a tale of_two-states-final

A Tale of 2 States

Amy Lee Special Deputy Commissioner, Policy and Research, Texas Department of Insurance, Division of Workers’

Compensa@on

Dr. Gary Franklin Medical Director, Washington State Department of Labor and Industries

Learning Objec@ves

1.  State what is needed to pass regula@ons and legisla@ons to control opioid use.

2.  Analyze different approaches to determine what would work in their jurisdic@on.

3.  Formulate ideas you can implement in your home states.

2

Disclosure Statement

•  Amy Lee has no financial rela@onships with proprietary en@@es that produce health care goods and services.

•  Gary Franklin has no financial rela@onships with proprietary en@@es that produce health care goods and services.

3

Third-‐Party Payer Track: A Tale of Two States

Amy Lee Texas Department of Insurance,

Division of Workers’ Compensa@on

Presenta@on Highlights

•  Overview of Texas WC system

•  Pharmacy Closed Formulary – how it works

•  Preliminary impact

•  Transi@on of legacy claims, next steps

5

Overview of Texas WC System •  More than 270 insurance companies ac@vely wri@ng WC

•  $2 billion in direct wriXen premium

•  Including self-‐insured employers and governmental en@@es, more than 800 insurance carriers with WC claims

•  67% of private year-‐round employers have WC and all governmental en@@es have WC

•  About 225,000 new claims filed each year (including medical only claims) and about 340,000 claims receiving medical and/or indemnity benefits each year

•  Pharmacy accounts for 14% of medical payments –  Opioids account for 4.6% of medical payments

6

Overview of Texas WC System •  U@lizes evidence-‐based medicine treatment guidelines, Official Disability

Guidelines (ODG) and return-‐to-‐work guidelines (Medical Disability Advisor)

•  Requires certain services to be pre-‐authorized by the insurance carrier/u@liza@on review agent and allows retrospec@ve u@liza@on review of any service that is not pre-‐authorized

•  Sets fee guidelines for professional, inpa@ent/outpa@ent hospital, ASC and pharmacy services and allows pharmacy contractual discounts

•  Has administra@ve dispute resolu@on process for medical necessity and medical fee disputes

•  Collects medical charges, payments and u@liza@on data via EDI

•  Allows cer@fied networks, which require employees to select network trea@ng doctors, but allows employees choice of pharmacy

7

Pharmacy Formulary Rules

28 TAC Chapter 134 Benefits—Guidelines for Medical Services, Charges and Payments

Subchapter F, Pharmaceu=cal Benefits

8

9

Insert open formulary reference here

DefiniBons Exclusions from the Closed Formulary:

–  drugs with “N” status iden@fied in the current edi@on of the Official Disability Guideline (ODG) Treatment in Workers’ Comp/ Appendix A, ODG Workers’ Compensa=on Drug Formulary and any updates

–  any compounded drugs that contains a drug iden@fied with an “N” status in ODG; and

–  inves@ga@onal or experimental drugs as defined in Texas Labor Code §413.014(a)

10

“N” Status Drugs •  ODG’s appendix A is the most current publica@on for “N” status drugs

www.worklossdata.com

•  TDI-‐DWC will post the “N” status drugs from ODG’s Appendix A on its website: hXp://www.tdi.state.tx.us/wc/dm/index.html

•  “N” status drugs is updated monthly

11

12

Opioids Buprenorphine Suboxone® No N (for pain)

Opioids Buprenorphine (transdermal) Butrans™ No N

Opioids Butalbital (a barbiturate) Fioricet® Yes N

Opioids Fentanyl buccal Fentora® No N Opioids Fentanyl buccal film Onsolis™ No N Opioids Fentanyl lollipop Actiq® Yes N

Opioids Fentanyl nasal spray Lazanda No N

Opioids Fentanyl sublingual spray Subsys® No N

Opioids Fentanyl transmucosal Abstral No N

Opioids Hydrocodone/ibuprofen Vicoprofen® Yes N

Opioids Hydromorphone ER Exalgo No N

Texas Department of Insurance Division of Workers’ Compensation

This table is provided as a convenience only and is not a substitute for the current edition of ODG Treatment in Workers' Comp / Appendix A: ODG

Workers' Compensation Drug Formulary (see memo). ODG Texas Workers’ Compensation Status "N" Drugs

(Excluded from the Closed Formulary as of May 31, 2012)

Drug Class Generic Name Brand Name Generic

Equivalency Status

Preliminary Impact of Closed Pharmacy Formulary

13

Data and Methods

•  Injury months: September – February •  Injury years: 2009 – 2011 •  Injury year 2011 (Sept 2011 – Feb 2012): new injuries

that occurred after the implementation of the pharmacy closed formulary

•  Nine months maturity per claim •  N-drug list: approximately 150 drugs that require carrier

preauthorization.

14

Number of Claims Receiving an N-‐Drug, by Injury Year (Sept-‐Feb)

15

8,957 9,104

3,616

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

2009 2010 2011

-‐60%

Source: Texas Department of Insurance, Workers’ Compensa@on Research and Evalua@on Group, 2013.

N-‐drug Claims, as a Percentage of All Pharmacy Claims, by Injury Year (Sept-‐Feb)

16

18.9% 18.2%

7.4%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

2009 2010 2011

-‐59%


Number of N-‐drug Prescrip@ons, by Injury Year (Sept-‐Feb)

17

20,473 20,895

6,467

0

5000

10000

15000

20000

25000

2009 2010 2011

-‐69%


N-‐drugs as a Percentage of All Prescrip@ons by Injury Year (Sept-‐Feb)

18

9.5% 9.0%

3.0%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

2009 2010 2011

-‐67%


N-‐drug Costs, by Injury Year (Sept-‐Feb)

19

$2,404 (000) $2,309

(000)

$470 (000)

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

2009 2010 2011

-‐80%


N-‐drug Costs as a Percentage of Total Drug Costs, by Injury Year (Sept-‐Feb)

20

20.1% 18.8%

4.6%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

2009 2010 2011

-‐76%


N-‐drug Generic Subs@tu@on Rate, by Injury Year (Sept-‐Feb)

21

4,821

1,214

5,150

2,595

2010 2011

Brand Generic

48%

32%

52%

68%


Other Drugs •  Key measures:

 Claim counts  Prescription utilization patterns  Prescription costs  Generic substitution rates  Most prescribed drugs

22

Number of Claims with Prescrip@ons for “Other” Drugs, by Injury Year (Sept-‐Feb)

23

46,265 48,827 48,406

0

10000

20000

30000

40000

50000

60000

2009 2010 2011

-‐1%


Claims with Prescrip@ons for “Other” Drugs as a Percentage of All Pharmacy Claims,

by Injury Year (Sept-‐Feb)

24

81.1% 81.8% 93.6%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2009 2010 2011

14%


Number of Prescrip@ons for “Other” Drugs, by Injury Year (Sept-‐Feb)

25

195,111 211,099 210,593

0

50000

100000

150000

200000

250000

2009 2010 2011

-‐<.1%


“Other” Drugs, as a Percentage of All Prescrip@ons, by Injury Year (Sept-‐Feb)

26

90.5% 91.0% 97.0%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

2009 2010 2011

7%


“Other” Drug Costs, by Injury Year (Sept-‐Feb)

27

$9,558 (000)

$9,998 (000)

$9,874 (000)

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

2009 2010 2011

-‐ <1%


“Other” Drug Costs as a Percentage of Total Drug Costs, by Injury Year (Sept-‐Feb)

28

79.9% 81.2%

95.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2009 2010 2011

17%


“Other” Drug Generic Subs@tu@on Rate, by Injury Year (Sept-‐Feb)

29

8,600 (9%)

5,290 (6%)

85,360 (91%)

82,231 (94%)

2010 2011

Brand Generic


Average Number of Prescrip@ons per Claim, by Injury Year (Sept-‐Feb)

2.3 2.3 1.8

4.2 4.3 4.4

0

1

2

3

4

5

2009 2010 2011

N-drug prescriptions per claim Other-drug prescriptions per claim

+2%

30

-‐22%


Transi@on of Legacy Claims to Pharmacy Closed Formulary

31

Open Formulary for Legacy Claims

•  Applies to both network and non-‐network claims with dates of injury prior to September 1, 2011

•  A legacy claim is any date of injury prior to September 1, 2011

•  Subject to the open formulary un@l September 1, 2013

32

Open Formulary for Legacy Claims

How are drugs prescribed in an open formulary? Non-‐Network

• According to the ODG treatment guidelines

Network

• According to the cer@fied network’s treatment guidelines

33

Open Formulary

•  Drugs included in an open formulary do not require preauthoriza@on, but are subject to retrospec@ve review

•  However, inves@ga@onal or experimental drugs require preauthoriza@on

34

TransiBon of Legacy Claims

To facilitate the transi@on, the prescribing doctor or the insurance carrier may:

•  Contact each other to discuss ongoing pharmacological management of the injured employee’s claim

•  When the par@es contact each other, they must provide a name, phone number, date and @me to discuss ongoing pharmacological management of the injured employee’s claim

35


Beginning no later than March 1, 2013, the insurance carrier shall:

•  Iden@fy legacy claims where an excluded drug has been prescribed aqer September 1, 2012

•  Provide wriXen no@fica@on to the injured employee, prescribing doctor and pharmacy, if known

36


The wriXen no@fica@on will contain:

•  Date the closed formulary will apply

•  Name, telephone number, and date and @me to discuss ongoing pharmacological management of the injured employee’s claim

37


Agreement:

During the discussion the insurance carrier and a prescribing doctor may enter into an agreement on the applica@on of the closed formulary on an individual claim-‐by-‐claim basis

38

TransiBon of Legacy Claims Agreement requirements: •  Must be documented by the carrier and shared with the prescribing doctor and injured employee

•  Health care provided as a result of the agreement is not subject to retrospec@ve review

If an agreement is not reached:

•  A denial of a request for an agreement is not subject to dispute resolu@on

•  Closed formulary applies as of 9/1/2013

39

Medical Interlocutory Order “MIO”

•  When the preauthoriza@on denial of a drug excluded from the closed formulary;

•  Poses an unreasonable risk of medical emergency to the injured employee;

•  Provides a means for an injured employee to con@nue use of the previously prescribed and dispensed drug(s) throughout the dura@on of the appeals/dispute process.

40

Number of Legacy Claims Receiving N-‐Drugs, by Prescrip@on Year (Sept-‐Nov)

41

15,682

8,032

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

2011 2012

-‐49%


Contact Us

•  www.tdi.texas.gov/wc/indexwc.html

•  [email protected]

•  512-‐804-‐4000 or 800-‐372-‐7713

42

Gary M. Franklin, MD, MPH Medical Director

WA Dept of Labor and Industries

Research Professor University of washington

Guidelines for Prescribing opioids to Treat Pain in Injured workers -‐NaBonal Rx Drug Abuse Summit-‐

Orlando, FL Wed April 3, 2013

"To write prescrip@ons is easy, but to come to an understanding with people is hard." -‐-‐ Franz Kaua, “A Country Doctor”

!

“We can’t solve problems by using the same kind of thinking we used when we created them”

  By the late 1990s, at least 20 states passed new laws, regulations, or policies moving from near prohibition of opioids to use without dosing guidance   WA law: “No disciplinary action will be taken

against a practitioner based solely on the quantity and/or frequency of opioids prescribed.” (WAC 246-919-830, 12/1999)

  Laws were based on weak science and good experience with cancer pain

Change in National Norms for Use of Opioids for Chronic, Non-cancer Pain

WAC-Washington Administrative Code

46

Similarities Between Illicit & Prescription Drugs

Portenoy and Foley Pain 1986; 25: 171-‐186

  Retrospective case series chronic, non-cancer pain

 N=38; 19 Rx for at least 4 years   2/3 < 20 mg MED/day; 4> 40 mg MED/day   24/38 acceptable pain relief  No gain in social function or employment could

be documented  Concluded: “Opioid maintenance therapy can

be a safe, salutary and more humane alternative…”

 Overall, the evidence for long-‐term analgesic efficacy is weak  PutaBve mechanisms for failed opioid analgesia may be

related to rampant tolerance  The premise that tolerance can always be overcome by dose

escalaBon is now quesBoned  100% of paBents on opioids chronically develop dependence

 More than 50% of paBents on opioids for 3 months will sBll be on opioids 5 years later

Ballantyne J. Pain Physician 2007;10:479-91; Martin BC et al. J Gen Intern Med 2011; 26: 1450-57

Limitations of Long-term (>3 Months) Opioid Therapy

49

Risk/Benefit of Opioids for Chronic Non-‐Cancer Pain

Dentists and Emergency Medicine Physicians were the main prescribers for patients 5-29 years of age

0

100

200

300

400

500

600

700

800

900

0-‐4 5-‐9 10-‐14 15-‐19 20-‐24 25-‐29 30-‐39 40-‐59 60+

Rate per 10,000 pe

rson

s

Age Group

GP/FM/DO

IM

DENT

ORTH SURG

EM

5.5 million prescripBons were prescribed to children and teens (19 years and under) in 2009

Source: IMS Vector ®One Na@onal, TPT 06-‐30-‐10 Opioids Rate 2009

52

Opioid-Related Deaths, Washington State Workers’ Compensation, 1992–2005

Franklin GM, et al, Am J Ind Med 2005;48:91-9

0 2 4 6 8

10 12 14

De

ath

s

Definite Probable

Year

‘95 ‘97 ‘00 ‘02 ‘96 ‘98 ‘99 ‘01

53

Age-‐adjusted rate per 100,000 populaBon

UnintenBonal and Undetermined Intent Drug Overdose Death Rates by State, 2007

MD MA NH RI CT DE DC VT NJ

12.5 12.5 11.7 11.1 11.1 9.8 8.8 7.9 7.5

National Vital Statistics System, http://wonder.cdc.gov

UnintenBonal Poisoning Fatality Rate, 1999-‐2010, WISQARS NCHS data

0 2 4 6 8

10 12 14 16

Deaths/100,000

Year

California n=3580

Ohio n=1678

Utah n=273

Washington n=754

Evidence linking specific doses to morbidity and mortality

Dunn et al, Ann Int Med 2010; 152: 85-92  Risk of morbidity and mortality increased 8.9 fold at

100 mg MED  Editorial-McLellan-White House Office of National

Drug Control Policy  “Smarter, more responsible (prescribing)

practices are the only hope to avoid tragic, avoidable deaths”

Braden et al, Arch Int Med 2010; 170: 1425-32 Opioid doses >120 mg/day MED and use of long acting Schedule II opioids associated with incresed risk of alcohol- or drug- related ER visit

*

Evidence linking specific doses to morbidity and mortality

Bohnert et al, JAMA 2011; 305: 1315-‐21

•  Risk of mortality 7.18 (chronic pain), 6.64 (acute pain)

Gomes et al, Arch Int Med 2011; 171: 686-‐91

•  Risk of mortality 2.04 at 100 mg and 2.88 at 200 mg

57

Unintentional Overdose Deaths Involving Opioid Analgesics Parallel Opioid Sales

United States, 1997–2007

National Vital Statistics System, multiple cause of death data set and Drug Enforcement Administration ARCOS system; 2007 opioid sales figure is preliminary

 Distribution by drug companies   96 mg/person in 1997   698 mg/person in 2007

  Enough for every American to take 5 mg Vicodin every 4 hrs for 3 weeks

 Overdose deaths   2,901 in 1999   11,499 in 2007

Opioid sales * (mg/person)

Opioid deaths

627% increase

296% increase

Year

Year

Washington Agency Medical Directors’ Opioid Dosing Guidelines

58

•  Developed with clinical pain experts in 2006 •  Implemented April 1, 2007 •  First guideline to emphasize dosing guidance •  Educational pilot, not new standard or rule •  National Guideline Clearinghouse

–  http://www.guideline.gov/content.aspx?id=23792&search=wa+opioids

www.agencymeddirectors.wa.gov

59

•  Part I – If patient has not had clear improvement in pain AND function at 120 mg MED (morphine equivalent dose) , “take a deep breath” –  If needed, get one-time pain management

consultation (certified in pain, neurology, or psychiatry)

•  Part II – Guidance for patients already on very high doses >120 mg MED

Washington Agency Medical Directors’ Opioid Dosing Guidelines

www.agencymeddirectors.wa.gov

 Establish an opioid treatment agreement  Screen for

  Prior or current substance abuse   Depression

 Use random urine drug screening judiciously   Shows pa@ent is taking prescribed drugs   Iden@fies non-‐prescribed drugs

 Do not use concomitant sedaBve-‐hypnoBcs  Track pain and funcBon to recognize tolerance  Seek help if dose reaches 120 mg MED, and pain and funcBon have

not substanBally improved

Guidance for Primary Care Providers on Safe and Effective Use of Opioids for Chronic Non-cancer Pain

60

http://www.agencymeddirectors.wa.gov/opioiddosing.asp MED, Morphine equivalent dose

Open-source Tools Added to June 2010 Update of Opioid Dosing Guidelines

61

 Opioid Risk Tool: Screen for past and current substance abuse

 CAGE-‐AID screen for alcohol or drug abuse

 PaBent Health QuesBonnaire-‐9 screen for depression  2-question tool for tracking pain and function

 Advice on urine drug testing

hXp://www.agencymeddirectors.wa.gov/opioiddosing.asp#DC

Available as mobile app: hXp://www.agencymeddirectors.wa.gov/opioiddosing.asp

Washington State Primary Care Survey 2009: Physician Concerns

Please check the statement that most accurately reflects your experience when prescribing opioids

for chronic, non-‐cancer pain

NO concerns about development of psychological dependence, addicBon, or diversion

2%

OCCASIONAL concerns about development of psychological dependence, addicBon, or diversion

45%

FREQUENT concerns about development of psychological dependence, addicBon, or diversion

54%

62

Interim Evalua@on of the Opioid Dosing Guidelines. hXp://www.agencymeddirectors.wa.gov

Washington State Primary Care Survey 2009: Adherence to State Guidelines

Guidance Never or almost never SomeBmes Olen

Always or almost always

Use treatment agreement 10% 22% 20% 49%

Screen for substance abuse <1% 3% 15% 81%

Screen for mental illness <1% 12% 30% 58%

Use random urine screen 30% 32% 18% 20%

Use paBent educaBon 34% 38% 19% 9%

Track pain 40% 31% 15% 15%

Track physical funcBon 69% 20% 7% 5%

63

Interim Evalua@on of the Opioid Dosing Guidelines. hXp://www.agencymeddirectors.wa.gov

2009 CDC recommendations

 For practitioners, public payers, and insurers

 Seek help at 120 mg/day MED if pain and function not improving

 http://www.cdc.gov/HomeandRecreationalSafety/pdf/poision-issue-brief.pdf

Franklin et al, Natural History of Chronic Opioid Use Among Injured Workers with Low Back Pain-Clin J Pain,

Dec, 2009 •  694/1843 (37.6%) received opioid early •  111/1843 (6%) received opioids for 1 yr •  MED increased sign from 1st to 4th qtr

•  Only minority improved by at least 30% in pain (26%) and funcBon (16%)

•  Strongest predictor of long term opioid use was MED in 1st qtr (40 mg MED had OR 6)

•  Avg MED 42.5 mg at 1 yr; Von Korff 55 mg at 2.7 yrs

Randomized trial Re effec@veness of escala@ng dose

•  RCT of “hold the line” vs escala@ng dose strategies •  N=135, parallel group pragma@c study

•  No change in any primary pain or func@on outcome •  27% discharged due to misuse/non-‐compliance

*Naliboff et al, 2011 (FEB); 12: 288-‐96

New state policies

ConnecBcut WC policy-‐7/1/2012 The total daily dose of opioids should not be increased above 90mg oral MED/day (Morphine Equivalent Dose) unless the pa@ent demonstrates measured improvement in func@on, pain or work capacity. Second opinion is recommended if contempla@ng raising the dose above 90 MED/day.

MaineCare (Medicaid)-‐4/1/2012 Total 45 day maximum for non-‐cancer pain

New Mexico-‐Rule 16.10.14-‐Proposed rules Aug, 2012 A health care prac@@oner shall, before prescribing, ordering, administering or dispensing a controlled substance listed in schedule II, III or IV, obtain a pa@ent PMP report for the preceding twelve (12) months

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

Num

ber o

f Opi

oid

Pre

scrip

tions

Yearly Trend of Scheduled Opioids

(Franklin et al, Am J Ind Med 2012; 55: 325-31 )

Schedule II Schedule III Schedule IV

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

Percent of Timeloss Claimants on Opioids 2000 - 2010

Opioids Highdose Opioids

Average Daily Dosage for Opioids, Washington Workers’ Compensation, 1996–2010

70

0

20

40

60

80

100

120

140

1996 Q1

1996 Q3

1997 Q1

1997 Q3

1998 Q1

1998 Q3

1999 Q1

1999 Q3

2000 Q1

2000 Q3

2001 Q1

2001 Q3

2002 Q1

2002 Q3

2003 Q1

2003 Q3

2004 Q1

2004 Q3

2005 Q1

2005 Q3

2006 Q1

2006 Q3

2007 Q1

2007 Q3

2008 Q1

2008 Q3

2009 Q1

2009 Q3

2010 Q1

MED

(m

g/d

ay)

Long-acting opioids

Short-acting opioids

Year/Quarter

96-

Q1

96-

Q3

97-

Q1

97-

Q3

98-

Q1

98-

Q3

99-

Q1

99-

Q3

00-

Q1

00-

Q3

01-

Q1

01-

Q3

02-

Q1

02-

Q3

03-

Q1

03-

Q3

04-

Q1

04-

Q3

05-

Q1

05-

Q3

06-

Q1

06-

Q3

07-

Q1

07-

Q3

08-

Q1

08-

Q3

09-

Q1

09-

Q3

10-

Q1

0

5

10

15

20

25

30

35

Opi

oid-

rela

ted

Dea

th

WA Workers' Compensation Opioid-related Deaths 1995-2010

Possible Probable Definite

Unintentional Prescription Opioid Overdose Deaths Washington 1995-2010

* Tramadol only deaths included in 2009, but not in prior years.

Source: Washington State Department of Health, Death Certificates

0

100

200

300

400

500

600

95

96

97

98

99

00

01

02

03

04

05

06

07

08

09

10

Num

ber o

f dea

ths

Prescription Opioid + alcohol or illicit drug

Prescription Opioid +/- Other Prescriptions

24

420

There is substanBal clustering among providers on dosing and mortality

CA CWCI study-‐Swedlow et al, March, 2011: 3% of prescribers account for 55% of Schedule II opioid Rxs:hXp://www.cwci.org/research.html

Dhalla et al, Clustering of opioid prescribing and opioid-‐related mortality among family physicians in Ontario. Can Fam Physician 2011; 57: e92-‐96 Upper quin@le of frequent opioid prescribers associated with last opioid Rx in 62.7% of public plan beneficiary uninten@onal poisoning deaths

DLI sent leXers to all prescribers with any pa@ent on opioid doses at or above 120 mg/day MED-‐ONLY N=60 •  Call their aXen@on to AMDG Guidelines and new WA state

regula@ons •  Associate medical director will meet with these docs

personally

Early opioids and disability in WA WC. Spine 2008; 33: 199-‐204

 Popula@on-‐based, prospec@ve cohort  N=1843 workers with acute low back injury and at least 4 days lost @me

 Baseline interview within 18 days(median)

 14% on disability at one year  Receipt of opioids for > 7 days, at least 2 Rxs, or > 150 mg MED doubled risk of 1 year disability, aqer adjustment for pain, func@on, injury severity

38% Increase since 2001

What can PCP do to safely and effectively use opioids for CNCP?

  Opioid treatment agreement   Screen for prior or current substance abuse/

misuse (alcohol, illicit drugs, heavy tobacco use)   Screen for depression   Prudent use of random urine drug screening

(diversion, non-prescribed drugs)   Do not use concomitant sedative-hypnotics or

benzodiazepines   Track pain and function to recognize tolerance   Seek help if MED reaches 120 mg and pain and

function have not substantially improved   Use PDMP!

Concrete steps to take

•  Track high MED and prescribers •  Reverse permissive laws and set dosing and best practice standards

for chronic, non-cancer pain •  Implement AMDG Opioid Dosing Guidelines (

http://www.agencymeddirectors.wa.gov/opioiddosing.asp) •  Implement effective Prescription Monitoring Program; check the PDMP

on every new injured worker who receives opioid Rx •  Encourage/incent use of best practices (web-based MED calculator,

use of state PMPs) •  DO NOT pay for office dispensed opioids •  ID high prescribers and offer assistance •  Incent community-based Rx alternatives (activity coaching and

graded exercise early, opioid taper/multidisciplinary Rx later) •  Offer assistance (academic detailing, free CME,ECHO)

Nov, 2012 WA Workers Compensa@on Opioid Guideline

•  Adop@on of the 2010 AMDG Interagency Guideline on Opioid Dosing for Chronic Non-‐cancer Pain

•  This Supplement provides addi@onal informa@on and guidance for trea@ng work-‐related injuries

79

DOH pain management rules, 2010 AMDG Guideline and this Supplement are reflec@ve of the prac@ce standard for

prescribing opioids for a work-‐related injury or occupa@onal disease.

80

Clinically Meaningful Improvement in

Func@on

Case Defini@on &

Algorithms for

Discon@nuing COT

Managing Surgical Pain in

Workers on COT

Stop and Take a Deep Breath at 6 weeks and

before COT

Proper and Necessary Care

for Opioid

Prescribing

Addic@on Treatment

Disability Prevention is the Key Health Policy Issue

Adapted from Cheadle et al. Am J Public Health 1994; 84:190–196.!

12 11 10 9 8 7 6 5 4 3 2 1 0 0

20

40

60

80

100

Time loss duraBon (months)

% of cases on

Bme loss

Opioid Use in Workers’ Compensa@on

1

•  Measuring the Impact of Opioid Use – Beyond acute phase, effec@ve use should result in clinically meaningful improvement in func@on (CMIF)

– CMIF is an improvement in func@on of at least 30% compared to start of treatment or in response to a dose change

– Evalua@on of clinically meaningful improvement should occur at 3 cri@cal phases (acute, subacute and during COT)

Con@nuing to prescribe opioids in the absence of CMIF or aqer the development of a severe adverse outcome is not proper and necessary care. In addi@on, the use of escala@ng doses to the point of developing opioid use disorder is not proper and

necessary care.

For electronic copies of this presentation, please e-mail

Laura Black [email protected]

For questions or feedback, please

e-mail Gary Franklin [email protected]

THANK YOU!

a tale of_two-states-final

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