Opioid dispensing to workers injured on the job has decreased substantially in recent years in all 27 state workers’ compensation systems studied, according to a WCRI report, Interstate Variations in Dispensing of Opioids, 5th Edition. Increases in non-opioid pain medications did not fully offset these decreases. As a result, the percentage of workers’ compensation claims with pain medication decreased in each of the 27 study states.

However, workers continued to receive treatment for their pain for the most part. The WCRI study suggests that providers have switched from multi-pronged pain treatments, which involve pain medications (including opioids) and other restorative therapies, to a treatment protocol that more frequently relies solely on non-pharmacologic services.

This change in treatment patterns conforms to the recommendations of opioid prescribing and pain treatment guidelines and policies implemented in a number of states, which call for broad adoption of alternatives to opioids for treating acute and chronic pain. While this switch occurred, in some states, there were small net increases in the percentage of claims that received neither pain medications nor non-pharmacologic treatment.

What are these non-pharmacologic pain management services and how frequently are they used? To answer these questions, we looked at nonsurgical claims with more than seven days of lost work-time. The claims were for work-related injuries occurring between October 2015 and September 2016. We observed services provided to treat pain for these claims over an average 24-month experience period, that is, through the first quarter of 2018.

FINDINGS:

• The most frequent services billed and paid under workers’ compensation were physical medicine evaluation, active and passive physical medicine, and passive manipulations. We found that the frequency of use of each of the non-pharmacologic pain management services varied across the 27 states (See Table A). Workers’ compensation policies governing non-pharmacologic pain treatments (i.e., fee schedules, utilization limits, and prior authorization requirements) as well as local practice norms may influence delivery of these services to workers.
• Physical medicine evaluations were conducted in the majority (more than 50 percent) of claims in 24 of 27 states. The percentage of claims with physical medicine evaluation ranged from 46 percent in Louisiana to 66 percent in Nevada. As part of an evaluation, the physical therapist may decide whether additional treatments are necessary. The provider may offer additional treatment, they may demonstrate some home exercises for the worker to do on their own, and they may recommend some self-care during that visit.
• Active physical medicine was the most frequent form of treatment in all 27 states. The percentage of claims with active physical medicine ranged from a low of 50 percent in Massachusetts and 51 percent in Louisiana to a high of 67 percent in California and 68 percent in Nevada. Active physical medicine is exercises and movements performed by the worker. These types of exercises are typically used in the later stages of care once the injury or condition has improved enough that the worker is able to perform these motions without extreme pain. They include stretching, strength training, and stability training.
• Passive physical medicine modalities were the second most frequent treatment in 18 states, with the percentage of claims ranging from a low of 30 percent in Texas and 32 percent in Massachusetts to over 50 percent in California, Connecticut, Delaware, Maryland, and Nevada. Passive treatments, including the modalities covered here and passive manipulations covered below, are administered by the manual therapy provider to the affected area. They are used in the early stages of treatment when the patient is too injured or their condition is causing too much pain for them to do active exercises. Passive physical medicine modalities include electrical stimulation therapy and hot and cold therapy.
• Passive manipulations were relatively frequent in the study states, ranging from 24 percent of claims in Arkansas to 58 percent in Nevada. Passive manipulations include manual therapy and massage. Chiropractic manipulations were used in 10–14 percent of claims in seven states, while they were rarely used in most other states.
• Interventional pain management was the fourth most frequent pain treatment, ranging from 16 percent of claims in Maryland to 27 percent in Georgia. This category of pain treatment includes epidural procedures, facet and sacroiliac joint interventions, trigger point injections, and other injections and nerve blocks.
• Fifteen percent of claims in California and 4 percent of claims in New York received acupuncture, but this treatment was rarely seen elsewhere. Behavioral evaluation and behavioral treatments were very infrequently used.

The data underlying these measures comprise over 222,000 nonsurgical workers’ compensation claims with more than seven days of lost time from 27 states. These claims had injuries arising between October 2015 and September 2016, and we observed their medical treatment through March 2018, for an average of 24 months postinjury. The sample of claims in the study represents 37–72 percent of workers’ compensation claims in each state.

The 27 states in the study are Arkansas, California, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Jersey, New York, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Wisconsin.

 

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