Joseph Paduda

Paduda Compliance with Narcotic Guidelines.pptx

Compliance with Narcotics Guidelines

April 10-12, 2012 Walt Disney World Swan Resort

Learning Objectives: 1. Describe how managed care programs, employers, health

care providers and insurers are susceptible to increased workers compensation costs due to prescription drug abuse.

2. Identify strategies employers and medical professionals can use to help drug-dependent and addicted employees regain control of their lives and return to work using results of CompPharmas survey, Prescription Drug Management in Workers Compensation The Eighth Annual Survey.

3. Describe how Washington State has addressed the over use of opioids in workers compensation.

Disclosure Statement

Joseph Paduda has disclosed that he has a relationship with Reckitt Benckisers Suboxone Sublingual Film and Millennium Laboratories.

Dr. Richard A. Victor has disclosed no relevant, real or apparent personal or professional financial relationships.

Agenda

The problem The impending disaster Efforts to prevent the disaster

Exhibit 5

0%

5%

10%

15%

20%

25%

Pcnt Scripts 1.2% 1.4% 1.9% 1.4% 1.8% 3.3% 5.5% 5.7% 5.8%Pcnt Pymts 4.3% 4.6% 6.5% 3.7% 4.2% 10.0% 17.7% 19.0% 19.6%

2002 2003 2004 2005 2006 2007 2008 2009 2010

Pharmaceutical Utilization & Cost - Schedule-II Opioid Drugs1

1 Calculations are on a calendar year basis

California Workers Comp Institute, Preliminary Results

383.3%

355.8%

Exhibit 6

Diagnostic Category

Pcnt of S-II Opioid Claims

Pcnt of S-II Opioid Scrips

Pcnt of S-II Opioid Pymnts

Medical Back w/o Spinal Cord Invlvmnt 35.7% 47.1% 50.2% Spine Disorders w/ Spinal Cord or Root Invlvmnt 11.3% 15.1% 16.1% Cranial & Peripheral Nerve Dis 5.0% 6.8% 6.5% Degen, Infect & Metabol Joint Dis 9.3% 6.1% 5.4% Other Injuries, Poisonings & Toxic Effects 5.5% 5.9% 6.8% Ruptured Tendon, Tendonitis, Myositis & Bursitis 6.0% 3.6% 2.7% Sprain of Shoulder, Arm, Knee or Lower Leg 6.8% 3.2% 2.8% Wound, FX of Shoulder, Arm, Knee or Lower Leg 6.3% 2.7% 1.6% Other Mental Disturb 1.2% 1.7% 1.5% Other Diagnoses of Musculoskeletal Sys 1.5% 1.4% 1.1%

CWCI 3/2011

Analysis of Prescribing Patterns Schedule II Opioids

Top Injury Categories w/ Schedule II Opioids

Exhibit 7

Pain Management and the Use of Opioids

Exhibit 8

Opioids are often used to treat pain

Background on Pain Management

Exhibit 9

CWCI - Pain Mgt and the Use of Opioids Distribution by Primary Diagnosis

ICD-9 Primary Diagnosis Claims Percent of

Sample 847.2 Sprain Lumbar Region 59,738 35.9% 846 Sprain Lumbosacral 25,334 15.2% 847 Sprain of Neck 24,950 15.0% 847.1 Sprain Thoracic Region 15,681 9.4% 724.2 Lumbago 9,449 5.7% 847.9 Sprain of Back NOS 4,935 3.0% 724.5 Backache NOS 5,208 3.1% 722.52 Lumbar/Lumbosacral Disc

Degeneration 3,542 2.1%

846 Sprain Lumbosacral 3,040 1.8% 723.1 Cervicalgia 2,963 1.8% Sub-Total 154,840 93.1%

Exhibit 10

Pain Mgt and the Use of Opioids

Distribution by Category of Number of Morphine Equivalents

Category

Average Number of Morphine

Equivalents in Category

Range of Number of Morphine

Equivalents in Category

No MEs 0 0

Category 1 124 3-240

Category 2 406 241-650

Category 3 1,207 651-2100

Category 4 14,870 2,101 and up

Exhibit 11 Pain Mgt and the Use of Opioids

Average Benefit Cost Outcomes

$0

$5,000

$10,000

$15,000

$20,000

$25,000

No MEs $6,733 $3,207 $3,526 Level 1 $6,499 $2,938 $3,561 Level 2 $10,550 $4,411 $6,139 Level 3 $14,950 $6,356 $8,594 Level 4 $20,389 $9,488 $10,901

Total Benefits Medical Indemnity

+203%

+196% +209%

Relationship Between Early Opioid Prescribing for Acute Occupational Low Back Pain and

Disability Duration Webster B Spine: September 2007

8443 claimants from a large WC database with new-onset, disabling LBP

Pts > 450 mg MEA were, on average, disabled 69 days longer than those who received no early opioids

Risk for surgery was 3 times greater and the risk of receiving late opioids was 6 times greater in the highest MEA group

Given the negative association between receipt of early opioids for acute LBP and outcomes, it is suggested that the use of opioids for the management of acute LBP may be counterproductive to recovery.

Narcotics NCCI Study

Opioids and Claim Outcomes Those who received more than 450 mg MEA were, on average,

disabled 69 days longer than those who received no early opioids (Webster et al, Spine 2007)

For the small group of workers with compensable back injuries who receive opioids longer-term (111/1843, 6%), opioid doses increase substantially and only a minority shows clinically important improvement in pain and function. The amount of prescribed opioid received early after injury strongly predicts long-term use. (Franklin et al, Clin J Pain 2009)

Average claim costs of workers receiving seven or more opioid prescriptions were three times more expensive than those of workers who receive zero or one opioid prescription, and these workers were 2.7 times more likely to be off work and had 4.7 times as many days off work (Swedlow et al CWCI Special Report 2008)

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

Population-based, prospective cohort N=1843 workers with acute low back injury and at least 4

days lost time 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, after adjustment for pain, function, injury severity

Cost of Addiction

Drug cost - $1000 - $12,000/month Associated drug costs for treating depression,

constipation, alertness, insomnia Associated medical costs Extended disability duration Settlement expense

Large regional insurer 48,000 claimants on opioids >180 days

Rating agencies and actuaries havent fully grasped the impact

These claimants: arent going back to work are likely addicted/dependent wont settle their claims

The impending disaster

2011 Survey of Pharmacy Management in Workers Comp

20 payers, in-depth survey of decision makers and implementers

Ranged from very large national players to state funds to TPAs Covering 19% of total WC premium and equivalents

Focused on assessing awareness and level of concern defining the problem identifying solutions assessing program results

Respondents views on narcotics (1-5 scale)

Rated a 4.8 - very significant problem (highest score recorded in eight years of the Survey)

Concern about risk of addiction/dependency - 4.4, very concerned 60% rated this a 5, extremely concerned

Over a quarter said opioids are the single biggest problem in work comp pharmacy management

Level of concern is higher than last year

Narcotics - Respondent Quotes

It is not curing the problem, just temporary relief and it is being used as long-term treatment causing major dependency and death in some cases

Because they are addictive and opioids don't necessarily control pain; long term use is not efficacious; once addicted, they become the pain generator; too much influence / pressure on docs to prescribe; utilization is a problem; our programs have been built on pricing, yet utilization is the real driver of cost, not price; so the more the doc does, the more he gets paid; it is a never ending cycle; we are not getting good quality medicine; only 15-20% docs are aware of evidence based protocols

Respondent quotes

Partly nature of the business; in an injury-driven line of insurance, that increases the potential exposure to opiates; also related to a certain mentality that exists among providers that equates comp with a difference in how they manage pain vs. a non comp patient; there is a misperception on what the expectations are for treatment (by injured worker) that the absence of pain means will go back to a pre-injury status; often that is not realistic in terms of the injury; there is a high demand for opiates because they expect to get back to a pain-free state; often that is not possible

Respondent Quotes

Socially driven; providers trying to get claimants out of their office; think wc is a very pain-focused environment and wanting to relieve pain, but don't understand what's driving the pain...too many factors out of control involving all parties - providers, injured workers, wc environment

Too many claimants are treating with physicians that don't really understand how to deal with pain management; there are too few pain management experts in the industry; seldom discontinue usage of opioids without looking at functionality of injured workers; disconnect between functionality and what they are prescribing; so it is a physician - driven problem - don't know how to deal with ongoing pain

Respondent quotes

Most work comp injuries are going to include a script for pain; you have people who never get off of [their pain drugs and payers] continue to fill them, they become dependent on them; the longer the injured worker is on a narcotic, the less likely they are to RTW; many jobs can't return to if on narcotics

Our concern is that it may increase disability as well risk associated with chronic use of opioids; sleep apnea, risk of abuse and addiction, and possibly death

Pharmacy Management Programs

>75% had implemented significant changes to their pharmacy management programs in 2010

Primarily clinically oriented; identification of potentially problematic claimants, physicians, medications

Tighter formularies

Improved tracking of narcotics, coordination of efforts around narcotics especially for long term users

New programs/initiatives

Every single clinical utilization management tool that our PBM offers

Developed a program called "[proprietary]" that looks at people who are first time narcotic users; chronic narcotic users; high dollar cost products being used; antidepressants and anti-psychotic meds controlling our formulary and utilization; re: utilization

Hired a nurse for our precertification dept; dedicated to pain management program; also a separate nurse works with PBM to review every request for pre-authorization; these nurses are on our staff

New programs/initiatives

Implemented a narcotic focus program; doing a lot of work re: injured workers taking narcotic meds; also did some work re: looking at utilization of drugs within work injury claims and doing some work with utilization review

Increased custom reporting to fraud; clinical escalation alerts when drugs fall outside of formulary; enhanced our process with handling on clinical side for long acting opioids in first dispense; approved alert to adjuster to notify them of an of aforementioned conditions / issues

One states solution

Washington developed pilot dosing guidelines in 2007

Opioid dosing guidelines signed into law in 2010, effective in 2011

PDMP began 1/1/2012

28

WA 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 patient is taking prescribed drugs Identifies non-prescribed drugs

Do not use concomitant sedative-hypnotics Track pain and function to recognize tolerance Seek help if dose reaches 120 mg MED, and pain and function have

not substantially improved

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

29

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

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Yearly Trend of Scheduled Opioids

Schedule II Schedule III Schedule IV

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Percent of Timeloss Claimants on Opioids 2000 - 2010

Opioids Highdose Opioids

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60

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120

140

1996 Q1

1996 Q3

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ME

D (m

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Average Daily Dosage for Opioids, Washington Workers Compensation, 19962010

Long-acting opioids

Short-acting opioids

Year/Quarter

96-Q

1

96-Q

3

97-Q

1

97-Q

3

98-Q

1

98-Q

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99-Q

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25

30

35

Opi

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WA Workers' Compensation Opioid-related Deaths 1995-2010

Possible Probable Definite