2018 Annual Meeting & Educational Conference Opioids In Workers Compensation: Research From WCRI

Transcription

1 2018 Annual Meeting & Educational Conference Opioids In Workers Compensation: Research From WCRI John W. Ruser, Ph.D. NCSI 2018 Annual Meeting June 12, 2018

2 AGENDA Introduce WCRI Opioid dispensing to injured workers How does opioid prescribing vary across geographic areas? How has it changed over time and why? What measures are stakeholders taking to control opioid prescribing? Impact of opioid prescriptions on duration of temporary disability 2

3 ABOUT WCRI Independent, not-for-profit research organization founded in 1983 Diverse membership and funding support Including larger self-insured and insured employers Research focuses on WC benefit delivery systems Not pricing Resource for public officials & stakeholders 3

4 WCRI APPROACH Mission Be a catalyst for improving WC systems by providing the public with high-quality, credible information on important public policy issues. Don t make policy recommendations nor take positions on issues Provide just the facts by means of peer-reviewed studies 4

5 OPIOID DISPENSING TO INJURED WORKERS: COMPARISONS ACROSS 26 STATES

6 FINDINGS BASED ON SEVERAL WCRI STUDIES Interstate Variations in Use of Opioids, 4th Edition Longer-Term Dispensing of Opioids, 4th Edition Impact Of Kentucky Opioid Reforms 6

7 DATA FOR INTERSTATE COMPARISONS Injuries from 2010 to 2013 with Rx observed over an average 24-month period postinjury Nonsurgical claims with more than 7 days of lost time with Rx paid under workers compensation Large samples from 26 states Sample represents percent of claims across study states 7

8 MAJOR FINDINGS Frequency and amount of opioids per claim decreased in most states over the study period Reflect measures taken by many stakeholders More than 2 out of 3 injured workers with pain medications received opioids in majority of states Amount of opioids per claim continued to be higher in LA, PA; also higher in NY despite large decrease Opioids were frequently dispensed together with other sedating drugs Few injured workers with longer-term opioids received guideline recommended services 8

9 DECLINES IN OPIOID PRESCRIBING

10 CDC: OPIOID PRESCRIBING DECREASED IN SEVERAL COUNTIES FROM 2010 TO 2015 Change In Morphine Milligram Equivalents Prescribed Per Capita ( ) Increased Stable Decreased Insufficient Data Source: Guy et al. (2017). Vital Signs: Changes In Opioid Prescribing In The United States,

11 % Point Change In % Claims With Pain Medications That Had Opioids, 2010/12 To 2013/15 KY* NY* MD* NV* TN* LA* NJ* VA* IN* FL* AR* PA* NC* CT* CA* KS MA WI GA IL MI TX MN IA SC MO FEWER INJURED WORKERS WITH PAIN MEDICATIONS RECEIVED OPIOIDS IN LATEST STUDY PERIOD * Statistically Significant At 10% Level /15: Nonsurgical Claims With > 7 Days Of Lost Time, Injuries Occurring From October 1, 2012, To September 30, 2013, Prescriptions Filled Through March 31, 2015; Similar Notation Used For 2010/12 Source: Interstate Variations In Use Of Opioids, 4th Edition (2017) 11 2

12 Average Morphine Equivalent Amount (MEA) Per Claim With Opioids, 2010/12 To 2013/15 MO IA WI IN NJ* AR MN* KS* IL FL* TN* VA NV* CT* MI* GA* TX* NC* SC CA* KY* MA* MD* PA* NY* LA SIGNIFICANT REDUCTIONS IN AMOUNT OF OPIOIDS PER CLAIM SEEN IN MOST STATES 4,000 3,500 3,000 2,500 2,000 1,500 1, ,000-1,500-9% -6% 4% 2% -21%-16% -9% -26%-27% -22% -24% -4% -6% -29% -26% -37% -24%-22% -15% -15% -23% -11% -28% -34% -37% -35% Average MEA per Claim, 2010/2012 Difference between 2010/2012 and 2013/2015 Claims * Statistically Significant At 10% Level Source: Interstate Variations In Use Of Opioids, 4th Edition (2017) 12

13 Change In % Pain Medication Rx: 2010/12 To 2013/15 % PAIN RX FOR NON-OPIOID ANALGESICS INCREASED IN MOST STATES 15% 10% 5% 0% -5% -10% -15% Hydrocodone-acetaminophen Non-opioid pain medications NY KY CA FL CT VA MN TX PA OK GA NJ TN AR MDMA IA IN KS NC MI LA MO WI IL SC 13

14 FEDERAL AND STATE POLICIES ADDRESSING OPIOIDS PRESCRIBING AND DISPENSING Federal CDC Guideline for Prescribing Opioids for Chronic Pain Up-scheduling of Hydrocodone Combination Products State Prescription drug monitoring programs (PDMP) Drug formularies Limits on prescribing and dispensing of opioids Treatment guidelines addressing opioids Other policies addressing opioid prescribing 14

15 SEVERAL REFORMS COINCIDED WITH REDUCTIONS IN OPIOIDS FILLED OVER THE STUDY PERIOD Change In % Claims With Pain Meds. That Had Opioids Change In Average Amount Of Opioids Per Claim KY NY MD MI TN MA TX -16 ppt -9 ppt -6 ppt 0 ppt -5 ppt -1 ppt 0 ppt -34% -35% -37% -37% -24% -23% -22% PDMP Use Chronic Opioid Guidelines Drug Formulary Quantity Limits Provider Education CME Pain Clinic Regulations CME: Continuing Medical Education; ppt: Percentage Points 15

16 IMPACT OF KY REFORMS SCOPE OF KY HOUSE BILL (HB) 1 Mandatory use of PDMP (KASPER) use (July 2012) Mandatory prescribing, dispensing, and reporting standards (September 2012) Regulation of pain clinics KASPER: Kentucky All Schedule Prescription Electronic Reporting 16

17 IMMEDIATE INCREASE IN KASPER QUERIES BY PRESCRIBERS AFTER MANDATE Prescriber Use Mandate Went Into Effect Source: Kentucky House Bill 1 Impact Evaluation (2015) 17

18 % Claims With Pain Medications That Received Opioids KY OPIOID REFORMS IMMEDIATELY DECREASED OPIOIDS DISPENSED TO KY INJURED WORKERS 70% 60% 50% 40% MO, 1% IN, -3% IL, 0% KY, -10% 30% 20% 10% 0% Claims With Injuries Occurring In Calendar Years 2011 (pre-reform) And 2013 (post-reform), Opioid Rx Filled For One Year Following The Date Of Injury. Kentucky HB 1 Went Into Effect On July Case-Mix Adjusted Measures Are Reported. Source: Impact Of Kentucky Opioid Reforms (2017) 18

19 AVERAGE AMOUNT OF OPIOIDS RECEIVED BY KENTUCKY WORKERS DECREASED POST-HB 1 Average MEA Per Claim With Opioids (mg) 1,600 1,400 KY, -16% 1,200 IL, -9% 1,000 IN, -7% 800 MO, -9% MEA: Morphine Equivalent Amount 19

20 STATE POLICIES ADDRESSING OPIOIDS PRESCRIBING AND DISPENSING Prescription drug monitoring programs (PDMP) Drug formularies Limits on prescribing and dispensing of opioids Treatment guidelines addressing opioids Other policies addressing opioid prescribing 20

21 20 STATES ADOPTED COMPREHENSIVE PDMP PRESCRIBER USE MANDATES AS OF 12/2016 AK States With Limited PDMP Prescriber Use Mandates CA WA NV States With Comprehensive PDMP Prescriber Use Mandates States Without Prescriber Use Mandates AZ UT Source: NAMSDL And Sherry L. Green & Associates, LLC. Key State Requirements For Mandatory Use Of PDMPs By Prescribers ( CO NM 21 ND OK MN AR LA WI MS NH VT ME MA NY RI PA CT IN OH NJ WV DE VA KY MD NC TN SC GA

22 % Of Claims With Pain Medications That Had Opioids, Change From MORE PDMP QUERIES BY PRESCRIBERS CORRELATED WITH DECEASES IN OPIOID DISPENSING /12 To 2013/15 b TX WI MA IA SC MN IL KS CA CT MD FL VA NJ AR LA NC IN MI TN NY KY Queries Per DEA-Registered Prescriber In 2014 a a Source For X-Axis: The Pew Charitable Trusts (2016). Prescription Drug Monitoring Programs: Evidence-Based Practices To Optimize Prescriber Use b Source For Y-Axis: Interstate Variations In Use Of Opioids, 4th Edition (2017) 22

23 STATE POLICIES ADDRESSING OPIOIDS PRESCRIBING AND DISPENSING Prescription drug monitoring programs (PDMP) Drug formularies Limits on prescribing and dispensing of opioids Treatment guidelines addressing opioids Other policies addressing opioid prescribing 23

24 16 STATES IMPLEMENTED OR PASSED LEGISLATION TO IMPLEMENT A DRUG FORMULARY WA MT ND WY NY CA NV IN OH KY DE AZ OK AR TN Formulary or preferred drug list in place TX Legislation passed to implement a formulary 24

25 EXAMPLES OF IMPACT OF DRUG FORMULARY Ohio s Bureau of Workers Compensation reported that their formulary resulted in 25% decrease in opioid Rx 74% decrease in muscle relaxant Rx TDI Study on Impact of Texas Closed Formulary Formulary resulted in decrease in non-formulary ( N ) drugs Non-formulary opioids decreased 60%, all opioids decreased 10% N opioids largely long-acting Sources: Fiscal Year 2014 Report Ohio Bureau of Workers Compensation; Impact Of TX Pharmacy Closed Formulary: A Preliminary Report Based On 12-Month Injuries With 24-Month Services & Legacy Status TX Department Of Insurance, Workers Compensation Research & Evaluation Group. 25

26 STATE POLICIES ADDRESSING OPIOIDS PRESCRIBING AND DISPENSING Prescription drug monitoring programs (PDMP) Drug formularies Limits on prescribing and dispensing of opioids Treatment guidelines addressing opioids Other policies addressing opioid prescribing 26

27 STATE POLICIES LIMITING PRESCRIBING AND DISPENSING OF OPIOIDS FL: banned physician dispensing of CII, CIII opioids (Jul. 2011) KY: physician dispensing of opioids limited to 48-hour supply (Sep. 2012) TN: restricts dispensing of opioids and benzodiazepines to a 30-day supply (Oct. 2013) MA: landmark legislation limiting first fills to 7-day supply with exceptions for chronic pain and cancer patients (Mar. 2016) Several other states adopted similar first fill limits (AZ, CT, IN, ME, NH, NJ, NY, PA, RI, VT) 27

28 STATE POLICIES ADDRESSING OPIOIDS PRESCRIBING AND DISPENSING Prescription drug monitoring programs (PDMP) Drug formularies Limits on prescribing and dispensing of opioids Treatment guidelines addressing opioids Other policies addressing opioid prescribing 28

29 INCREASING NUMBER OF STATES ADOPTED TREATMENT GUIDELINES FOR CHRONIC PAIN Workers compensation jurisdictions with treatment guidelines for chronic pain, include CA, CO, CT, LA, MA, MN, NY, OK, and WA Evidence-based guidelines also developed at the national level ODG ACOEM CDC chronic pain guidelines FSMB model policy guidelines 29

30 TREATMENT GUIDELINES FOR MANAGEMENT OF LONG-TERM OPIOID USE FOR CHRONIC PAIN Random urine drug testing Psychological and psychiatric evaluations and treatment Active physical therapy Maximum daily dose exceed with caution Check state prescription drug monitoring program (PDMP) database Co-prescribing of other drugs Interdisciplinary and multidisciplinary care Alternative care 30

31 GAP OBSERVED BETWEEN PRACTICE AND TREATMENT GUIDELINE RECOMMENDATIONS % Of Claims With Opioids That Had Opioids On A Longer-Term Basis Median Of States Studied Of These, % That Received Recommended Services Range Among States Studied 6% 3% 18% Drug Testing 40% 22% 59% Psychological Evaluation 7% 3% 30% Psychological Treatment 3% 1% 12% Active Physical Therapy 87% 73% 91% Nonsurgical Claims With > 7 Days Of Lost Time That Were Identified As Receiving Opioids On A Longer-Term Basis, Injury Year 2012, Prescriptions Filled Through March 2014, Average 24 Months Of Experience; Source: Longer-Term Dispensing Of Opioids, 4th Edition (2017) 31

32 GEOGRAPHIC VARIATION IN OPIOID PRESCRIBING 32

33 CDC: OPIOIDS PRESCRIBED VARIED SUBSTANTIALLY ACROSS THE COUNTRY Morphine Milligram Equivalents Prescribed Per Capita (2015) Source: Guy et al. (2017). Vital Signs: Changes In Opioid Prescribing In The United States,

34 % Of Claims With Pain Medications That Had Opioids, 2013/15 AT LEAST 2 IN 3 INJURED WORKERS WITH PAIN MEDICATIONS RECEIVED OPIOIDS IN MOST STATES 90% 80% 70% 85% 60% 50% 52% 40% 30% 20% 10% 0% NJ IL MD KY CT MI NY CA PA FL TN MO IN GA MA IA VA KS TX NV WI NC MN SC LA AR 1 Opioid Prescription 2 Or More Opioid Prescriptions Source: Interstate Variations In Use Of Opioids, 4th Edition (2017) 34

35 OPIOID DRUGS COMMONLY PRESCRIBED TO INJURED WORKERS, PAID UNDER WORKERS COMPENSATION % Of Pain Medication Rx That Were For Federal Schedule Median State 26-State Range Hydrocodone-APAP (Vicodin ) II * 29% 9% 45% Tramadol (Ultram ) IV 15% 9% 25% Oxycodone (Percocet, OxyContin ) II 9% 1% 30% All Other Opioids (Morphine, Fentanyl, Buprenorphine, etc.) II & III 3% 2% 6% Non-Opioid Pain Medications 42% 32% 57% * The Drug Enforcement Agency rescheduled hydrocodone-combination products from Schedule III to Schedule II, effective October Source: Interstate Variations In Use Of Opioids, 4th Edition (2017) 35 35

36 Average Morphine Equivalent Amount Per Claim With Opioids, 2013/15 AMOUNT OF OPIOIDS PER CLAIM CONTINUES TO BE HIGHER IN LA, FOLLOWED BY PA AND NY 4,000 3,000 2,000 1,000 0 MO IA NJ KS MN WI TN MI IN NV FL AR CT IL KY GA MD VA TX CA NC SC MA NY PA LA Source: Interstate Variations In Use Of Opioids, 4th Edition (2017) 36

37 MEA Per Claim With Opioids, 2013/15 SMALL PROPORTION OF CLAIMS HAVE LARGE AMOUNT OF OPIOIDS 18,000 16,000 14,000 12,000 10,000 16,863 LA 12,450 PA 10,950 NY 8,000 6,000 4,000 2,000 0 p0 p5 p10 p15 p20 p25 p30 p35 p40 p45 p50 p55 p60 p65 p70 p75 p80 p85 p90 p95 Source: Interstate Variations In Use Of Opioids, 4th Edition (2017) 37

38 HIGHER AMOUNT COULD BE DRIVEN BY LONGER DURATION OR STRONGER DOSES MEA per claim = Number of Rx * Quantity * Strength * Morphine conversion factor (CF) Rx Fill Date Drug Name Morphine CF Narcotic Strength Qty. MEA 01/01/2012 Vicodin 1 5mg /10/2012 Percocet mg

39 LARGER VARIATIONS IN DURATION OF OPIOIDS, SMALLER VARIATIONS IN AVERAGE DAILY DOSE OF OPIOIDS Based On Claims With Opioids That Had Days Supply Populated For All Opioid Rx Average Duration Of Opioids Dispensed (days) Average Morphine Equivalent Daily Dose (MED) Of Opioids (milligrams) Median Of States Studied Range Among States Studied Source: Interstate Variations In Use Of Opioids, 4th Edition (2017) 39 39

40 METRICS OF HIGHER RISK OPIOID DISPENSING Dispensing of opioids on a chronic basis Dispensing of opioids at doses exceeding guideline recommended maximum daily doses Concomitant dispensing of opioids with other sedating drugs 40

41 7 29% OF WORKERS WITH OPIOIDS HAD CHRONIC OPIOID USE; SOME WORKERS HAD HIGH-DOSE CHRONIC OPIOID USE Based On Claims With Opioids That Had Days Of Supply Populated For All Opioid Rx Median Of States Studied Range Among States Studied Receiving 60 days or more of opioids in any 90-day period 13% 7% 29% More than 50 MED of opioids for 60 days or more in any 90-day period 1.7% 0.6% 4.0% More than 90 MED of opioids for 60 days or more in any 90-day period 0.5% 0.2% 1.2% Source: Interstate Variations In Use Of Opioids, 4th Edition (2017) 41 41

42 RECEIPT OF OPIOIDS WITH OTHER SEDATING DRUGS IS ASSOCIATED WITH HIGHER RISK OF OVERDOSE DEATHS CDC guideline cautions prescribers about the dangers of prescribing opioids with central nervous system depressants A 2017 WA study found higher risk of opioid overdose deaths when WA Medicaid enrollees received opioids with other sedatives Example: Risk Of Opioid-Related Death Among WA Medicaid Enrollees With 1 Opioid Rx Who Concomitantly Received None Benzodiazepines Only Benzodiazepines And Skeletal Muscle Relaxants Skeletal Muscle Relaxants Only Source: Garg, Fulton-Kehoe, & Franklin (2017): Patterns Of Opioid Use And Risk Of Opioid Overdose Death Among Medicaid Patients 42 Adjusted Hazard Ratio (95% confidence interval) 1.0 (base) 7.5 ( ) 12.6 ( ) 2.8 ( )

43 10% 8% 6% 4% OPIOIDS ARE FREQUENTLY DISPENSED TOGETHER WITH OTHER SEDATING DRUGS IN MOST STATES % Of Claims With Opioid That Concomitantly Received 9% Benzodiazepines (Valium, Xanax ) Muscle Relaxants (Flexeril, Soma ) 60% 50% 40% 30% 20% 28% 48% 2% 0% 0% TX KS FL TN MO GA AR CA KY IA NJ NY IN IL MD MN NC PA NV VA MI SC CT LA WI MA 10% 0% NJ MO WI MA IA NY MI IN MN IL KS TN PA CT AR VA KY SC TX NC NV MD CA GA FL LA 6% 5% Sedatives (Ambien ) 60% 5% 50% Any Sedating Drug 51% 4% 40% 3% 30% 30% 2% 20% 1% 10% 0% AR IA WI MA CT TN MDMOMN NJ MI NC KS IN NV NY VA KY SC FL TX GA IL CA PA LA 0% NJ MO WI IA NY KS TN IN MI MA IL AR KY VA CT TX PA MN SC NC MD CA NV GA FL LA Source: Interstate Variations In Use Of Opioids, 4th Edition (2017) 43

44 MA: HIGHER RATE OF CONCOMITANT DISPENSING OF SEDATING DRUGS AMONG MA WORKERS WITH CHRONIC OPIOID USE % That Received Opioid Simultaneously With Among MA Claims With Opioids Among MA Claims With Chronic Opioids Benzodiazepines (Valium, Xanax ) 9% 23% Muscle Relaxants (Flexeril, Soma ) 31% 55% Sedatives (Ambien ) 1% 3% Any Sedating Drug 36% 65% Source: Interstate Variations In Use Of Opioids, 4th Edition (2017) 44

45 IL: WORKERS WITH PHYSICIAN- AND PHARMACY-DISPENSED OPIOIDS HAD HIGHER RATE OF OPIOIDS & MUSCLE RELAXANTS Pharmacy-Dispensed Opioids Only Physician-Dispensed Opioids Only Both Physician- And Pharmacy-Dispensed Opioids % Of IL Claims With Opioids, By Dispensing Point % Of IL Claims With Opioids That Concomitantly Received Muscle Relaxants, By Dispensing Point 61% 29% 28% 34% 10% 52% Similar patterns were seen in other states with frequent physician dispensing of opioids and muscle relaxants: CA, CT, FL, GA, MD, and PA Source: Interstate Variations In Use Of Opioids, 4th Edition (2017) 45

46 RECAP OF MAJOR FINDINGS Frequency and amount of opioids per claim decreased in most states over the study period More than 2 out of 3 injured workers with pain medications received opioids in majority of states Amount of opioids per claim continued to be higher in LA, PA; also higher in NY despite large decrease Opioids were frequently dispensed together with other sedating drugs Few injured workers with longer-term opioids received guideline recommended services 46

47 THE IMPACT OF OPIOID PRESCRIPTIONS ON DURATION OF TEMPORARY DISABILITY

48 MOTIVATION Impact of opioids on injured workers is not well understood Does it improve ability to return to work or does it delay return to work? Does it have therapeutic value? Is there a different impact of short-term versus longer-term prescribing? 48

49 STUDY GOAL IS TO EXAMINE CAUSAL EFFECT OF OPIOID USE Prior studies, as they admit, did not establish a causal impact of opioids on injured workers Estimating effect of opioid use is challenging since cases with opioids are different from cases without Unobserved injury severity Unobserved personal characteristics Study uses statistical approaches that address concerns about differences in unobserved injury severity and worker characteristics 49

50 THIS STUDY EXAMINES CAUSAL IMPACT OF OPIOID PRESCRIPTIONS ON TD DURATION What is the effect of opioid use on duration of temporary disability benefits? What is the effect of longer-term opioid prescribing on duration of temporary disability benefits? 50

51 DATA Workers with primarily low back pain cases in Cases with more than seven days of lost time Measures at 24 months after an injury 28 states 51

52 MAJOR FINDINGS Longer-term opioids lead to substantially longer duration of temporary disability Controlling for injury severity Shorter-term opioid use has little or no effect on duration of disability Local prescribing patterns matter: Workers receive more prescriptions for opioids in areas where prescribing is more prevalent 52

53 LONGER-TERM OPIOIDS DEFINITION Claim has opioid prescriptions in the first 3 months postinjury and 3+ opioid prescriptions in 7 through 12 months postinjury 53

54 IMPACT OF LONGER DURATION OPIOIDS Estimates For Duration Of Temporary Disability Benefits Change In Duration Of TD Due To Opioid Use Longer-Term Opioid Prescribing 251%*** Compared To No Opioids, TD Duration More Than Triples When Opioids Prescribed On Longer-Term Basis *** Statistically Significant At 1% Level. Regression Controls Include Worker, Injury, And Employer Characteristics, And State Dummies. Longer-Term Prescribing Defined As Having Prescriptions Within The First Three Months After An Injury And Three Or More Visits To Fill Opioid Prescriptions Between The 7th And 12th Months After An Injury. 54

55 LITTLE IMPACT OF ANY OPIOIDS USE ON DURATION OF DISABILITY Estimates For Duration Of Temporary Disability Benefits Change In Duration Of TD Due To Opioid Use Any opioids within 24 months after an injury 5% 55

56 LOCAL PRESCRIBING PATTERNS ARE STRONG PREDICTORS OF OPIOID USE Opioid prescribing rate varies across areas within states; of claims with low back injuries in our sample, % with opioids: 62% in Philadelphia 71% in Harrisburg Change In Individual Opioid Prescriptions Due To 10 ppt Increase In Local Prescribing Any Opioid Use 10 ppt increase in rate of any opioids within local area 3.4 ppt Based On OLS Estimates For Any Opioids Specifications. All Estimates Shown Are Statistically Significant At 1% Level. Regression Controls Include Worker, Injury, And Employer Characteristics, And State Dummies. 56

57 THANK YOU! For comments/questions about the findings: John Ruser (617) The research I discussed today is available for purchase on our website at For information about membership, visit We invite you to follow us on social media 57