Editor’s Note: This is part of a team report on opioid use by injured workers. For the national story read: Opioid Epidemic Plagues Workers’ Comp
Washington and California are among states in the U.S. Western Region that have publicly struggled with opioid abuse in workers’ compensation.
In California, home to one-in-eight Americans, just 3 percent of the state’s doctors prescribe 55 percent of the opioids, according to findings from the California Workers’ Compensation Institute.
California has seen a large increase in opioid prescriptions over the last decade, according to CWCI, which has been tracking opioid usage in workers’ comp for the past eight years.
Between 2002 and 2011 CWCI tracked a 300 percent increase in opioids, according to CWCI President Alex Swedlow.
In 2002 roughly 1 percent of all injured worker outpatients were prescribed opioids. By 2011 it was 5 percent, and payments for opioid prescriptions rose from 4 percent to 18 percent during that period, according to Swedlow.
“That’s a 321 percent increase in payments,” he added.
Driving these escalations were not more workers being injured, nor were there more injuries that warranted doctors prescribing more painkillers, according to Swedlow.
“It really had no significant relationship to changes in workplace injuries,” he said. “They were just prescribing more.”
CWCI published a study in 2008 that looked at different levels of opioid prescriptions and different workers’ comp claim outcomes. The study population consisted of a sample of 166,336 workers’ comp claims for back conditions without spinal cord involvement with dates of injury between 2002 and 2005.
What it found was the higher the dose level the worse the outcome. Higher dosage equated to higher cost, more time out of work, and more litigation.
Average claim costs of workers receiving seven or more opioid prescriptions were three times more expensive than workers who received one or no opioid prescription, and those workers receiving more opioids were 2.7 times more likely to be off work and had 4.7 times as many days off work, according to the study.
The study shows the likelihood of indemnity payments among claims with no filled opioid prescriptions was 34 percent. When there was one opioid prescription, the likelihood of rose to 56 percent, and when there were two or three opioid prescriptions, the likelihood of indemnity payments was more than 86 percent. That likelihood rose to nearly 90 percent among claims that had four to seven opioid prescriptions, according to the report.
Washington is in the process of introducing a set of more stringent guidelines for workers’ comp medical providers that detail when opioids should and shouldn’t be prescribed, as well as consequences for failure to follow these best practices.
Washington has been among the states with the highest rate of prescription opioid-related deaths, according to a CDC, which reports on the U.S. and the rate of death from overdoses, and it breaks out opioids.
The latest report shows there are 14.7 drug overdose deaths per 100,000 population in Washington. Of those, 6.1 per 100,000 were opioid related overdoses, according to the report. The report shows the national average for drug overdose deaths was 11.9 per 100,000, with opioids accounting for 4.8 per 100,000.
New Mexico (27.0, and 5.7), West Virginia (25.8, 5.9) and Kentucky (17.9, 6.0) were among the top states with drug overdose and opioid-related deaths, according to the report.
That report was one of the factors that prompted the state to take action, said Jaymie Mai, pharmacy manager for Washington’s Department of Labor & Industries.
“We’re in the higher tier states,” Mai said.
Washington is now taking action to limit opioid prescription for injured workers to when such drugs can help bring about a “clinical meaningful improvement in function and pain,” Mai said.
They are also setting triggers for when opioids should be used to set a clear bar for when such potent pain relievers should be prescribed, she said.
“We want to balance the use of opioids with all the risk that comes,” Mai said. “I think what we’ve seen in the last 10 years or so there’s been an uptick in the use of opioids. And when we look at our data there’s been an uptick in the use of Schedule II opioids.”
The department’s stance is that ensuring best practices is the best place to start. The department closed a public comment period in late April on proposed rules, which are based on the new guidelines approved by the state’s Industrial Insurance Medical Advisory Committee – the committee is comprised of practicing providers in state, and its role is to help create treatment guidelines.
The committee adopted the guidelines in October, 2012 and the department began the rulemaking process in January when the guidelines were published.
“Our primary focus is that these rules will help providers prescribe opioids in an effective and safe manner,” she said.
Medical providers who don’t follow the best practices can face a variety of corrective steps. In cases of imminent harm, the patient can be removed from the provider’s care, or where a pattern of harm is established the provider can be removed from the network.
During the acute phase following a workplace injury the guidelines advise medical providers to set expectations about clinical improvement required for continued payment of pain medication. Providers are also being encouraged to check the state’s prescription monitoring program database before prescribing opioids for new injuries.
During the subacute phase, six to 12 weeks from injury, providers are being asked to assess whether there is clinical improvement in function and pain with acute use and for opioid risk and psychological comorbidity disorders.
The guidelines also address the chronic phase, greater than 12 weeks from injury.
Terms echoed throughout the guidelines encourage the use of pain medications for “clinically meaningful improvement in function,” and “clinically meaningful improvement in pain” and set standards and definitions for those terms.
Providers are required to administer a urine drug test and document results during the subacute phase and repeat this at intervals according to a worker’s risk category as described in the agency medical directors’ group’s guideline if prescribing chronic opioid therapy.
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