WCRI Study Shows State Policy Changes Result in Reduced Use of Opioids

By Thomas A. Robinson, co-author, Larson’s Workers’ Compensation Law

A July 2021 study published by Workers’ Compensation Research Institute (WCRI) suggests that relatively recent implementation by some states of (1) must-access prescription drug monitoring programs (PDMPs) related to opioids, and (2) policies setting limits on initial opioid prescriptions, have contributed to declines overall in opioid utilization and in the morphine milligram equivalent amount (MME) of opioids distributed in workers’ compensation claims. The study, “Effects of Opioid-Related Policies on Opioid Utilization, Nature of Medical Care, and Duration of Disability,” was authored by David Neumark and Bogdan Savych [a copy of the study is available at the following URL: https://www.wcrinet.org/reports/effects-of-opioid-related-policies-on-opioid-utilization-nature-of-medical-care-and-duration-of-disability]. The study gives credence to the position, fostered by many in the medical-legal community, that the provision of opioids among injured workers should be more carefully managed and that when managed, the results can be favorable.

Background

Virtually everyone within the workers’ compensation world is familiar with the opioid problem in America. As has been noted in multiple studies describing the use of opioids both within and without the workers’ compensation world, while the United States makes up 4.4 percent of the world’s population, it consumes more than 80 percent of the world’s opioids. This disparity is particularly well-delineated for hydrocodone, a drug that Americans consume over 99 percent of the world supply [United Nations International Narcotics Control Board, 2017].

According to data released by the Centers for Disease Control and Prevention (CDC) [CDC, 2019], the U.S. saw a steady increase in the overall national opioid dispensing rate starting in 2006. The total number of prescriptions dispensed peaked in 2012 at more than 255 million and a dispensing rate of 81.3 prescriptions per 100 persons. The overall national opioid dispensing rate declined from 2012 to 2019, and in 2019, the dispensing rate had fallen to the lowest in the 14 years, for which the CDC had data at 46.7 prescriptions per 100 persons (total of more than 153 million opioid prescriptions).

In 2019, however, dispensing rates continued to remain very high in some areas across the country. According to the CDC, in 5 percent of U.S. counties, enough opioid prescriptions were dispensed for every person to have one. And while the overall opioid dispensing rate in 2019 was 46.7 prescriptions per 100 people, some counties had rates that were six times higher than that amount. The CDC has described the opioid crisis as “the worst drug epidemic in US history” (Kolodny, et al., 2015). Between 1999 and 2017, overdose deaths from opioids, including prescription opioids and illegal opioids, increased six-fold [Substance Abuse and Mental Health Services Administration, 2017]. Every day, more than 1,000 people are treated in emergency departments for misusing prescription opioids [CDC, 2017].

While opioids may be effective in the treatment of pain, such treatment comes at a significant cost. The CDC estimates the total economic burden of prescription opioid misuse in the US is $78.5 billion a year, including the costs of health care, lost productivity, addiction treatment, and criminal justice involvement [Florence CS, 2016. Accessed 8/21/2021]. In an attempt to contain the epidemic, federal and state governments implemented various policies that limit access to prescription opioids to reduce addiction. As noted above, in a number of states, two policies were implemented: (1) the establishment of PDMPs, which legally require providers to access a state-level database with a patient’s prescription history before prescribing controlled substances under certain circumstances and (2) the enactment of regulations limiting the duration of initial opioid prescriptions—prescribing that initial prescriptions should be limited (e.g., to three, five, or seven days of supply). The purpose of the WCRI study was to assess whether these changes in overall policy had any positive effect on excessive prescribing and potential opioid abuse.

Source of Data and Methods Utilized

The study’s analysis sample was derived from payment information on workers’ compensation claims contained in WCRI’s Detailed Benchmark/Evaluation (DBE) database. The DBE covers claims from national and regional insurers, state funds, and self-insured employers (via their third-party administrators) and includes claims information for workers injured between October 1, 2009, and March 31, 2018, in 33 states [Alabama, Arizona, Arkansas, California, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nevada, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Wisconsin]. WCRI indicates that these states represent approximately 85 percent of benefits paid in a typical calendar year.

Since the researchers’ primary objective was to examine utilization of care and duration of disability, they extracted data on filled prescriptions, medical services provided, and temporary disability benefits made within 12 months after an injury.

The researchers estimated the effects of state policies by estimating regression models that compare how outcomes changed in states that adopted must-access PDMPs and initial prescribing limits, relative to states that did not, accounting for various other factors that could have affected these outcomes. The study also sought to account for the possibility that there are unmeasured factors that drive variation in outcomes across states.

Primary Findings

Overall, the researchers found that implementation of must-access PDMPs contributed to declines in opioid utilization. More specifically:

• Must-access PDMPs reduced the morphine milligram equivalent amount (MME) of opioids by 12 percent.
• This reduction was driven primarily by changes in the amount of opioids prescribed; there was little change in whether workers received opioids. Must-access PDMPs reduced both the amount of opioids prescribed and the number of opioid prescriptions for claims with opioids.
• Must-access PDMPs contributed to a 12 percent decrease in the likelihood that workers receive opioids on a longer-term basis (among those with opioids).

Significant also was the study’s finding that placing limits on initial opioid prescriptions resulted in a 19 percent decrease in the MME amount of opioids among claims with opioids.

Additional Findings

The researchers found limited evidence that workers increased the use of other types of care when policies restricted access to opioid prescriptions. For most groups of work-related injuries, the researchers observed a decrease in the amount of opioids prescribed due to must-access PDMPs, accompanied by small changes in use of other services that might substitute for opioids for managing pain.

For example, the study identified only small changes in the number of prescriptions for non-opioid pain medications. The researchers observed small changes in whether injured workers received active physical medicine services and the number of visits for those services. The absence of changes in other care that might be an alternative to opioid prescribing for managed pain might indicate that:

• Some of the prescriptions may have been unnecessary; or
• That workers were unable to find medical providers who could treat their pain.

Neurologic Spine Cases

The researchers noted one important exception. For neurologic spine pain cases, they found evidence consistent with partial substitution toward alternative types of care. For these injuries, the researchers observed that must-access PDMPs led to a 13-percent decrease in MME and a 14-percent increase in the number of prescriptions for non-opioid pain medications. The researchers found this phenomenon important because, of the injury groups they considered, it had the highest incidence of opioid prescriptions and the highest MME.

Temporary Disability Benefits

Finally, the researchers did not find evidence that either must-access PDMPs or limits on initial prescribing resulted in changes in the duration of temporary disability benefits captured at 12 months of maturity. According to the researchers, this suggested that decreases in supply of opioids were not related to longer recovery after injuries, and may provide another indication that some of the opioid prescribing was unnecessary. The researchers indicated that they lacked sufficient data to draw stronger conclusions.

The California Data

The researchers acknowledged that California had one of the largest decreases in opioid utilization between 2012 and 2016 for claims at 24 months of maturity [Thumula, Wang, and Liu (2019)]. The researchers attributed this change to the strengthening of the independent medical review (IMR) process for resolution of medical disputes. Because of the large California numbers, the researchers found that some of the study estimates presented in their main analysis were sensitive to whether they excluded California. They also found that their estimates were less precise when the samples included California.

Study Implications

The study provides solid evidence not only that the utilization of must-access PDMPs reduced the amount of opioids prescribed without the likelihood that injured workers received prescriptions, suggesting that workers were still able to get access to opioids to manage pain levels. The study also supports a point offered by some medical experts in recent years: that workers can receive fewer opioids without extending the recovery time for their injuries. The study suggests that while placing limits on initial opioid prescriptions had little effect on whether workers received opioid prescriptions, the policy change did result in a decrease in the amount of opioids prescribed among claims with opioids. This suggests that the policy is working, say the researchers. As noted above, the study findings tend to support the use of expanded independent medical review procedures like those put in place in California in recent years.

The researchers acknowledge that additional study is necessary to gain more specific insights into how policy changes affect opioid prescription patterns. Additional research is necessary to assess the effectiveness of opioid substitutes, such as non-opioid pain medications, physical therapy, and other pain management regimes. This study signals at least modest good news, however, in our efforts to stem the opioid epidemic in the United States.

Bibliography

Centers for Disease Control and Prevention. US prescribing rate maps. Updated October 3, 2018. Accessed August 21, 2021.

Centers for Disease Control and Prevention. Opioid basics. Updated August 27, 2017. URL: https://www.cdc.gov/opioids/basics/index.html. Accessed August 20, 2021.

Florence CS, Zhou C, Luo F, Xu L. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Med Care. 2016;54(10):901–906. URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5975355/. Accessed 8/21/2021.

Kolodny, Andrew, David T Courtwright, Catherine S Hwang, Peter Kreiner, John L Eadie, Thomas W Clark, and G Caleb Alexander, “The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction,” Annual review of public health, 2015, 36, 559–574.

Substance Abuse and Mental Health Services Administration. The National Survey on Drug Use and Health: 2017. URL: https://www.samhsa.gov/data/report/2017-nsduh-annual-national-report. Accessed August 21, 2021.

Thumula, V., D. Wang, and T. Liu. Interstate Variations in Dispensing of Opioids, 4th Edition. July 31, 2019.

United Nations International Narcotics Control Board. Estimated World Requirements for 2017. Statistics for 2015. URL: https://www.incb.org/incb/en/narcotic-drugs/Technical_Reports/2016/narcotic-drugs-technical-report-2016.html. Accessed 8/21/2021].

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