In their second of several policy-oriented guest posts below, Gregory J. Hubachek and D. Kirkhoff Brainard discuss Louisiana’s relationship with the national conversation surrounding opioids and addiction and how workers’ comp plays into it.
Read the first installment in the series here.
By now you’ve probably heard about “America’s opioid epidemic.” Forty-four Americans die every day from an overdose of prescription painkillers, according to the Centers for Disease Control and Prevention. The DEA says heroin and prescription drugs overdoses now kill more Americans every year than gunshots or car accidents.
While the current crisis over narcotics abuse and the prescribing of painkillers has been building for years, it’s a hot-button issue today. And that means something must be done about it. No self-respecting politician wants to be perceived as being either soft on drugs or untouched by human tragedy.
We agree that there is a crisis. In fact, Louisiana has been hit particularly hard by the opioid epidemic. The state ranks near the top of the national list in several categories related to the abuse and cost of prescription opioids:
- Louisiana ranks among the top states for number of narcotic prescriptions written.
- About 675 Louisianans die from a prescription opioid overdose each year.
- More than five percent of adult Louisianans “engage in non-medical use of opioids, resulting in 15 deaths/100,000 residents” each year, according to Dr. David Holcombe, Assistant Secretary for the Louisiana Department of Health and Hospitals’ Department of Public Health.1
Questionable science and potential consequences
As public concern grows, lawmakers across the country are scrambling to take action. The CDC recently released new guidelines for the prescribing of opioid-based painkillers. But the department’s guidelines have already drawn heavy criticism.
Many physicians worry that the CDC guidelines are motivated more by politics than by concern for the health and wellbeing of Americans suffering from chronic pain. Although the Food and Drug Administration recently reversed course and endorsed the guidelines, members of the agency have spoken out against this decision, questioning the science underlying the creation of the guidelines.2
The American Academy of Pain Medicine also chided the CDC on its science, saying the CDC’s “recommendations are made on weak or no scientific evidence.” Of the 12 specific recommendations in the CDC’s proposal, the AAPM characterized five of them as based on “low quality evidence” and the remaining seven as based on “very low quality evidence.”3
In its response to the draft guidelines, the Academy also expressed concern that adoption of the guidelines would threaten the ability of physicians to meet the legitimate needs of their patients. Responding to the CDC’s recommendation of a three-day limit on initial prescriptions for cases of non-traumatic pain, the AAPM wrote, “[T]here is concern that physicians may misinterpret the guideline and inappropriately generalize the recommendation to all acute pain conditions.”4
This concern seems well-founded. In a recent interview on PBS NewsHour, Massachusetts Governor Charlie Baker said that he simply decided to follow the CDC’s recommendation when introducing legislation to combat the “epidemic” in his state.
“Our approach to this was to take the CDC preliminary recommendation, which was three days,” Baker said. He noted that the Massachusetts Medical Society had recommended a seven-day initial limit on first-time narcotics prescriptions, and predicted that lawmakers would compromise between the two figures.
“[W]e picked three days for first prescriptions, sort of acute pain, you have a wisdom tooth out, you break a finger, something like that,” Baker said. Baker is also head of the health committee for the National Governors Association.”5
Treatment guidelines should be formulated by state physicians, not mandated from the top down
Given the challenges facing the state of Louisiana in this area, we agree that action on this issue is certainly necessary in Louisiana, as in other states. But we propose there are better ways of solving our state’s prescription opioid abuse problem than the adoption of restrictive and unscientific drug formularies.
Nationally-recognized standardized guidelines can definitely help busy physicians – who are often under pressure from insurers and employers to finish treatment within the strict timeframes mandated in the ODG – choose the most beneficial treatment plan for their patients.
But they should remain guidelines, not legal regulations. The problem with proposed “one size fits all” regulations is that they tend to be driven by financial and/or political motives rather than by concern for the health of America’s workers.
It is beyond dispute that the subjective experience of pain (and the amount of time and treatment needed to recover from serious injury) varies widely from one individual to another. As the President pointed out in his speech to the National Governors Association on February 22nd, “[T]he pain is real. The mental illness is real.”6
While the CDC’s rush to publish its guidelines is presumably the result of political pressure, the questionable science underlying the guidelines will remind many physicians of two other sets of standard guidelines, the ODG and the ACOEM.* Touted as “evidence-based medicine” solutions for reducing the costs and risks inherent in the workers’ compensation system, these two formularies are produced by organizations with strong ties to the industry most concerned about workers’ comp costs – the insurance industry.7
In Louisiana, as elsewhere, physicians are already leaving the profession at an alarming rate. When we pass laws that mandate that doctors deny their patients a course of treatment deemed best for the patient (when it conflicts with the approved practice stated in the ODG), we disrespect the practice of medicine. Simply stated, physicians are not, and should not become, mere technicians.
In the same address to the Governors Association, President Obama rejected a request that he act to impose limits on how many pills physicians can prescribe. While acknowledging the seriousness of the issue, the President expressed his belief that reforms developed with bipartisan support at the state level would be more effective than those imposed on the states by the federal government.8
The President’s 2017 fiscal year budget proposal includes $920 million designated to help the states lower costs and expand access to treatment for people suffering from prescription opioid-related disorders.9
We concur with the President that treatment guidelines developed by Louisiana physicians with bipartisan support in the Legislature represent the best and most effective outcome for Louisiana patients – including workers’ compensation patients, of course.
In summary, treatment guidelines developed in Louisiana, by Louisiana physicians, will safeguard the quality and integrity of our healthcare system. While this approach will likely not be as fast or as cheap as the adoption of an existing set of treatment guidelines, it is a solution that benefits almost everyone:
- It assures the right of injured workers to access appropriate care.
- Doctors are more likely to adhere to guidelines over which they feel a sense of ownership.
- Insurers benefit as well, because the clarity of treatment options will increase predictability.
Regarding distribution of the funds sought in the 2017 national budget, the White House says, “States will receive funds based on the severity of the epidemic and on the strength of their strategy to respond to it.”10 Louisiana ranks higher than most states for severity of the national opioid-abuse crisis. We believe our state’s physicians can be leaders in crafting a strong and effective response to this crisis.
*In Part 2 of this piece we will examine the “evidence” for evidence-based medicine. We will also look at specific treatment guidelines and alternative healthcare strategies that can protect workers’ compensation patients – and our society at large – from the devastating effects of long-term dependence on prescription narcotics.
1 David J. Holcombe, M.D., “Opioid Abuse: A National Epidemic,” Cenla Focus, November 2014.
2 Pat Anson, “FDA Endorses CDC Opioid Guidelines,” Pain News Network, February 4, 2016. “Some of the FDA’s own experts have been highly critical of the CDC’s proposed guidelines, which discourage primary care physicians from prescribing opioids for chronic pain. […] Other panel members said they were ‘appalled’ by the guidelines, calling them an ‘embarrassment to the government.’”
3 AAPM, “Re: Docket No. CDC-2015-0112; Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain,” p. 3, January 12, 2016.
4 AAPM, p. 5
5 Judy Woodruff, “State Governments Strive to Curb Epidemic of Fatal Opioid Abuse,” PBS.org, PBS NewsHour, February 23, 2016.
6 The White House, Office of the Press Secretary, “Remarks by the President at National Governors Association Reception,” February 2, 2016.
7 Roselyn Bonanti, “Evidence-Based Medicine: Insurance Cost-Saving Scheme that Denies Treatment to Injured Workers,” Workers’ First Watch, Workers’ Injury Law & Advocacy Group, Spring 2012, pp. 12-13.
8 The White House, Office of the Press Secretary, “Remarks by the President at National Governors Association Reception,” February 2, 2016.
9 The White House, Office of the Press Secretary, “FACT SHEET: President Obama Proposes $1.1 Billion in New Funding to Address the Prescription Opioid Abuse and Heroin Use Epidemic,” February 2, 2016.
10 The White House, Office of the Press Secretary, “FACT SHEET: President Obama Proposes $1.1 Billion in New Funding to Address the Prescription Opioid Abuse and Heroin Use Epidemic,” February 2, 2016.
Gregory Hubachek, of Workers’ Compensation LLC, a law firm representing injured workers, has practiced in the field of workers’ compensation for over two decades. Since 2009, Hubachek has served on the governor’s Workers’ Compensation Advisory Council (WCAC) as an “at-large” appointment. In his role on the WCAC, Hubachek has sought to preserve fairness in the Louisiana Workers’ Compensation Act. As a result of his experience in the field of workers’ compensation, Hubachek has been enlisted to provide educational presentations for various organizations, for example, the Office of Workers’ Compensation Administration, the Louisiana Association of Business & Industry and the Workers’ Injury Law & Advocacy Group. Hubachek is a graduate of the University of California, Berkeley and the University of California, Hastings College of Law.
D. Kirkhoff Brainard is a freelance writer based in Atlanta, Georgia. With 20 years’ experience working as a journalist, copywriter and content developer, D.K. has written for some of America’s top companies including The Coca-Cola Company and General Motors Corporation. D.K. graduated magna cum laude with a double major in English and French from Hillsdale College. He earned the diplôme du Magistère from the University of Paris-Sorbonne IV before completing his master’s degree in French at the University of Cincinnati.
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