By the Numbers: Opioid Use in Nevadadir.nv.gov/.../content/WCS/TrainingDocs/OpioidUseInWCClaims.pdf · Opioid Use in Nevada Presented by: Raji Chadarevian, Manager & Associate Actuary,

© Copyright 2017 National Council on Compensation Insurance, Inc. All Rights Reserved.

By the Numbers:Opioid Use in NevadaPresented by:Raji Chadarevian, Manager & Associate Actuary, NCCISusan Schulte, Department of Labor Focus Lead, NCCI

August 25, 2017


DISCLAIMER

The views and opinions expressed in the written materials and inany of the presentations at this conference are those of thepresenter and do not necessarily reflect the official policy orposition of the Department of Business and Industry, Division ofIndustrial Relations. The Division does not warranty thematerials’ completeness or accuracy.

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Agenda

Overview of Nevada’s Medical

Data Report

Take a closer look at prescription

drugs

Dive deeper into opioids

3


Workers Compensation (WC) Average Medical Lost-Time Claim Severity

Private Carriers and State Funds—NCCI States

p Preliminary based on data valued as of 12/31/2016Source: NCCI’s Financial Call data, developed to ultimate, excludes high-deductible policies; based on data through 12/31/2015Values displayed reflect the methodology underlying the most recent rate/loss cost filingIncludes all states where NCCI provides ratemaking services; WV is excluded through 2007

$27.7

$29.1

-1.4%+5%

5

10

15

20

25

30

35

95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16p

Severity ($ Thousands)

Accident Year

Medical costs were growing—almost 60% of the total claim cost Average medical cost per lost-time claim increased:

1995: $8,900 to 2016: $29,100 Average medical share of claim grew

1985: 45% to 2015: 58%

4


WC Average Medical Lost-Time Claim SeverityAverage Annual Change 2011–2015, Private Carriers and State Funds—NCCI States

Source: NCCI’s Financial Call data, developed to ultimate, excludes high-deductible policies; based on data through 12/31/2015Values displayed reflect the methodology underlying the most recent rate/loss cost filingIncludes all states where NCCI provides ratemaking services

+10%

–10%

5


Medical Cost Containment: Prices

6


Medical Share of Total Benefit Costs

Source: NCCI Medical Data Call, Service Year 2015 Countrywide includes data for the following states: AK, AL, AR, AZ, CO, CT, DC, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MD, ME, MO, MS, MT, NC, NE, NH, NM, NV, OK, OR, RI, SC, SD, TN, UT, VA, VT, and WV

51%

50%

47%

49%

52%

53%

55%

54%

55%

52%56

%

56%

56%

57%

57%

58%

58%

58%

58%

58%

0%

10%

20%

30%

40%

50%

60%

70%

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Perc

ent

Accident Year

Nevada Countrywide

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Why NCCI Collects Medical Data

State regulators were asking why the medical costs were increasing Searching for information on cost containment measures and

their effectiveness (e.g., fee schedules)

NCCI didn’t have sufficient data to address the rising medical costs

NCCI began collecting Medical data the latter part of 2010 (test data)

The first Medical Data Report was created at the end of 2012 to assist states in understanding the medical cost drivers in workers compensation claims

8


Medical Data Reports A standard report was developed providing the same information for each

state

Data in this presentation represents medical transactions for Service Year 2015 Medical services delivered from January 1, 2015, to December 31,

2015

Insurance carriers must report if they write at least 1% of the market share in any one state for which NCCI is the advisory organization

Data is reported under the jurisdiction state—the state under whose WC Act the injured worker’s benefits are being paid

Medical transactions must continue to be reported until the transactions no longer occur The claim is closed or 30 years from the accident date

9


Medical Data Reports

Wherever possible, standard industry codes are used because they provide a clear definition of the data, increase efficiency of computer systems, and improve the accuracy and quality of the data

Lump-sum settlements are not required to be reported

Self-insured data is not included

10


Medical Payments Distribution

Distribution of medical payments by type of service Provides insight into the growth in medical benefits

Payments are categorized based on a combination of procedure code, place of service, and taxonomy code Drugs Durable Medical Equipment (DME), Supplies, and Implants Other—home health, transportation, vision, and dental Physicians Hospital Outpatient Hospital Inpatient Ambulatory Surgical Centers (ASC)

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Physicians, 54%

Hospital Outpatient, 9%

Hospital Inpatient, 7%

Ambulatory Surgical Centers,

3%

Drugs, 13%

DME, Supplies & Implants, 8%

Other, 6%

Nevada

Nevada Distribution of Medical Payments

Source: NCCI Medical Data Call, Service Year 2015

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Medical Payments Distribution

Source: NCCI Medical Data Call, Service Year 2015Region includes AZ, CO, NM, and UT. Countrywide includes data for the following states: AK, AL, AR, AZ, CO, CT, DC, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MD, ME, MO, MS, MT, NC, NE, NH, NM, NV, OK, OR, RI, SC, SD, TN, UT, VA, VT, and WV

13


Prescription Drugs

Drugs are identified by a national drug code (NDC)

Drug information contained in the Medical Data Report are for drugs with an NDC, whether the drugs are provided in a pharmacy, physician’s office, hospital, or other place of service

Drugs make up 13% of the total medical costs in Nevada Region—11% Countrywide—11%

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Nevada—Prescription Drugs

Information provided in the Medical Data Report includes the top 10 drugs listed by the amount paid and by prescription counts.

Name of the drug

Brand name or generic

Category of drug (muscle relaxant, analgesic, etc.)

Percentage of total drug payments

Price per unit for the state, region, and the countrywide (CW) average

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Nevada—Paid Amount

Name of DrugType B/G Category

% of Drug Payments

PPU Nevada

PPU Region

PPU Countrywide

Oxycontin® B Analgesics/Antipyretics 6.7% $9.00 $7.47 $7.76

Oxycodone HCl-Acetaminophen G Analgesics/Antipyretics 6.2% $1.97 $1.63 $1.83

Lyrica® B Miscellaneous Central Nervous System Agents 5.5% $5.38 $5.43 $5.54

Hydrocodone Bitartrate-Acetaminophen

G Analgesics/Antipyretics 3.6% $0.60 $0.60 $0.61

Oxycodone HCl G Analgesics/Antipyretics 3.3% $1.25 $1.12 $1.15

Gabapentin G Anticonvulsants 3.2% $1.06 $1.19 $1.25

Lidocaine GAntipruritics/Local Anesthesia, Skin/Mucous Membrane

3.0% $6.16 $6.54 $7.08

Morphine Sulfate G Analgesics/Antipyretics 2.4% $2.07 $2.71 $2.42

Opana ER® B Analgesics/Antipyretics 1.8% $9.71 $9.41 $9.91

Duloxetine HCl G Psychotherapeutic Agents 1.7% $4.59 $5.29 $5.41

Top 10 Workers Compensation Drugs in Nevada by Amount Paid


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Countrywide—Paid Amount



% of Drug Payments

PPU Nevada

PPU Region

PPU Countrywide


Oxycontin® B Analgesics/Antipyretics 4.8% $9.00 $7.47 $7.76



Meloxicam G Analgesics/Antipyretics 3.5% $3.06 $3.05 $3.34

Tramadol HCl G Analgesics/Antipyretics 3.0% $0.73 $1.01 $1.21



Duloxetine HCl G Psychotherapeutic Agents 2.7% $4.59 $5.29 $5.41

Celecoxib G Analgesics/Antipyretics 2.3% $4.79 $5.03 $5.24

Lidocaine GAntipruritics/Local Anesthesia, Skin/Mucous Membrane

2.2% $6.16 $6.54 $7.08

Top 10 Workers Compensation Drugs Countrywide by Amount Paid

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Nevada—Rx Counts


% of Drug Prescriptions

PPU Nevada

PPU Region

PPUCountrywide




Cyclobenzaprine HCl G Muscle Relaxants, Skeletal 4.9% $0.95 $1.02 $1.32

Ibuprofen G Analgesics/Antipyretics 4.2% $0.60 $0.48 $0.46




Naproxen G Analgesics/Antipyretics 2.9% $1.06 $0.91 $0.93

Carisoprodol G Muscle Relaxants, Skeletal 2.7% $0.43 $0.50 $0.60

Ibu® B Analgesics/Antipyretics 2.1% $0.30 $0.27 $0.26

Top 10 Workers Compensation Drugs in Nevada by Prescription Counts


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Countrywide—Rx Counts



PPU Nevada

PPU Region

PPUCountrywide




Cyclobenzaprine HCl G Muscle Relaxants, Skeletal 5.0% $0.95 $1.02 $1.32



Meloxicam G Analgesics/Antipyretics 3.9% $3.06 $3.05 $3.34

Ibuprofen G Analgesics/Antipyretics 3.8% $0.60 $0.48 $0.46


Naproxen G Analgesics/Antipyretics 2.3% $1.06 $0.91 $0.93


Top 10 Workers Compensation Drugs Countrywide by Prescription Counts


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Schedule Drugs

Drugs are grouped into five different schedules depending on certain qualifications, including the drug’s medical use and potential for abuse

Schedule V drugs have the lowest potential for abuse (some cough medicines that contain small amounts of codeine) while Schedule I drugs are basically illegal (no prescriptions may be written for the drug; e.g., heroin)

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$21.1M (25%)

$2.3M (3%)

$6.4M (8%)

$5.6M (7%)

$48.9M (57%)

Region

Schedule 2 Schedule 3 Schedule 4 Schedule 5 Non - Controlled

$156.5M (23%)

$13.2M (2%)

$48.1M (7%)

$42.5M (6%)

$416.7M (62%)

Countrywide


$3.8M (34%)

$0.3M (2%)

$0.6M (6%)

$0.6M (6%)

$5.9M (52%)

Nevada


Schedule Drugs

Source: NCCI Medical Data Call, Service Year 2015Region includes AZ, CO, NM, and UT; Countrywide includes data for the following states: AK, AL, AR, AZ, CO, CT, DC, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MD, ME, MO, MS, MT, NC, NE, NH, NM, NV, OK, OR, RI, SC, SD, TN, UT, VA, VT, and WV

The Medical Data Report contains charts that show the distribution of prescription drug costs by Controlled Substance Act schedule.

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Opioid Use in Nevada


Opioid Use in Nevada

• Opioids and Workers CompensationNevada Laws

• Utilization Trends• Cost Trends

Current Opioid Statistics

• Opioids and Benzodiazepines (Benzos)Concurrent Usage

• Trends in “heavy” usersMorphine Milligram Equivalents

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Nevada Laws: Opioid Controls

Several characteristics of Nevada’s opioid prescribing laws:

Nevada does not limit the quantity that a practitioner can prescribe for CII prescriptions or for any drug

Nevada State Board of Nursing follows the CDC Guideline for Prescribing Opioids for Chronic Pain

Nevada was one of seven states selected to participate in the 2014 Prescription Drug Abuse Reduction Policy Academy Nevada established a taskforce to research prescription

drug abuse in September 2014

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Nevada Laws: Opioid Controls

Nevada’s fight against the epidemic was changed in 2015 when the governor signed SB 459.

This act addressed physician education, Prescription Drug Monitoring Program (PDMP) utilization, Good Samaritan Immunity Laws, and access to the life-saving drug Naloxone

The Nevada PDMP is a database used by pharmacists and doctors to keep track of patients who are prescribed controlled substances

The PDMP helps dispensers identify recipients who may be “doctor shopping” or otherwise cheating the system

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Drug Overdose Death Rates by State in 2015

Source: https://www.cdc.gov/drugoverdose/data/statedeaths.html

Rate per 100,000 people(age-adjusted)

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Nevada Opioid Deaths in 2013

Source: Substance Abuse Prevention and Treatment Agency (SAPTA), Nevada Division of Public and Behavioral Health http://dpbh.nv.gov/uploadedFiles/dpbhnvgov/content/Programs/ClinicalSAPTA/Docs/Opioid Deaths Inforgraphic.pdf

Home, 63%

Out-Patient, ER or Trauma

Center, 12%

Inpatient, 8%

Nursing Homes and Other

Patient Care, 1%

Other, 16%

Location of Pronouncementof Death

Accident84%

Suicide11%

Homicide1%

Unknown4%

Manner ofDeath

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© Copyright 2017 National Council on Compensation Insurance, Inc. All Rights Reserved. 29

Prescription Drug Misuse in Nevada in 2013

Nevada has some of the highest rates of prescription painkillers sold and drug overdose deaths per capita.

2nd highest for hydrocodone (e.g., Vicodin and Lortab)

2nd highest for oxycodone (e.g., Percodan and Percocet)

4th highest for methadone

7th highest for codeine

4th highest drug overdose mortality

Source: Substance Abuse Prevention and Treatment Agency (SAPTA), Nevada Division of Public and Behavioral Health http://dpbh.nv.gov/uploadedFiles/dpbhnvgov/content/Programs/ClinicalSAPTA/Docs/PD Infographic x2.pdf


Current Opioid StatisticsWorkers Compensation


Current Drug Statistics

Source: NCCI Medical Data Call

Nevada Service Year 2015 All Rx Claims

Number of Claimants 11,865

Number of Scripts 82,996

Average Scripts per Claim 7

Paid Amount—All Rx’s $ 11,312,059

Average Rx Paid per Claim $ 953

An Rx claim is a workers compensation claim with at least one prescription drug in the corresponding year

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NevadaService Year 2015

Opioid Claims

Number of Claimants 5,586

Number of Scripts—Opioids 25,672

Average Opioid Scripts per Claim 5

Paid Amount—Opioids $ 3,928,397

Average Opioid Paid per Claim $ 703

A claim is classified as an “Opioid Claim” if the claimant received at least one opioid script in the service year

Those who have received at least one opioid and at least one benzo will be referred to as “Opioid Claims With Benzos” further on in this report

NCCI Proprietary and Confidential - Not For Distribution

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Nevada—Opioid Paid Amount

Name of Opioid DrugType B/G

% of Drug Payments

PPU Nevada

PPU Region

PPU Countrywide

Oxycontin® B 6.7% $9.00 $7.47 $7.76

Oxycodone HCl-Acetaminophen G 6.2% $1.97 $1.63 $1.83


G 3.6% $0.60 $0.60 $0.61

Oxycodone HCl G 3.3% $1.25 $1.12 $1.15

Morphine Sulfate G 2.4% $2.07 $2.71 $2.42

Opana ER® B 1.8% $9.71 $9.41 $9.91

Percocet® B 1.5% $12.59 $11.36 $12.10

Oral Transmucosal Fentanyl Citrate G 1.3% $19.55 $22.16 $20.40

Tramadol HCl G 1.2% $0.73 $1.01 $1.21

Fentanyl G 0.9% $23.55 $23.61 $21.62

Top 10 Workers Compensation Opioid Drugs in Nevada by Amount Paid


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Nevada—Opioid Rx Counts

Name of Opioid DrugType B/G


PPU Nevada

PPU Region

PPU Countrywide

Hydrocodone Bitartrate-Acetaminophen G 11.0% $0.60 $0.60 $0.61

Oxycodone HCl-Acetaminophen G 5.3% $1.97 $1.63 $1.83

Tramadol HCl G 3.3% $0.73 $1.01 $1.21

Oxycodone HCl G 3.0% $1.25 $1.12 $1.15

Morphine Sulfate G 2.0% $2.07 $2.71 $2.42

Oxycontin® B 1.3% $9.00 $7.47 $7.76

Methadone HCl G 1.0% $0.22 $0.23 $0.26

Acetaminophen-Codeine Phosphate G 0.5% $0.39 $0.44 $0.43

Hydromorphone HCl G 0.5% $1.09 $1.17 $2.29

Opana ER® B 0.4% $9.71 $9.41 $9.91

Top 10 Workers Compensation Opioid Drugs in Nevada by Prescription Counts


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60% 20% 4% 3% 12%

Distribution of Opioid Scripts by Claim Maturity

<= 1 2-5 6-10 11-15 16+


Source: NCCI Medical Data Call, Service Year 2015

Note: Maturity refers to the numbers of years subsequent to the injury.

35




Opioid Claims Without Benzos,

43%

Opioid Claims With Benzos, 4%

Other, 53%

Claim Distribution—Service Year 2015

36


Opioid Utilization Trends


58% 56%53% 54%51% 53%

50% 50%47% 46%

Nevada Region

Share of Drug Claims With at Least One Opioid ScriptBy Service Year

2011 2012 2013 2014 2015

Note: The Region contains the states of AZ, CO, NM, and UT.

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Service Year 2015Opioid Claims All Rx Claims

Nevada Region Nevada Region

Average Number of Opioid Scripts 4.6 4.2 2.2 1.9

Average Number of Non-Opioid Scripts 6.6 6.3 4.8 4.6

Average Number of Scripts 11.2 10.5 7.0 6.6


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5.6

4.6 5.3

4.4 4.7 4.3

4.8 4.3 4.6

4.2

Nevada Region

Average Number of Opioid Scripts per Opioid ClaimBy Service Year

2011 2012 2013 2014 2015


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36%

34%33%

32%31%

Service Year

Opioid Share of Total Scripts—Nevada2011 2012 2013 2014 2015

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Opioid Cost Trends


42%38%

34% 35% 35%

Service Year

Opioid Share of Total Rx’s Paid—Nevada2011 2012 2013 2014 2015

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Opioid Cost Trends


$800

$473

$701

$441

$611

$441

$703

$546

$703 $576

Nevada Region

Average Opioid Paid per Opioid Claim by Service Year

2011 2012 2013 2014 2015


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Concurrent Usage of Opioids and Benzodiazepines


Concurrent Use of Opioids and Benzos

According to a report published by the British Medical Journal (BMJ) “benzodiazepines enhance the effects of opioid painkillers, which means this drug combination has a high potential for abuse.”

“The BMJ study found that, of 2,400 veterans in the study’s population who died because of a drug overdose while taking opioid painkiller prescriptions, 49 percent had been concurrently prescribed benzodiazepines.”

Source: http://americanaddictioncenters.org/prescription-drugs/dangers-of-mixing/




Service Year 2015Opioid Claims No Benzos Opioid Claims With Benzos

Nevada Region Nevada Region

Average Number of Opioid Scripts 4.2 3.8 10.0 8.7

Average Number of Non-Opioid Scripts 5.3 5.2 22.4 18.9

Average Number of Scripts 9.4 9.0 32.5 27.6


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22%20%

16% 17%

Nevada Region

Share of Opioid Scripts for Opioid Claims With Benzos

2011 2012 2013 2014 2015

In both Nevada and the region, 4% of prescription drug claimants received at least one opioid and at least one benzo

In Nevada, during 2015, 16% of opioid scripts went to the 4% of claimants that were prescribed both an opioid and a benzo


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Morphine Milligram Equivalents


MME? If you google “MME,” you get

just under 100 million results Here are the top three: Midwest Motor Express French for “Mrs.” Membrane

Metalloendopeptidase, a gene If you google “MME drugs,” you

get just under 400 thousand results

First among them: MME (psychedelic)—Wikipedia 2,4-dimethoxy-5-

ethoxyamphetamine

48


MME Opioids

Morphine

Milligram

EquivalentsFor example,

Fentanyl patch(mcg/hr)

2.4

Codeine(mg/day)

0.15

Oxycodone(mg/day)

1.5

The Centers for Disease Control and Prevention(CDC) provides a way to convert daily, or hourly,doses of opioids to an equivalent daily dose ofmorphine by assigning a conversion factor toeach type of drug

Source: https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf

49


Morphine Milligram EquivalentsOpioid Use in Nevada


2,0101,896

1,7381,624 1,650

Service Year

Average MMEper Opioid Script

2011 2012 2013 2014 2015

5.65.3

4.7 4.8 4.6

Service Year

Average Opioid Scripts per Opioid Claim

2011 2012 2013 2014 2015

Note: The average MME per opioid script has been falling, as well as the average number of opioid scripts per claim.However, the average MME per opioid script increased in SY 2015 (though still below the SY 2013 average).

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11,2899,995

8,256 7,732 7,585

Service Year

Average Yearly MME per Opioid Claim

2011 2012 2013 2014 2015

This chart shows the average yearly amount of MME prescribed to a claimant with at least one opioid Rx

From 2011 to 2015, there has been a 33% drop in the yearly MME-per-opioid claim

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The top 20% of claims in Nevada included about 93% of the total MME prescribed during Service Year 2015.

80.3%

12.6%

3.6%

1.5%2.0%

Distribution of MME by Claim Quintile

90%–100% 80%–90% 70%–80% 60%–70% 60% and Below

52



A claimant who consumed 100 MME per day for each day of the year would have a yearly MME consumption of 36,500

For service year 2015, average “heavy users" were prescribed about 1.7 times more the MME of such a user


90,58080,619

67,272 62,148 60,831

2,492 2,175 1,739 1,679 1,664

2011 2012 2013 2014 2015

Service Year

Average Yearly MME Prescribed per Opioid Claim

Top 10% Bottom 90%


Concluding Remarks

Opioid use in Nevada’s workers compensation system is on a mild decline•The share of claims with an opioid

continues to decrease•The number of opioid prescriptions per

opioid claim is also declining

Nevada’s opioidpaid-per-opioid claim hasbeen slowly convergingto what the region pays

Roughly one in five opioidscripts goes to the 4% of

claimants who were concurrently prescribed both

an opioid and a benzo

From 2011 to 2015,there has been a33% drop in the

MME-per-opioid claim

NCCI Proprietary and Confidential - Not For Distribution

54


By the Numbers: Opioid Use in Nevadadir.nv.gov/.../content/WCS/TrainingDocs/OpioidUseInWCClaims.pdf · Opioid Use in Nevada Presented by: Raji Chadarevian, Manager & Associate Actuary,

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