The topic of opioid abuse in workers’ compensation largely focuses on the causes and costs of that abuse to the effectiveness of the state-level reforms that address what some experts identify as a “plague.” Particularly alarming opioid-related statistics and the high cost of prescription drugs in Florida have prompted a strong legislative response in the Sunshine State. In Florida, the high cost of prescription drugs, and not so much what was being prescribed, is what drove legislation after the pill mill bill was passed in 2011 to address the increased costs impacting the Florida workers’ compensation system.
A January 16, 2014 webinar titled “WCRI and Brandeis Discuss Lessons on How States Can Control the Misuse and Abuse of Opioids” hosted by the Workers Compensation Research Institute focused on high-profile efforts by Florida to reduce the extent to which claimants receive unduly large quantities of opioids. WCRI Policy Analyst Vennela Thumula and Peter Kreiner, Ph.D. of Brandeis University in Waltham, Massachusetts were the presenters.
Impact of Banning Physician Dispensing of Stronger Opioids in Florida
Thumula began her presentation with a primer on the scope of the “pill mill” problem in Florida that prompted state legislative reforms. These initiatives included House Bill 7095 (HB 7095), which was known as the “Florida Pill Mill Bill. The provisions in that legislation became effective July 1, 2011.
The term “pill mill” refers to some physicians in every state dispensing excessive quantities of prescription medications from their offices for prices that typically are higher than the cost of such drugs from pharmacies. Although this trend is not limited to opioids, the research on which Thumula based her discussion in the webinar was restricted to that class of drugs.
This scope was more specifically limited to Schedule II and Schedule III drugs. Thumula described opioids that were within the range of Schedule II drugs as having a potential for being highly addictive. She provided the examples of Percocet and Oxycontin.
The description of Schedule III drugs was that they presented a lower risk of addiction than Schedule II drugs. Thumula offered Vicodin as an example of this class of drugs.
Thumula illustrated the extent of the “pill mill” problem before the effective date of the provisions in HB 7095 by citing the statistic that 90 of the top 100 doctors who prescribed Oxycontin in the United States in 2010 were from Florida.
In discussing HB 7095, Thumula emphasized that the provisions in that legislation broadly governed the prescription-drug dispensing practices of all Florida doctors and was not specific to the workers’ compensation system in that state. That law generally prohibited physicians from dispensing any controlled substance that was classified as Schedule II or Schedule III.
The very limited exceptions to that prohibition included:
> Drug samples; and
> A limited quantity of medication for the period following a surgery
Other provisions in HB 7095 required that physicians to which it applied use prescription pads that could not be counterfeited and that those medical professionals additionally register as controlled-substance prescribing physicians. The available penalties for not complying with any provision under HB 7095 included a six-month suspension of a medical license.
The reported results of Thumula’s research indicated that HB 7095 largely achieved the objective of reducing the amount of physician-dispensed Schedule II and Schedule III drugs. She summarized these findings regarding the period after the effective date of HB 7095 as following:
> The level of physician-dispensed Schedule II and III opioids fell to practically zero;
> The remaining amount of physician-dispensed Schedule II and III opioids was attributable to either surgical cases and other exemptions under HB 7095 or were dispensed by out-of-state physicians who were not subject to the provisions in that legislation;
> Florida physicians who continued dispensing prescription drugs switched to pain medications, such as ibuprofen, that were not classified as Schedule II or III drugs; and
> The provisions in HB 7095 did not affect the level of pharmacy-dispensed Schedule II and Schedule III drugs.
These findings and other results related to HB 7095 demonstrated that it effectively addressed one aspect of the opioid “plague” by reducing the flow of those prescription drugs from the offices of physicians.
Prescription Drug Monitoring Program Data
Kreiner’s presentation focused on Florida and other states using Prescription Drug Monitoring Programs (PDMPs) to address the abuse and misuse of opioids. He described these programs as state-operated databases that amassed information regarding prescriptions for opioids and other prescription medications that fell within the scope of a PDMP in a state. Kreiner added that the reach of PDMPs extended to the general healthcare services in a state and was not specific to prescriptions within a workers’ compensation system.
The research that Kreiner and his colleagues at Brandeis’ PDMP Center of Excellence conduct under the Prescription Behavior Surveillance System (PBSS) relates to analyzing the data from PDMPs in several states. They use this information to identify prescription and dispensing trends.
These trends are studied to determine whether they indicate a probability of abuse and misuse related to opioids and/or other controlled substances. Federal government support of this effort includes grants from the U.S. Food and Drug Administration and the Centers for Disease Control.
Specific statistics that the PBSS calculated included:
> Information regarding opioid use among various age groups;
> Variations in opioid prescription practices among states; and
> Data regarding prescription practices of specific prescribers
The portion of Kreiner’s presentation that focused on privacy issues related to the data that a PDMP collected included limiting the use of some information to research purposes and redacting some personal information from the records; the non-disclosed data included a patient’s:
> Date of birth; and
Florida-Specific PDMP Information
The portion of Kreiner’s presentation that specifically addressed the PDMP program that Florida implemented in response to opioid-related issues, which included patients simultaneously obtaining prescriptions for opioids from multiple prescribers and filling those prescriptions at multiple pharmacies, initially reported that the program started in September 2011.
The data from Florida that the PBSS collected for the period following implementing the PDMP in that state showed significant across-the-board decreases in opioid-related statistics. One example was the daily opioid dosage measured in a morphine milligram equivalent (MME) dropping from an alarming 100 MME in the first quarter of 2011 to roughly 80 MME in the fourth quarter of 2012.
Kreiner reported as well that the number of deaths in Florida in which a controlled prescription drug was either the primary or contributing cause fell almost 18 percent in 2012 compared to the number of those deaths in 2011. The number of deaths during those periods in which Oxycontin played a significant role fell 41 percent.
Lessons From the Sunshine State
The data that Thumula and Kreiner presented showed that the Florida legislature did a good job drafting and implementing legislation that addressed practices that contributed to the abuse and misuse of opioids in that state. The indications regarding high compliance rates among the affected individuals further demonstrated that those reforms provided a good model for other states’ efforts to combat the opioid “plague.”
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