Although our nation is currently focused on the COVID-19 pandemic, the opioid abuse epidemic continues to claim many lives. According to data from the Centers for Disease Control and Prevention (CDC), almost 70% of the 67,000 deaths from drug overdoses in 2018 involved a prescription or illicit opioid. Attempts to curb opioid abuse have included a change in the CDC opioid prescribing guidelines for chronic pain, the implementation of Prescription Drug Monitoring Programs, the use of Medication Assisted Therapy and a focus on alternative treatments for pain. Today’s injured worker is less likely to be placed on opioid therapy for chronic pain than an injured worker ten years ago. Unfortunately, there are still many open workers’ compensation cases involving the long-term use of opioids for chronic pain management. This may be due to the reluctance of an addicted claimant to explore better options for pain control, or the relative ease of everyone involved in maintaining the status quo.
A recent Illinois Workers’ Compensation case, Gonzalez v Jewel Food Stores (20IWCC 0237; 2020 Ill. Wrk. Comp. LEXIS 324) provides a blueprint for one of the ways that an employer may challenge the reasonableness of an opioid medication regimen for chronic pain. In Gonzalez, the parties settled the indemnity portion of the claim in 2013 and left medical open for life. The work-related injury involved the low back with an interbody fusion at one level, followed by a subsequent hardware removal. Gonzalez’ post-operative care primarily consisted of narcotic medications. The reasonableness of the ongoing narcotic medication regimen was reviewed by the Respondent’s IME physician. He concluded that the opioids were no longer reasonable or clinically appropriate for chronic non-malignant pain. An inpatient or outpatient detoxification and weaning program with Suboxone treatment was recommended instead. Respondent’s attempts to secure the treating physician’s agreement to change the medication regimen were unsuccessful. The Petitioner also declined to participate in a detoxification and weaning program.
The Respondent subsequently filed a Petition under Section 8(a) of the Illinois Workers’ Compensation Act requesting a hearing on the reasonableness of the Petitioner’s ongoing medical care. Respondent sought a finding that the Respondent was no longer obligated to authorize the narcotic medications and that other treatment options such as, but not limited to, the detoxification and weaning recommendations, were reasonable. After a hearing on the issue, the Illinois Workers’ Compensation Commission issued an Order granting the Respondent’s motion to terminate Petitioner’s medical benefits for the opioid medications. The Order also stated that Petitioner was an appropriate candidate for the detoxification program that would be funded by Respondent. If the detoxification program were unsuccessful, the Petitioner would have the option of filing a Section 8(a) Petition for different treatment.
The proactive approach taken by the Respondent in this case is one that should be considered by claims handlers in similar situations. By challenging the reasonableness of long-term opioid medication usage for chronic pain, the Respondent is taking an active role in helping to address the opioid abuse epidemic while simultaneously working toward improving a claimant’s life and life expectancy. The Petitioner is also guided to a better evidence-based medicine pain management course. In settlements where Medicare’s interests must be considered, the weaning program may also result in a far more manageable Medicare Set-Aside allocation.
Our team of Workers’ Compensation and Medicare Secondary Payer compliance attorneys work together toward better outcomes for your claims, including claims like Gonzalez. We pride ourselves on achieving balance between aggressive and humane results for your cases and are available to help in all aspects of these difficult cases.