Report identifies risky opioid prescribing practices

Immediate release fentanyl preparations and meperidine, as well as methadone, pose particularly high risks of overdose, substance misuse, or toxicity, according to new research. The drugs warrant "particularly close scrutiny" or should not be prescribed to outpatients, according to the California Commission on Health and Safety and Workers' Compensation.

The commission released a draft report that assesses screening for higher-risk prescribing practices in the workers' comp system and information on opioid prescribing that can be used to develop screening criteria for assessing opioid prescribing risk. An additional memo summarizes the evaluation of guidelines for using opioids to treat pain among injured workers.

"Opioids can be an appropriate means of treating patients with chronic pain, particularly those with moderate to severe pain," the report says. "Nevertheless, the increasing use of opioids has been accompanied by real risks of substance misuse, addiction, diversion, overdose, and death."

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Better understanding can help employers address opioid crisis among injured workers (01/28/13)

The risks can be higher in workers' comp, the researchers explain. "In workers' comp settings, opioids are used more often in the treatment of chronic non-cancer pain and the doses used tend to be higher."

Additionally, "the value of ensuring that the patients being prescribed opioids return to their baseline functional status as quickly as possible," is unique to workers' comp, according to the report. "Observational studies, including one in California, found use of higher dose opioids associated with longer disability and higher workers' compensation claim costs."

The report identifies higher risk practices that are thought to be associated with suboptimal patient outcomes, while the potential screening criteria to identify them target areas of practice where providers "should proceed with caution or not at all." Since any criteria implemented by a state or worker' comp payer would likely be applied to pharmaceutical claims data, "the criteria should be able to identify high risk practices based on medication name and formulation, route of administration, dose per unit of medication, number dispensed, and patterns of refills over time."

In terms of dosages of opioids, the researchers said most medical treatment guidelines they studied agreed that doses above 200 mg of morphine equivalents per day warranted additional scrutiny "because many patients achieve pain control with doses about half that level."

For drug interactions, benzodiazepines was identified as among the top medications for potential screening criterion. The authors suggested each potential interaction be cataloged according to the individual drugs involved.

Switching opioids is a particular problem noted in the report. "These transitions are fraught with risks of overdose due to the characteristics of the different drugs as well as variability across individual patients in how they metabolize different opioids."

Based on a study of opioid claims in the Ohio workers' comp system, the researchers say "the potential screening criteria suggested by the various guideline recommendations will identify quite a number of medical claims warranting review."

Read more at the WorkersComp Forum homepage.

January 18, 2013

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