Focus on Opioids

Thursday, October 30, 2014 | 0

The California Division of Workers’ Compensation has yet to unveil opioid guidelines, though a draft was circulated for public comment in April.

The DWC isn’t the only California agency working on the topic.

CA DWC drafts opiod guidelines (image via shutterstock)

The Medical Board of California posted a draft in September titled “Guidelines for Prescribing Controlled Substances for Chronic Pain.”

The background for all of this is increased national concern about prescription drug abuse. The Medical Board analysis notes that:

“In 2013, the Centers for Disease Control and Prevention declared prescription drug abuse to be a nationwide epidemic. Drug overdose is now the leading cause of accidental deaths, exceeding deaths due to motor vehicle accidents. A majority of those overdose deaths involved prescription drugs. The diversion of opioid medications to non-medical uses has also contributed to the increased number of deaths, although the problem is not limited to the aberrant, drug-seeking patient. Injuries are occurring among general patient populations, with some groups at high risk (i.e., those with depression). Consequently, the Board called for revision of the guidelines to provide additional direction to physicians who prescribe controlled substances for pain."

Those conclusions are not just academic. In my workers' comp practice I have had two clients who died from overdoses.

Nationally, a 2012 multi-state study by NCCI (the National Council on Compensation Insurance) claimed the following findings:

• Narcotics costs per claim were increasing.
• The share of medical claims receiving narcotics within one year after injury has increased.
• The top 1% of narcotics users consume 40% of all narcotics.
• Claims continuing to receive narcotics receive higher morphine equivalent amounts.
• Early narcotic use is indicative of prolonged use.

A 2012 study of 21 states by the Workers Compensation Research Institute claimed that there was low compliance with prescription guidelines in most states.

In California a 2011 study by the California Workers’ Compensation Institute documented that from 2005 to 2008 payments for Schedule II narcotics rose from 2% to 18% of all California workers’ comp prescription payments.

The goal of many of these studies is not to stigmatize workers who truly need extraordinary pain relief. Rather, the goal is to make sure that pain-relieving meds are delivered to the right patients under the right circumstances and for the right reasons.

By 2012 there was much alarm on this issue from many stakeholders. Greg Jones of WorkCompCentral noted in an Oct. 2, 2012, piece that opioids were an issue on the table in the pre-SB 863 reform talks. Specific opioid regulations were eventually dropped from the SB 863 negotiations, but at the time the proposal discussed would have required the following:

• A statement that nonopioid analgesics were not successful during a trial period.
• A functional assessment of the injured worker.
• Drug screening before the drugs were subscribed.
• A statement of specific reasons for prescribing opioids.
• That treatment alternatives be listed and an explanation given for why those were not tried.
• Listing of treatment goals.
• A written “opioid agreement” signed by the injured worker.

Interestingly, many of those requirements listed in the pre-SB 863 draft are recommended in the September 2014 Medical Board of California draft.

Since 2012, what has occurred in California on this subject?

A May 2014 CWCI study did show some modulation in use of Schedule II opioids, though usage of Schedule II opioids (including oxycontin, fentanyl and morphine) was nearly six times the proportion of California prescriptions (at 7.3%) when compared to 2002. Schedule II medications amounted to one-fifth the cost of all California workers’ comp prescriptions. According to the CWCI, Schedule III pain medications are about 20% of the total prescriptions and between 10% to 11% of total prescription spending.

CWCI sounded the alarm, claiming that almost half of all Schedule II drugs prescribed in the 2012/2013 sample “were for relatively minor injuries for which use of these drugs is not supported by evidence-based medicine.”

Further, CWCI seemed to indicate that a relatively small number of doctors might be  overprescribing. According to CWCI, in the 2012/2013 sample the top 10% of prescribing doctors were prescribing 82% of Schedule II meds which cost 86% of the associated payments.

This sort of data has added fuel to the debate in the California comp system over opioids. But as noted above, it is a debate raging nationally and not just in workers’ comp.

In the past few years there has been controversy about the California Controlled Substance Utilization Review and Evaluation System (CURES) database. Physicians will now be required to join the CURES system, but are not currently required to actually check the CURES database before prescribing.

For now there are no final regs from the DWC or Medical Board, but we may see further action soon.

Currently, the Medical Board’s Guidelines are just that, a draft. But those guidelines will provide further steam for adoption of whatever the DWC decides to adopt.

According to the Medical Board of California draft:

“There are differing opinions among reputable experts and organizations as to what MED should trigger a consultation. The Board recommends that physicians proceed cautiously (yellow flag warning) once the MED reaches 80 mg/day. Referral to an appropriate specialist should be considered when higher doses are contemplated."

Meanwhile, there is increasing discussion among some stakeholders as to whether California should adopt a formulary. How a formulary would be designed and the interaction between yet-to-be promulgated opioid guidelines and any formulary is likely to be a subject of intense future analysis.

Here is a link to the Medical Board of California draft.