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The report, Interstate Variations in Use of Narcotics, compares the use of pain medications among injured workers in 17 large states. The study's release coincides with one state's implementation of rules that may be at least part of the solution to the growing concerns about opioid use in the workers' comp system.

The study. "I think this study is one of the more important ones," said Richard A. Victor, executive director of the Workers Compensation Research Institute, which produced the report. "It shows there are some large opportunities to manage better."

A summary of recommendations for chronic opioid management shows most suggest careful screening of patients for chronic opioid therapy and close monitoring and management.

Nevertheless, "few cases that were identified as longer-term users of narcotics received those recommended services," the report said. "Only 7 percent of the longer-term users in the median state had urine drug screening tests. . . . Similarly, few longer term users of narcotics had the psychological evaluation and treatment recommended by guidelines."

Victor said he was surprised by the wide variations in the length of use of narcotics among the states. "In certain states, such as Louisiana, there's a relatively high likelihood if you start narcotics you will be taking them six months later," he said.

Nearly 1 in 6 injured workers who received any narcotics in Louisiana were identified as longer-term users of narcotics, compared to 1 in 20 in the typical state. Other states with higher numbers of long-term narcotics users were New York, Pennsylvania, Texas, California, Massachusetts, and North Carolina.

The amount of narcotics per claim also varied substantially. The average injured worker in New York received over 4,000 milligrams of morphine equivalent narcotics per claim. Also high were Louisiana, Massachusetts, and Pennsylvania.

Tied in with the amount of narcotics per claim was the type of narcotics prescribed. Injured workers in Massachusetts, New Jersey, Maryland, Minnesota, North Carolina, Pennsylvania, and Wisconsin were more likely to have stronger, Schedule II narcotics prescribed.

The authors noted, however, that more frequent prescribing of Schedule II narcotics did not always imply an overuse of narcotics. In Wisconsin and Minnesota, even though physicians were more likely to prescribe Schedule II narcotics, the average morphine equivalent amount of narcotics per claim was lower than the 17-state median.

Resulting actions. The results signal the need for further research. Additionally, the authors hope the findings spark discussion and perhaps action among the following stakeholders:

• Injured workers. "If my physician said to me, 'I'm going to prescribe narcotics and you should know that data shows you have a 1 in 6 chance of being on them six months from now,' I'd think long and hard," Victor said.
• Physicians. "If I'm a clinician and I'm in the Northeast or Mid-Atlantic states where I have a preference for prescribing Schedule II narcotics, I'd want to know whether my counterparts in states that have a preference for Schedule III narcotics are getting good outcomes," Victor said.
• Employers and insurers. "If I'm a payer in states where workers get high amounts of narcotics, I'd want to focus my utilization management there," he said.
• Elected representatives. "If I'm a public official in a state with high narcotics use, I'd want to take a look at the effectiveness of public policies in place and look at what other states do to see if they get different results," Victor said.

Public sector action. In Washington state, officials are taking actions to stem the potential overuse of narcotics. A state law adopted last year requires health care regulatory boards and commissions to develop rules for the management of chronic non-cancer pain by this summer.

"The law was very direct about what needed to be in the rules in terms of setting up a daily threshold for dosage," said Kristi Weeks, director of legal services for the Washington Department of Health. "If the patient exceeds the daily dosage, they have a consultation with a pain management specialist."

The rules also cover evaluating and monitoring patients who are prescribed narcotics. "The idea was, 'let's not just keep giving somebody more drugs but let's assess if it's helping them and, if not, let's look at other things," Weeks said.

Under the rules, physicians are required to evaluate chronic patients for current and past treatment, comorbidities, and any history of substance abuse. Also required is a physical evaluation, "not just hearing subjective complaints," Weeks said.

Finally, the rules require periodic reviews of patients. Included must be whether the patient is complying with the treatment plan.

Read more at the WorkersComp Forum homepage.

August 8, 2011

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