By Leslie Yeransian
For a decade, drug-induced deaths have claimed more lives than any other injury deaths, including injury by firearms, homicide, suicide, and motor vehicle accidents, according to the National Center on Health Statistics.
In just five years, there has been a 345 percent increase in deaths linked to oxycodone, the powerful narcotic found in Percocet and OxyContin and recent studies show a dramatic increase in accidental deaths linked to the use of prescription opioids, according to the Centers for Disease Control and Prevention.
In addition to costing lives, this trend is costing money. Pharmacy-related waste accounts for $408 billion dollars of damage each year, of that total, $317.4 billion represents nonadherence, from drug misuse to diversion, according to the 2011 Drug Trend Report by Express Scripts.
At the first National Rx Drug Abuse Summit in Orlando, Fla., earlier this year, Joseph T. Rannazzisi, deputy assistant administrator, Office of Diversion Control in the Drug Enforcement Administration, addressed the progression from opioids to illicit drugs.
"We will lose a whole generation to heroin because they started on Hydro[codone]," he said. "They start with hydro but because you build up a tolerance, they go to the oxy combination products -- they're a little stronger."
It's a path we're being led down, warn experts, with hydrocodone being the No. 1 most prescribed drug in the nation. In 2010, more than 131 million hydrocodone prescriptions were dispensed, according to the IMS Institute for Healthcare Informatics.
Excessive use of pain medications is a national health crisis, requiring public health prevention campaigns to shift expectations and behavior.
One successful prevention campaign was led by Fred Wells Brason II, executive director of Project Lazarus, who sought a solution to Medicaid patients shopping for prescription medication among North Carolina Emergency Departments in Wilkes County.
"We literally had some Medicaid patients with 50 emergency department visits a year," said Brason.
The emergency departments and North Carolina Medicaid flagged these "frequent fliers" and used case management protocols to refer them to an appropriate care provider and opioid-related deaths in Wilkes County decreased by 71 percent between 2009 and 2011.
Prior to this pilot program, in 2007, Wilkes was the third worst county for prescription-related deaths in the nation. The program is now being implemented across all of North Carolina. This strategy could be easily adapted from a Medicaid population to a workers' compensation population, Brason said.
For an example of how to apply evidence-based, opioid treatment guidelines there is no better example than Washington State.
In 2007, Gary Franklin, medical director with the Washington State Department of Labor & Industries, helped put into place the Washington State Agency Medical Directors (AMDG) Opioid Dosing Guideline with a 120mg morphine equivalent dose "yellow flag" threshold. If the patient wasn't getting better on 120mg, then the physician should consult a pain management specialist.
"I think that insurers can work with care management companies, especially if they are working with state agencies to identify your high dose patients and your high roller doctors," Franklin said.
In Texas, a drug formulary, which took effect on Sept. 1, 2011, serves as a prevention measure that targets "N" (not recommended) drugs. Under the formulary, "N" drug costs declined by 75 percent, claims receiving "N" drugs were cut by 54 percent; the frequency of opioid prescriptions dispensed to injured employees decreased by 10 percent; and the costs associated with opioid prescriptions dropped by 17 percent, the Texas Department of Workers' Compensation reported. These findings were based on claims occurring from September to November 2011 and claims during that same time frame in 2010.
The Importance of Education
Prevention starts with education and education starts at the graduate school level, yet is sorely lacking. "You have a lot of physicians trying to do the right thing without the proper training," said Dr. Nora Volkow, director, National Institute on Drug Abuse, speaking at the National Rx Drug Abuse Summit.
Despite Volkow's assertions, the Food and Drug Administration, backed by the American Medical Association, rejected its own experts' recommendation that physicians receive mandatory opioid training. Meanwhile, some states have developed incentives and rules that steer physicians to pain management training.
The state of Washington is giving free education to physicians, and in 2011 changed the Continuing Medical Education (CME) offering from three to four hours. "We have thousands of doctors who have taken advantage of the free CME. Doctors know the new regulations, and the AMDG Opioid Dosing Guideline, reflect best practices that will allow those who choose to use opioids to do so safely and more effectively," said Franklin.
Colorado workers' compensation regulators made strides through fee-based incentives for training.
"We can't expect doctors to do things they are not getting paid for," said Professor Kathryn Mueller of the University of Colorado's School of Public Health. "We've been educating doctors since 2003; what we discovered in 2009 is that they weren't doing it in an organized fashion where they were actually performing all of the required activities in the guidelines. So we said, 'Let's pay them."
More states are attempting to curb the epidemic at the monitoring level. Prescription Drug Monitoring Programs -- strategies to track vital prescription data so physicians and pharmacists know when a prescription is being abused, and investigators can identify overprescribing problems -- are currently operational in 41 states.
Unfortunately, only about half of the states analyze their data to identify questionable activity, then send prescription histories or alert letters to prescribers and/or pharmacies used by flagged patients.
To help the effort, legislators on both sides of the aisle have introduced bills to make PDMPs interoperable through the Interstate Drug Monitoring Efficiency and Data Sharing (ID MEDS) Act.
John Eadie, director of the Prescription Monitoring Program Center for Excellence at Brandeis University, is working on a way to link more stakeholders into the monitoring process.
"We need to, at least, on a trial basis, find a state or states willing to share data with people in the private industry to see what kind of an impact we can make on this epidemic," he said.
Private industry doesn't have access to PDMPs due to legal and patient privacy reasons.
"It's very tricky, there are a lot of legal issues involved," Eadie said.
"However, I think given the number of people dying, the number of people injured by overdoses, and the number of family members being harmed, that we need to find a way to address this epidemic as hard and fast as we can."
Experts outside the industry see the value of mining claims information.
Christopher M. Jones of the Centers for Disease Control and Prevention said, "One of our policy recommendations is leveraging insurers and managed care mechanisms. This can include prospective or retrospective claims review programs to identify patients at the point of dispensing, or identify patient claims histories with patterns of inappropriate use."
Jones' policy recommendations are being executed in workers' comp, with the development of detection systems and rapid response protocols.
Rising Medical Solutions (Rising) is using analytics to monitor an injured worker's prescription profile and alert users to "at risk" cases.
"In any pharmacy review, if a person is taking one drug they are taking ten," said Anne Kirby, Rising's chief compliance officer and vice president of Medical Review Services.
"You cannot just deal with opioids in a vacuum because there are other drugs that are impacting how they're used and what the impact is on their use."
Perhaps the most important industry development in curbing prescription drug misuse is the significant reduction of time and effort necessary to identify the claimant population that needs pharmaceutical intervention.
The pharmacy review process used to require manual case evaluations, often resulting in excessive man hours with few cases to take action on.
Now the workers' compensation community is gaining efficiencies through technologies that deliver actionable, claims intelligence and allow users to quickly respond to questionable prescription activity.
Proof that the needle is moving in the right direction comes from the California Workers' Compensation Institute's July study analyzing drug utilization trends.
The study reported use of Schedule II opioids growing five times between 2002 and 2010, but declining since. No recent changes in law or regulations explain this reversal.
The CWCI concludes that "increased public awareness of the dangers of Schedule II drugs, as well as enhanced medical management and pharmaceutical controls implemented by the payer and medical provider communities" drove the change.
A multipronged approach of evidence, prevention, education, monitoring and Rx intelligence is the remedy to America's prescription drug scourge. It's a cure that will ensure painkillers are prescribed and dispensed only when necessary, with patients monitored closely.
LESLIE YERANSIAN is a writer specializing in the health care and workers' compensation industries. She works at Rising Medical Solutions.
August 22, 2012
Copyright 2012© LRP Publications