Third-Party Payer Track, National Rx Drug Abuse Summit, April 2-4, 2013. Presentation by Amy Lee and Dr. Gary Franklin

1. 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

2. 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

3. 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

4. Third-­‐Party
Payer
Track:
A
Tale
of
Two
States
Amy
Lee
Texas
Department
of
Insurance,
Division
of
Workers’
Compensa@on

5. Presenta@on
Highlights
• Overview
of
Texas
WC
system
• Pharmacy
Closed
Formulary
–
how
it
works
• Preliminary
impact
• Transi@on
of
legacy
claims,
next
steps
5

6. 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

7. 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

8. 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
9

10. 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

11. “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. 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)
Generic
Drug Class Generic Name Brand Name Equivalency Status
N (for
Opioids Buprenorphine Suboxone® No pain)
Buprenorphine
Opioids (transdermal) Butrans™ No N
Butalbital (a
Opioids barbiturate) Fioricet® Yes N
Opioids Fentanyl buccal Fentora® No N
Opioids Fentanyl buccal film Onsolis™ No N
Opioids Fentanyl lollipop Actiq® Yes N
Fentanyl nasal
Opioids spray Lazanda No N
Fentanyl sublingual
Opioids spray Subsys® No N
Fentanyl
Opioids transmucosal Abstral No N
Hydrocodone/
Opioids ibuprofen Vicoprofen® Yes N
Opioids Hydromorphone ER Exalgo No N
12

13. Preliminary
Impact
of
Closed
Pharmacy
Formulary
13

14. 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

15. Number
of
Claims
Receiving
an
N-­‐Drug,
by
Injury
Year
(Sept-­‐Feb)
10000
8,957 9,104
9000
8000
7000
6000
5000
4000
3,616
3000
2000
-­‐60%
1000
0
2009 2010 2011
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
15

16. N-­‐drug
Claims,
as
a
Percentage
of
All
Pharmacy
Claims,
by
Injury
Year
(Sept-­‐Feb)
20.0%
18.9% 18.2%
18.0%
16.0%
14.0%
12.0%
10.0%
8.0%
7.4%
6.0%
4.0%
-­‐59%
2.0%
0.0%
2009 2010 2011
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
16

17. Number
of
N-­‐drug
Prescrip@ons,
by
Injury
Year
(Sept-­‐Feb)
25000
20,473 20,895
20000
15000
10000
6,467
5000
-­‐69%
0
2009 2010 2011
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
17

18. N-­‐drugs
as
a
Percentage
of
All
Prescrip@ons
by
Injury
Year
(Sept-­‐Feb)
10.0%
9.5%
9.0%
9.0%
8.0%
7.0%
6.0%
5.0%
4.0%
3.0%
3.0%
2.0%
1.0%
-­‐67%
0.0%
2009 2010 2011
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
18

19. N-­‐drug
Costs,
by
Injury
Year
(Sept-­‐Feb)
$3,000
$2,404
(000) $2,309
$2,500
(000)
$2,000
$1,500
$1,000
$470
(000)
$500
-­‐80%
$0
2009 2010 2011
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
19

20. N-­‐drug
Costs
as
a
Percentage
of
Total
Drug
Costs,
by
Injury
Year
(Sept-­‐Feb)
25.0%
20.1%
20.0%
18.8%
15.0%
10.0%
4.6%
5.0%
0.0%
-­‐76%
2009 2010 2011
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
20

21. N-­‐drug
Generic
Subs@tu@on
Rate,
by
Injury
Year
(Sept-­‐Feb)
Brand Generic
5,150
4,821
2,595
48%
52%
1,214
32%
68%
2010 2011
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
21

22. Other
Drugs
• Key measures:
 Claim counts
 Prescription utilization patterns
 Prescription costs
 Generic substitution rates
 Most prescribed drugs
22

23. Number
of
Claims
with
Prescrip@ons
for
“Other”
Drugs,
by
Injury
Year
(Sept-­‐Feb)
60000
46,265 48,827 48,406
50000
40000
30000
20000
10000
-­‐1%
0
2009 2010 2011
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
23

24. Claims
with
Prescrip@ons
for
“Other”
Drugs
as
a
Percentage
of
All
Pharmacy
Claims,
by
Injury
Year
(Sept-­‐Feb)
100.0%
93.6%
90.0%
81.1% 81.8%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
14%
10.0%
0.0%
2009 2010 2011
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
24

25. Number
of
Prescrip@ons
for
“Other”
Drugs,
by
Injury
Year
(Sept-­‐Feb)
250000
211,099 210,593
195,111
200000
150000
100000
50000
-­‐<.1%
0
2009 2010 2011
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
25

26. “Other”
Drugs,
as
a
Percentage
of
All
Prescrip@ons,
by
Injury
Year
(Sept-­‐Feb)
120.0%
97.0%
100.0%
90.5% 91.0%
80.0%
60.0%
40.0%
20.0%
7%
0.0%
2009 2010 2011
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
26

27. “Other”
Drug
Costs,
by
Injury
Year
(Sept-­‐Feb)
$12,000
$9,998
$9,874
$9,558
(000)
(000)
$10,000
(000)
$8,000
$6,000
$4,000
$2,000
$0
-­‐
<1%
2009 2010 2011
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
27

28. “Other”
Drug
Costs
as
a
Percentage
of
Total
Drug
Costs,
by
Injury
Year
(Sept-­‐Feb)
100.0%
95.4%
90.0%
79.9% 81.2%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
17%
2009 2010 2011
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
28

29. “Other”
Drug
Generic
Subs@tu@on
Rate,
by
Injury
Year
(Sept-­‐Feb)
Brand Generic
85,360 82,231
(91%) (94%)
8,600 5,290
(9%) (6%)
2010 2011
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
29

30. Average
Number
of
Prescrip@ons
per
Claim,
by
Injury
Year
(Sept-­‐Feb)
N-drug prescriptions per claim Other-drug prescriptions per claim
5 4.4
4.2 4.3
4
3
2.3 2.3
1.8
2
+2%
1
-­‐22%
0
2009 2010 2011
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
30

31. Transi@on
of
Legacy
Claims
to
Pharmacy
Closed
Formulary
31

32. 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

33. 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

34. 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

35. 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

36. TransiBon
of
Legacy
Claims
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

37. TransiBon
of
Legacy
Claims
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

38. TransiBon
of
Legacy
Claims
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

39. 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

40. 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

41. Number
of
Legacy
Claims
Receiving
N-­‐
Drugs,
by
Prescrip@on
Year
(Sept-­‐Nov)
18000
15,682
16000
14000
12000
10000
8,032
8000
6000
4000
-­‐49%
2000
0
2011 2012
Source:
Texas
Department
of
Insurance,
Workers’
Compensa@on
Research
and
Evalua@on
Group,
2013.
41

42. Contact
Us
• www.tdi.texas.gov/wc/indexwc.html
• Medicalbenefits@tdi.texas.gov
• 512-­‐804-­‐4000
or
800-­‐372-­‐7713
42

43. Guidelines
for
Prescribing
opioids
to
Treat
Pain
in
Injured
workers
-­‐NaBonal
Rx
Drug
Abuse
Summit-­‐
Orlando,
FL
Wed
April
3,
2013
Gary
M.
Franklin,
MD,
MPH
Medical
Director
WA
Dept
of
Labor
and
Industries
Research
Professor
University
of
washington

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

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

46. Change in National Norms for Use of Opioids
for Chronic, Non-cancer Pain
 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
WAC-Washington Administrative Code
46

47. Similarities Between Illicit & Prescription Drugs

48.
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…

49. Limitations of Long-term (>3 Months)
Opioid Therapy
 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
49

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

51. Dentists and Emergency Medicine Physicians were the main
prescribers for patients 5-29 years of age
5.5
million
prescripBons
were
prescribed
to
children
and
teens
(19
years
and
under)
in
2009
900
800
700
600
Rate
per
10,000
persons
GP/FM/DO
500
IM
400
DENT
300
ORTH
SURG
EM
200
100
0
0-­‐4
5-­‐9
10-­‐14
15-­‐19
20-­‐24
25-­‐29
30-­‐39
40-­‐59
60+
Age
Group
Source:
IMS
Vector
®One
Na@onal,
TPT
06-­‐30-­‐10
Opioids
Rate
2009

52. Opioid-Related Deaths,
Washington State Workers Compensation, 1992–2005
14
Definite Probable
12
10
8
Deaths
6
4
2
0
95 96 97 98 99 00 01 02
Year
Franklin GM, et al, Am J Ind Med 2005;48:91-9
52

53. UnintenBonal
and
Undetermined
Intent
Drug
Overdose
Death
Rates
by
State,
2007
MD
12.5
MA
12.5
NH
11.7
RI
11.1
CT
11.1
DE
9.8
DC
8.8
VT
7.9
NJ
7.5
Age-­‐adjusted
rate
per
100,000
populaBon
National Vital Statistics System, http://wonder.cdc.gov
53

54. UnintenBonal
Poisoning
Fatality
Rate,
1999-­‐2010,
WISQARS
NCHS
data
16
14
Deaths/100,000
12
10
8
California
n=3580
6
Ohio
n=1678
4
2
Utah
n=273
0
Washington
n=754
Year

55. 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
*

56. 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
 Distribution by drug
Opioid sales * (mg/
companies person)
 96
mg/person
in
1997
627%
 698
mg/person
in
2007
increase
 Enough
for
every
American
to take 5 mg Vicodin
every 4 hrs for 3 weeks
Year
 Overdose deaths Opioid deaths
 2,901
in
1999
296%
increase
 11,499
in
2007
Year
National Vital Statistics System, multiple cause of death data
set and Drug Enforcement Administration ARCOS system;
57 2007 opioid sales figure is preliminary

58. Washington Agency Medical Directors
Opioid Dosing Guidelines
• 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
58
www.agencymeddirectors.wa.gov

59. Washington Agency Medical Directors
Opioid Dosing Guidelines
• 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
59
www.agencymeddirectors.wa.gov

60. Guidance for Primary Care Providers on Safe and
Effective Use of Opioids for Chronic Non-cancer Pain
 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
http://www.agencymeddirectors.wa.gov/opioiddosing.asp
MED, Morphine equivalent dose
60

61. Open-source Tools Added to June 2010
Update of Opioid Dosing Guidelines
 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
Available
as
mobile
app:
hXp://
www.agencymeddirectors.wa.go
v/opioiddosing.asp
61 hXp://www.agencymeddirectors.wa.gov/opioiddosing.asp#DC

62. 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,
2%
addicBon,
or
diversion
OCCASIONAL
concerns
about
development
of
psychological
45%
dependence,
addicBon,
or
diversion
FREQUENT
concerns
about
development
of
psychological
54%
dependence,
addicBon,
or
diversion
Interim
Evalua@on
of
the
Opioid
Dosing
Guidelines.
hXp://www.agencymeddirectors.wa.gov
62

63. Washington
State
Primary
Care
Survey
2009:
Adherence
to
State
Guidelines
Always
or
Never
or
Guidance
SomeBmes Olen almost
almost
never
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%
Interim
Evalua@on
of
the
Opioid
Dosing
Guidelines.
hXp://www.agencymeddirectors.wa.gov
63

64. 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

65. Franklin et al, Natural History of Chronic Opioid Use
Among Injured Workers with Low Back Pain-Clin J Pain,
• 694/1843
(37.6%)
received
opioid
early
Dec, 2009
• 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

66. 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

67. 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

68. Yearly Trend of Scheduled Opioids
(Franklin et al, Am J Ind Med 2012; 55: 325-31 )
100,000
Number of Opioid Prescriptions
90,000
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
Schedule II Schedule III Schedule IV

69. Percent of Timeloss Claimants on Opioids
2000 - 2010
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
Opioids Highdose Opioids

70. Q1
10-
Q3
09-
Q1
09-
Q3
08-
Q1
08-
2010 Q1
Q3
2009 Q3
Washington Workers Compensation, 1996–2010
07-
2009 Q1
Q1
07-
2008 Q3
Q3
2008 Q1
06-
2007 Q3
Average Daily Dosage for Opioids,
Q1
06-
2007 Q1
Q3
2006 Q3
05-
2006 Q1
Q1
Long-acting opioids
05-
2005 Q3
Short-acting opioids
2005 Q1
Q3
04-
2004 Q3
Q1
2004 Q1
04-
2003 Q3
Q3
03-
2003 Q1
Year/Quarter
Q1
2002 Q3
03-
2002 Q1
Q3
02-
2001 Q3
Q1
2001 Q1
02-
2000 Q3
Q3
01-
2000 Q1
Q1
1999 Q3
01-
1999 Q1
Q3
00-
1998 Q3
Q1
1998 Q1
00-
1997 Q3
Q3
1997 Q1
99-
1996 Q3
Q1
99-
1996 Q1
Q3
98-
140
120
100
80
60
40
20
0
70
Q1
98-
MED (mg/day)
Q3
97-
Q1
97-
Q3
96-
Q1
96-

71. WA Workers' Compensation Opioid-related
Deaths 1995-2010
35
30
Opioid-related Death
25
20
15
10
5
0
Possible Probable Definite

72. Unintentional Prescription Opioid Overdose Deaths
Washington 1995-2010
600
500
420
Number of deaths
400
300
200
100 24
0
95
96
97
98
99
00
01
02
03
04
05
06
07
08
09
10
Prescription Opioid + alcohol or illicit drug
Prescription Opioid +/- Other Prescriptions
* Tramadol only deaths included in 2009, but not in prior years.
Source: Washington State Department of Health, Death Certificates

74. 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

75. 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

76. 38% Increase since 2001

77. 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!

78. 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)

79. 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-­‐
DOH
pain
management
rules,
2010
AMDG
Guideline
and
related
injuries
reflec@ve
of
the
prac@ce
standard
for
this
Supplement
are
prescribing
opioids
for
a
work-­‐related
injury
or
occupa@onal
disease.
79

80. Proper
and
Necessary
Care
Stop
and
Take
a
Deep
for
Breath
at
6
weeks
and
Clinically
Meaningful
Opioid
before
COT
Improvement
in
Prescribing
Func@on
Case
Defini@on
Managing
Surgical
&
Addic@on
Treatment
Pain
in
Workers
on
COT
Algorithms
for
Discon@nuing
COT
80

81. Disability Prevention is the Key
Health Policy Issue
100
80
%
of
cases
on
Bme
loss
60
40
20
0
0 1 2 3 4 5 6 7 8 9 10 11 12
Time
loss
duraBon
(months)
Adapted from Cheadle et al. Am J Public Health 1994; 84:190–196.!

82. Opioid
Use
in
Workers’
Compensa@on
• 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
Con@nuing
to
prescribe
opioids
in
the
absence
of
CMIF
or
aqer
the
development
of
– Evalua@on
of
clinically
meaningful
improvement
a
severe
adverse
outcome
is
not
proper
and
necessary
care.
In
addi@on,
the
use
of
escala@ng
doses
to
tccur
at
3dcri@cal
phases
(acute,
subacute
and
should
o he
point
of
eveloping
opioid
use
disorder
is
not
proper
and
during
COT)
necessary
care.
1

83. THANK
YOU!
For electronic copies of this
presentation, please e-mail
Laura Black
ljl2@uw.edu
For questions or feedback,
please
e-mail Gary Franklin
meddir@u.washington.edu