them to understand that IBH is actively involved in the administration of this program. It isn’t just sending them a utilization review and authorizing a certain number of days. It really is a partnering approach.”

He adds, “That’s how we get beyond the situation where a workers comp claimant is referred to a particular treatment center and that’s it. We’re involved right from the start with the approval and acceptance of the professionals—medical and psychological—and program administrators. That makes a big difference.”

The future

What does the future hold for the battle against the opioid crisis? “I’m licensed in a number of states, and several of them have required me to complete an on-line form to register for any opioids I prescribe,” says Keith. “The form allows the state to monitor these prescriptions. Insurance companies are doing the same thing using their pharmacy benefit managers. They can easily track the number of opioid prescriptions for a given patient and can see if multiple physicians are prescribing them. They have algorithms that will search their pharmacy databases to pick out these kinds of patients, and when they’re identified, someone contacts the doctor to ask, ‘Are you aware that this patient is getting opioids from you and two other doctors?’ They also monitor the pharmacies that are filling the prescriptions.

“Subsequently we developed anti-craving medications for both alcohol and opioids. The American Society for Addiction Medicine put out a statement last year that the use of these medications is now considered the standard of care. Many substance abuse programs are built around a 12-step model; they do not like the use of any kind of medications, so they’ve been resistant to this trend for years, but now are accepting it more. Anti-craving medications increase by about 30% the likelihood that someone will stay clean and sober for a long period of time.”

“We’re seeing carriers move toward more assertive involvement with nurses and others in the early injury stage either to prevent the use of opioids or to prevent dependence after they’ve started,” adds Mayhugh. “On the front end, I think the carriers and some of the early intervention vendors are having an impact on the number of people who, nine to 12 months after their injury, are still taking opioids.”

“One reason the crisis is getting more attention is the number of deaths that are occurring as a consequence of opioid abuse” says Keith. “I think we’re going to see more pro because they’re having a huge economic and social impact on families who have an addicted member.”

By Christopher W. Cook

For more information:

Integrated Behavioral Health

www.ibhcorp.com