The opioid crisis has cost Rhode Islanders a lot — in human lives, as well as money spent on treatment and lost productivity. The prevalence of opioid dependence among injured workers has placed a great burden on the workers’ compensation system.
Now, Rhode Island healthcare providers, insurance companies and courts are tackling the issue head-on, teaming up to get injured workers off of opioids and back to work.
“It’s an uphill battle,” says Recovery Radio host and former state Senator John Tassoni, who sits on the Rhode Island Overdose Prevention and Intervention Task Force. “And workers’ comp rates are going up because of it.”
Steve Reid, 54, of Warwick, became dependent on opioids after he was prescribed them for an on-the-job shoulder injury that required surgery. Reid estimates the costs of his surgery, his opioid addiction and his years of addiction recovery and rehabilitation totaled half a million dollars. This price was paid in large part by workers’ compensation.
Joseph Paduda, president of the workers’ compensation pharmacy advocacy and education firm CompPharma, estimates that costs due to opioid dependence have totaled 15 to 20 percent of total workers’ compensation costs over the past decade. Paduda says these costs have gone down incrementally in recent years, as doctors have learned more about the addictiveness of opioids and their prescription habits have been more closely monitored. But still, he estimates the cost of opioid prescriptions and addiction treatments to be about 10 percent of workers’ compensation expenses.
Much of this cost falls on insurance companies that provide workers’ compensation coverage, which then pass the expense on to employers through higher premiums. Paduda has surveyed workers’ compensation payers nationwide each year since 2004 about how they manage their pharmacy expenditures. Since 2011, he has included questions specifically about how much they spend on opioids and their concerns about claimants’ opioid use. Opioid use was named “the single biggest problem in workers’ compensation pharmacy” by survey respondents every year from 2011 to 2016, and it has continued to rank among the top concerns in recent years. In Paduda’s 2018 survey, many respondents reported that around half of all their lost-time claimants had been prescribed opioids, reflecting “rampant over-prescribing.”
Claims involving opioid dependence are among the most expensive workers’ compensation claims, according to David Blair, vice president of claims at Beacon Mutual, which covers the majority of workers’ compensation claims in Rhode Island. Opioid dependence “does have an impact on the overall trajectory of a claimant cost,” Blair says. “It can increase cost because you have the additional medical treatment. People who have developed an addiction may have a harder time returning to work. There can be costs associated with weaning them off of the drug and, in some instances, rehab, as well as a host of other medical problems that may arise because of their dependency.”
In workers’ compensation claims in which the claimants’ opioid addictions resulted from treatment for their workplace injuries, the insurance companies are usually responsible for all of these medical costs, as well as partial wage replacement for the time they are out of work due to opioid dependence, Blair says. Paduda adds that wage replacement is typically the most expensive of these opioid-related costs.
According to Dr. James Gallo, a psychiatrist in Warwick who has treated patients with opioid addictions for 30 years, rehabilitation is also expensive. Suboxone, a medication used to help patients avoid withdrawal symptoms when detoxing from opioids, used to cost about $20 a day, Gallo says. This cost has gone down significantly in recent years, but it still adds up.
Reid says his latest three-month period in rehab cost $100,000. During his years of addiction, he says he took hundreds of thousands of dollars worth of opioids. Workers’ compensation paid for Reid’s wage replacement, his surgery and the opioids he was prescribed following his surgery.
In his 2016 survey, Paduda found that in total, workers’ compensation insurers spent 10 times more of their dollars on opioids than did other payers, including private insurance, Medicare and Medicaid. Since then, opioid spend in workers’ compensation has fallen significantly each year, as workers’ compensation insurance and healthcare providers have worked together to control opioid prescribing and curb addiction among injured workers.
“Workers’ comp was the first industry that really started paying attention to opioids and said, ‘Oh, my God, this is a disaster,’” Paduda says.
In recent years, Beacon Mutual and other workers’ compensation insurers have implemented guidelines for opioid prescribing to reduce the risk of dependency, Blair says. Many pharmacies have taken similar steps. “If a provider is prescribing something that is outside of those guidelines, it gives us an opportunity to have a discussion with the provider,” he says, “to understand the treatment plan and to make sure that there is a plan in place to mitigate the risk of long-term addiction or negative impact.”
Paduda’s 2019 survey concluded that the reduction in money workers’ compensation insurers spent on opioids for newly injured employees had decreased fatal overdoses and addiction risk, hastened injury recovery and saved money by reducing medical costs and disability duration.
Still, Paduda says workers’ compensation payers have a long way to go, especially when it comes to claimants who have been on opioids for a long time. Although they have significantly reduced initial usage of opioids among newly injured workers, insurers are having a lot less success in curbing opioid usage among chronic patients, he says.
This is “a very knotty problem,” Paduda adds, because it involves complex psychosocial and behavioral health issues. “The work that you have to do to address those individual patients’ needs who are already dependent on or addicted to opioids is way more involved, way more complicated, way more expensive, way more difficult than it is to simply not administer opioids in the first place,” he says.
Paduda thinks workers’ compensation insurers need to crack down more to address this problem. He says the workers’ compensation industry faces “crisis fatigue” after a decade of working to address the opioid epidemic among injured workers. “They’ve been dealing with opioids as a crisis for ten years, they just want to be done with it,” says Paduda. “So I think people are saying, ‘Yeah opioids are a problem, but we’ve got other issues now and we’re moving on.’”
“This is a mistake,” he adds. Instead of moving on, Paduda believes insurance companies that cover injured workers should double down on efforts to help chronic opioid users by incorporating behavioral health into chronic pain management. This will reduce costs passed on to employers in the form of increased workers’ compensation premiums, and to taxpayers, who cover workers’ compensation expenses for government employees.
In an effort to help opioid-dependent workers and stem costs to their insurers and employers, the Rhode Island Workers’ Compensation Court has implemented several such measures to combat the opioid epidemic in the state.
In 2013, the court’s Medical Advisory Board put forward a set of protocols to guide the treatment of chronic pain for injured workers. The court also hosts seminars for physicians and an annual conference for attorneys, both of which have focused on appropriate opioid prescribing for injured workers and how to best treat and represent these workers.
“We knew that this was a crisis that was certainly being affected by workers’ comp injuries,” says Chief Judge Robert Ferrieri of the Rhode Island Workers’ Compensation Court, adding that each judge on his court has likely seen several cases of injured workers who became addicted to opioids. So in 2014, Ferrieri and Superior Court Magistrate Judge John F. McBurney III started attending meetings of a state Department of Health opioid panel, which consisted of healthcare providers, insurance companies and representatives from the Robert F. Arrigan Rehabilitation Center, which treats employees injured in Rhode Island.
Shortly after Ferrieri and McBurney joined this panel, the Workers’ Compensation Court established a program in partnership with the Arrigan Center to offer injured workers comprehensive pain management without the use of opioids. The Interdisciplinary Chronic Pain Management Program allows workers’ compensation judges to refer injured workers to the Arrigan Center for treatment and counseling by teams of healthcare workers with diverse specialties. Rather than treating the workers’ pain with opioids, this program aims to teach them how to best manage their pain and join the workforce again.
The Arrigan Center sees about seven patients each day, says Harriet Connor, assistant administrator of patient care. When patients enter the Interdisciplinary Chronic Pain Management Program, they are evaluated by a nurse case manager, either a physical therapist or an occupational therapist, a psychologist, the medical director and a mental health and substance use counselor. Together, these evaluators write a report and make recommendations as to whether the patient needs more physical therapy and whether the patient should be evaluated by an addiction specialist to be referred to detox.
As part of her screening process that she began in 2019, Kayla Villegas, Supervisor of Vocational Services at the Arrigan Center and a licensed mental health and substance use counselor, has conversations with patients about their medication use and assesses their readiness to get help if they do have addictions. When she identifies that a patient is an opioid user, she checks the state’s Prescription Drug Monitoring Program to make sure the person is not abusing the medications or seeking prescriptions from multiple providers. Villegas provides information about detox and harm reduction resources to patients whose opioid use she finds troubling.
“If we don’t treat the whole person … it will affect their recovery, the claim will drag on longer, and these people won’t get better and they won’t go back to work,” Villegas says. “Then you add opiates, and it adds the physical dependence and that’s going to make things even worse.”
When Villegas is very concerned about a patient, she asks to have a conversation with their workers’ compensation attorney. Patients are often hesitant to allow this and to admit their drug use to others, because they worry they might lose the payments they are receiving for lost wages if their opioid dependence is brought to the attention of their insurance company. While Villegas thinks this is a misconception, she said it is true that a case manager might look at a patient’s workers’ compensation case more closely if an opioid use issue comes to light.
Connor adds that many patients are also afraid of being cut off from the opioids on which they depend. “We have had some patients here that were so worried about their medication being stopped, that one gentleman attempted suicide,” Connor says. “He was just so afraid. Fortunately, he survived, and did not come here again.”
Another patient in the Interdisciplinary Chronic Pain Management Program died before the Arrigan Center team even finished evaluating him. He was in his mid-40s and had been prescribed several different opioid medications for pain from his workplace injury. Connor suspects the opioids he was taking may have suppressed his respiratory system, a deadly combination with his emphysema and chronic obstructive pulmonary disorder.
Although some of the Arrigan Center’s patients are dependent on opioids, and some come to the Arrigan Center in active withdrawal, Connor says that, “surprisingly, the majority of people that we see here are not using opioids.”
Until a few years ago, doctors were prescribing opioids for injured workers all the time, but in recent years, as the opioid epidemic has claimed more and more lives, some doctors have become hesitant to do so, says Connor. She says she’s noticed a dip in the number of prescriptions written by orthopedic physicians but that the primary care doctors with whom the center communicates are often very reluctant to stop prescribing opioids for their patients.
“The person comes in and is saying what terrible pain they’re experiencing, and they don’t want them to have that experience, so they continue to prescribe,” Connor says. “In workers’ comp it kind of limits your ability to call them to task, because they’re seeing them apart from the injury. They’re not seeing them for the injury, they’re seeing them for pain complaints.”
While the Arrigan Center staff can now better identify injured workers who need intervention for opioid use disorders, they can’t force patients to follow through with their recommendations.
But in recent months, the Workers’ Compensation Court has taken a harder line. It has decided it is within its power to order patients to be evaluated by addiction specialists and go through detox if necessary, Connor says. If patients refuse to go through detox, the court can threaten to reduce their benefits.
According to Villegas, “the court’s very invested in getting people off opiates and doing whatever is necessary to make that happen,” including ordering workers’ compensation claimants to attend treatment and ordering insurers to pay for the treatment.
Workers’ Compensation Court Judge Steven Minicucci says that the Court does use its control over the benefits an opioid-dependent worker may seek to encourage them to get addiction treatment. But ultimately, he says, “we do have to hope that they can recognize the problem and then take some personal responsibility to want to get the treatment that’s going to get them through this.”
According to Dr. Joanne Fowler, a psychologist at the Arrigan Center, this can be a difficult feat. Patients are afraid to stop getting their opioids, she says, and prescribers are often loath to take their patients off of medication that seems to be helping them. “That’s been frustrating,” she adds, “because you have a person sitting before you who’s still complaining about significant pain, taking a significant amount of pain medication that is prescribed and is monitored appropriately, but they’re not really getting functional.”
A legal battle over whether or not the insurance carrier is liable for addiction treatment can add another barrier to rehabilitation, Fowler says. Sometimes, she explains, workers’ compensation insurers are not willing to pay for the treatment recommended by a physician, and the process turns adversarial, which causes delays as well as stress for the patient. This can lead to “injured workers possibly going to their primary care doctors or going to illicit ways of getting opioids, which makes it very hard to track and difficult to treat,” she adds.
According to Paduda, the top reason insurers may be hesitant to pay for addiction treatment is a misguided perception that if they do, they will then “own” the psychosocial issues related to the workers’ compensation claim. He says this is a shortsighted view, as these insurers are already paying the price of the addiction through the expensive opioids that sustain it, as well as wage replacement while the claimant is out of work due to opioid dependence.
Fowler says this problem is sometimes remedied by the court, which can order insurers to pay for treatment even if they are resisting. While this has happened in some of Beacon Mutual’s claims, Blair says, often the insurance company decides to cover addiction treatment without a court order because “it’s the best thing for the injured employee, it’s the best thing for us and it’s the best thing for the policyholder.”
Most of the time, Chief Judge Ferrieri says, all sides of the courtroom — attorneys for the employer, the employee and the insurance carrier — are on board with whatever it takes to treat the addiction. “When we have an employee who is suffering from opioid addiction, everyone wants that person to free themselves from this sickness and to get better,” Ferrieri says. “So usually it's a joint effort with everyone.”