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Two new studies published by Workers’ Compensation Research Institute (WCRI) show that on average three out of four injured workers in the United States receive opioid prescriptions for pain relief following workplace injuries and that generally, even when opioids are prescribed over an extended period of time, the injured workers rarely receive services commonly recommended for chronic opioid management, such as urine drug testing, psychological and psychiatric evaluation, and physical therapy and exercises. [See Thumula, V. and Wang, D., “Interstate Variations in Use of Narcotics” (2nd ed.) and “Longer-Term Use of Opioids” (2nd ed.), May 2014. Moreover, the percentage of injured workers receiving opioid prescriptions is significantly higher in some states, such as Louisiana and New York.
The two studies were based on approximately 264,000 workers’ compensation claims and 1.5 million prescriptions associated with those claims from 25 states. The claims represent injuries arising from October 1, 2007, to September 30, 2010, with prescriptions filled up to March 31, 2012. The underlying data reflect an average of 24 months of experience.
Included in the studies were Arkansas, California, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, New Jersey, New York, North Carolina, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Wisconsin. Those 25 were chosen on the basis of population size and geographic diversity. According to the researchers, claims in these states represent more than 75 percent of the workers’ compensation benefits paid across the nation each year.
Both studies focused on self-administered prescriptions taken by mouth, excluding opioids dispensed in hospitals or opioids received by injection in medical offices and other clinics.
Four Core Questions
The studies concentrated on four questions:
> How often did injured workers use opioids?
> Which states had higher or lower use and longer-term use of opioids?
> Do prescribing patterns vary by state?
> How often were drug testing and other guideline recommended services used among injured workers with longer-term use of opioids?
Variation in Percentages of Injured Workers Receiving Opioid Prescriptions
In most states, three out of four injured workers received opioids for pain relief. The level of opioids per claim was unusually high in Louisiana and Arkansas, where close to 90 percent of injured workers with pain received opioids. The studies noted that a higher proportion of records in these states also had longer-term opioid use.
In three of the states studied—New Jersey, Connecticut, and Illinois—the proportion of injured workers receiving opioids for pain was much smaller—about 60 percent. The researchers stress that there is no hard and fast rule to determine what level is “high” and what level is “low,” that the large grouping of states was utilized in order to show the range across a broad spectrum.
Looking at the median state (Iowa), 22 percent of all pain medication prescriptions were for hydrocodone acetaminophen products (e.g., Percocet®, OxyContin®).
Substantial Variation in Amounts Prescribed
The researchers observed substantial variation in the amounts of opioids prescribed to an injured worker across the 25 states studied. For comparison purposes, the researchers converted the opioid data into Morphine Equivalent Amounts (MEA), a process that combines the number of prescriptions, the quantity of pills within each prescription, and the strength of each pill. The results ranged from a low of 900 MEA in Missouri to more than four times that much in New York and Louisiana.
Long-Term Use Also Varies Among the Study States
The number of injured workers taking opioids on a long-term basis (defined for purposes of the study as a worker who had his or her first opioid prescription filled within three months of injury, who continued to receive opioids after six months post-injury, and who had more than three refills between the seventh and twelfth month post-injury) varied considerably. For example, in Wisconsin and Indiana, approximately four percent of injured workers took opioids on such a long-term basis. In four states, however, Texas, Pennsylvania, New York and Louisiana, the percentage was greater than ten percent. Louisiana was in a category of its own, with some 16 percent of injured workers receiving opioids on a long-term basis. Consistent with that finding, the average number of opioid prescriptions filled for a Louisiana worker was seven, whereas for most other states, it ranged from four to five. Generally, prescription size (in number of pills) was more consistent among the states, with an average of 45 to 55 pills per prescription. New York was an outlier here, however, with an average of more than 70 per prescription.
More Frequent Prescribing of Stronger Schedule II Opioids in the Northeast
The study indicates the use of stronger, Schedule II opioids is higher in several Northeast states—New York, Pennsylvania, Connecticut and Massachusetts—as well as North Carolina. Among the states studied, California, Texas, and Oklahoma had the lowest use of the stronger opioids.
Few Workers With Longer-Term Use of Opioids Receive Recommended Management Services
The studies note another important and disappointing factor: few injured workers with longer-term opioid use receive services for chronic opioids management recommended by medical treatment guidelines. The studies looked primarily at the following recommended services:
> Urine drug testing
> Psychological and psychiatric evaluation, and
> Physical therapy and exercises
The researchers determined that less than 14 percent of longer-term users received drug testing. Psychological and psychiatric evaluations were also rare, as were programs providing physical therapy and/or exercises, even where the latter has been shown to aid in recovery. On an individual state level, the researchers noted an increase in longer-term opioid use in Michigan and a decrease in Connecticut.
Other Study Observations
The researchers noted that effective October 1, 2014, the Federal Drug Enforcement Administration (DEA) will categorize hydrocodone combination products as Schedule II. The effect of that change is not yet clear, but as a Schedule II drug, refills are severely limited and they expire generally in 90 days. Moreover, physicians may not phone in a prescription for a Schedule II drug; it must be submitted either in electronic or written form. This may lead to a reduction in the overall number of longer-term opioid prescriptions. Future studies will examine this issue.
The researchers stressed that the data examined was as of 3/2012. Some states have passed a number of recent “reforms”—e.g., Louisiana’s new physician treatment guidelines, New York’s recent amendments related to opioids, the adoption by Texas of a closed formulary, and the adoption in Massachusetts of chronic pain treatment guidelines are a few. The effect of those reforms is not examined in these two WCRI studies. The researchers plan to update the studies and anticipate that the reforms could reduce the number of opioid prescriptions written for injured workers.
Studies Provide Tools for Employers, Advocates and Public Officials
As noted by the researchers, narcotic misuse is an important public health problem in the United States. It results in death and addiction to far too many of our citizens. Narcotic misuse is particularly problematic with the workers’ compensation community since it lengthens the recuperative period and sometimes prevents it altogether. The WCRI studies provide data and observations to a host of important constituencies—public officials, employers, worker advocates, and others. Additional research along these same lines will be invaluable as injured workers seek and receive medical treatment and employers and other stakeholders try to exert some control over costs.
Commentary by Stuart D. Colburn, Esq.
According to Stuart D. Colburn, Esq., a Shareholder at Downs Stanford, P.C.: “The studies cast another beam of transparency on the business of prescriptions medications. Mr. Robinson does a fine job of taking the academic findings of two recent studies and presenting it to the rest of us in a language that is easy to understand. Reasonable care and best practices opioid treatment practiced by health care providers to injured workers should be the same in Louisiana as it is in Iowa. But study after study shows surprisingly divergent practices that vary by state and region. Some theorize the training in local medical schools and residencies play a significant role in shaping the prescribing habits of future doctors. Other factors include state regulations and laws including Prescription Drug Management Programs, drug formularies, and physician dispensing. And don’t forget the recent revelation that drug and DME providers gave 3.5 billion (that we know about) to health care providers. The addictive (and dangerous) properties of opioids are dispensed in a system that increases the profits of drug manufacturers, pharmacies, and sometimes doctors. The best practices to opioid management may not align with the business interests of prescribing the drugs. The study authors and Mr. Robinson pull back the proverbial shade revealing a system that does not seem to work with much efficiency or for the best interests of the injured worker and his employer.”
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