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"This is a big issue," said Swedlow, executive vice president for research at the California Workers' Compensation Institute. "We've been talking with senior people in Washington, D.C., who are very interested in possible solutions at the federal level."

The report is believed to be the first to examine the prescribing patterns of workers' comp medical providers and the injured workers getting the prescriptions. It was based on an analysis of nearly 17,000 California workers' comp claims incurred between January 1993 and December 2009 and included a total of more than 9,000 physicians.

• 3 percent of the prescribing physicians -- 93 -- were responsible for 65 percent of Schedule II narcotics costs.
• The top 10 percent of injured workers receiving Schedule II morphine equivalents obtained their scripts from an average of 3.3 different physicians, compared to 1.9 doctors for all claims.
• The top 10 percent of injured workers receiving the drugs are getting average levels of morphine equivalents per claim that are consistent with an increased risk for overdose and addiction.

The study also revealed the top 12 diagnosis categories in California's workers' comp system for which Schedule II opioids are prescribed. The top one was minor back problems.

"It's just bad medical practice," said Joe Paduda, principal of Health Strategy Associates, a pharmacy benefit manager. "It's completely inappropriate. It's damaging to the individual and damaging to the system."

Previous research by CWCI found that the graduated use of opioids in minor back injury cases was associated with delayed recoveries, escalating medical costs, and an increased likelihood of litigation. Other studies have additionally shown a greater number of lost time days.

"Back pain is a significant issue in workers' comp," Paduda said. "Now you've got a lot of these people getting these narcotics. They're not going to get back to work."

The use of opioids is not unique to the workers' comp system. It has become a significant public health emergency.

Swedlow says people from Washington, D.C., as well as Sacramento have been calling him nonstop since the study was released. Among their first questions is "What can be done?"

"We don't write public policy but clearly there needs to be further investigation and thought put into possible limits in the use of these Schedule II drugs," Swedlow said.

The majority of states, including California, have operational prescription drug monitoring programs -- statewide electronic databases of prescription data administered by regulatory, administrative, or law enforcement agencies. State laws vary in terms of how proactive they are in their approaches to regulation.

"I think you have to have a prescription drug monitoring program in place and it has to require participants to access it," Paduda said. "I think states need to report information, like the CWCI is doing. There is a wealth of evidence that narcotics usage in the workers' comp population is exploding . . . . The only state that's taken a close look is California. It's incumbent upon other states to look at this as well."

Paduda says there is no magic bullet to address the problem of opioid use in workers' comp, but there are a number of things that can be done. He says the onus is not only on states to address the problem.

"Payers have to stop lamenting that their state doesn't have this rule, or that regulation, or this law," he said. "You have what you have. It's your responsibility as a payer to work within those guidelines to do the best job you can."

Read more at the WorkersComp Forum homepage.

March 21, 2011

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