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Last month I wrote about the Opioid Tipping Point -- the explosion in opioid use and abuse that threatened our workers' compensation programs. In the second part of the article, I'll identify some effective state programs and physician group resources addressing the problem.

National Workers' Compensation and Disability Conference

Throughout my career, I have been unconvinced that government legislating workers' compensation treatment is a viable way to effectively manage treatment protocols. I would much rather see the medical profession and the payors in the system direct the course of medical practice for workers' compensation claimants. Most PPO/MPN providers have not been aggressive in dealing with the prescription medication issue and pharmacy benefit managers have been challenged to provide adequate controls. While increased pressure from employers and employee advocates has begun to make an impact, I am convinced that with the magnitude of the opioid problem, state involvement as discussed below has proved a viable alternative. Thoughtful and sensible intervention directed by physicians and public-health officials knowledgeable in the areas of pain management and appropriate use of these medications may be a large part of a successful solution.

Effective State Responses

Washington and California are leading states in efforts to reign in the use and abuse opioids in their Medicaid and workers' comp systems.

Washington State Department of Labor and Industries, led by Medical Director Dr. Gary M. Franklin first introduced guidelines then proposed legislation to reign in the impact on employees and their families and the costs associated with the use, misuse and abuse of opiods.

To Franklin, the connection was clear: cut down the number and duration of prescriptions and provide pain-management alternatives to curb the problem. Washington rules require doctors and other prescribers to maintain and update detailed screening, history and treatment-plan records for pain patients. A prescriber whose patient reaches a certain dosage level must consult a pain specialist. Washington's prescription management process has dramatically cut overdose deaths, emergency care and costs.

Similarly, in California, abuse and workers' comp program costs were driving factors in tackling the opioid problem. A multi-prong approach, led by Dr. Bernyce Peplowski, California State Fund medical director, has been curbing the use, misuse and abuse of opioids. California developed a physician contract that outlined two week/60 day parameters, with requirement of utilization review approval beyond 60 days. Side effect warning letters are sent to physician and patient by the pharmacy benefits manager after first fill of narcotics and early utilization reviews by pain specialty matched peers are mandatory.

Both Washington and California provide education, cover and support to physicians who are serving workers' comp patients, but until more states get on board with legislation, national physician organizations will have to fill the void.

Florida Feels the Pain

Contrast the Washington and California state successes with Florida, where physicians, pain clinics, drug repackagers, pharmacies, the state workers compensation program and many other stakeholders are embroiled in a battle about limiting opioid distribution. The hotly-debated HB 7095 -- the state's newest proposal regulating opioid distribution -- bans doctor dispensing of drugs and subjects pharmacies to inspection of prescription records. A side effect of HB 7095 is that the state workers' comp program will reap millions in savings if opioids are limited to pharmacy dispensing and avoid the physician and pain clinic repackaging mark-ups.

Previously, several other bills that limit the use of opioids in the State workers' comp program and require additional physician reporting have previously been stalled in budget committees.

Until the hotly contested bill is passed, Florida will keep the dubious distinction of leading the nation in the sale of Oxycodone with more than 400 million pills sold annually, plus the distinction of having 98 of the top 100 doctors dispensing Oxycodone nationally hailing from the state. The ripple effect of HB 7095 may be felt in other states since the Florida Attorney General's office reports that the state is the primary source of illegal prescription narcotic drugs for the eastern United States

As mentioned above, both Washington and California provide education, cover and support to physicians who are serving workers' compensation patients, but until more states get on board with guidelines and legislation, national physician organizations will have to fill the void.

Physicians Education and Cover

One resource physicians can turn to is the American College of Occupational and Environmental Medicine -- the nation's largest organization representing physicians who practice occupational and environmental medicine.

In December, ACOEM submitted a draft document entitled Blueprint for Prescriber Education for the Long-Acting/Extended-Release Opioid Class-Wide REMS to the FDA. The Blueprint contains core messages intended for use by continuing education providers to develop educational materials to train prescribers of opioids.

ACOEM had already produced an updated Guidelines for the Chronic Use of Opioids earlier last year which provides an excellent set of checklists, screening/treatment guides and even a patient Opioid Contract. The full 25-page guide is available free on the ACOEM website. Guideline highlights include:

* Routine use of opioids for treatment of chronic non-malignant pain conditions is not recommended

* Screening patients prior to initiation of opioids for Chronic Pain

* Opioid Treatment Agreement ("Opioid Contract") for patients with chronic pain

* Urine drug screening for patients prescribed opioids for chronic pain

Other Stakeholders Must Get on Board

With national physician organizations, state workers' compensation systems, and individual practitioners buying into controls that will ultimately reduce the use, misuse and abuse of opioids, the industry has reached its tipping point. Other industry stakeholders -- pharmaceutical companies, insurance carriers, TPAs, and companies that self-insure -- will need to follow suit.

Opioid use, misuse and abuse is one of the most pressing challenge facing the workers' compensation system in 2012 and no doubt, we will continue to see study after study about the increasing costs in terms of lives, families and worker productivity. The societal and personal costs, not to mention the organizational costs associated with opioid use will bury us if we do not join forces to push forward and conquer this threat.

March 8, 2012

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