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A	  Tale	  of	  2	  States	                   Amy	  Lee	  Special	  Deputy	  Commissioner,	  Policy	   and	  Research,	  T...
Learning	  Objec@ves	  1.  State	  what	  is	  needed	  to	  pass	  regula@ons	      and	  legisla@ons	  to	  control	  op...
Disclosure	  Statement	  •  Amy	  Lee	  has	  no	  financial	  rela@onships	  with	     proprietary	  en@@es	  that	  produ...
Third-­‐Party	  Payer	  Track:	    A	  Tale	  of	  Two	  States	                     Amy	  Lee	   Texas	  Department	  of	...
Presenta@on	  Highlights	  •  Overview	  of	  Texas	  WC	  system	  •  Pharmacy	  Closed	  Formulary	  –	  how	  it	  work...
Overview	  of	  Texas	  WC	  System	  •  More	  than	  270	  insurance	  companies	  ac@vely	  wri@ng	  WC	  •  $2	  billi...
Overview	  of	  Texas	  WC	  System	  •  U@lizes	  evidence-­‐based	  medicine	  treatment	  guidelines,	  Official	  Disabi...
Pharmacy	  Formulary	  Rules	  28	  TAC	  Chapter	  134	  	  Benefits—Guidelines	  for	  Medical	    Services,	  Charges	  ...
Insert	  open	  formulary	  reference	  here	                                    9	  
DefiniBons	  Exclusions	  from	  the	  Closed	  Formulary:	      –  drugs	  with	  “N”	  status	  iden@fied	  in	  the	  cur...
“N”	  Status	  Drugs	  •  ODG’s	  appendix	  A	  is	  the	  most	  current	  publica@on	         for	  “N”	  status	  drug...
Texas Department of Insurance                       Division of Workers’ Compensation  This table is provided as a conveni...
Preliminary	  Impact	  of	  Closed	  Pharmacy	                    Formulary	                                              ...
Data	  and	  Methods	  •  Injury months: September – February•  Injury years: 2009 – 2011•  Injury year 2011 (Sept 2011 – ...
Number	  of	  Claims	  Receiving	  an	  N-­‐Drug,	       by	  Injury	  Year	  (Sept-­‐Feb)	            10000	             ...
N-­‐drug	  Claims,	  as	  a	  Percentage	  of	  All	  Pharmacy	              Claims,	  by	  Injury	  Year	  (Sept-­‐Feb)	 ...
Number	  of	  N-­‐drug	  Prescrip@ons,	            by	  Injury	  Year	  (Sept-­‐Feb)	            25000	                   ...
N-­‐drugs	  as	  a	  Percentage	  of	  All	  Prescrip@ons	                by	  Injury	  Year	  (Sept-­‐Feb)	              ...
N-­‐drug	  Costs,	                        by	  Injury	  Year	  (Sept-­‐Feb)	          $3,000	          $2,404             ...
N-­‐drug	  Costs	  as	  a	  Percentage	  of	  Total	  Drug	  Costs,	                  by	  Injury	  Year	  (Sept-­‐Feb)	  ...
N-­‐drug	  Generic	  Subs@tu@on	  Rate,	              by	  Injury	  Year	  (Sept-­‐Feb)	                                  ...
Other	  Drugs	  •  Key measures:       Claim counts       Prescription utilization patterns       Prescription costs   ...
Number	  of	  Claims	  with	  Prescrip@ons	  for	  “Other”	  Drugs,	  by	  Injury	  Year	  (Sept-­‐Feb)	            60000	...
Claims	  with	  Prescrip@ons	  for	  “Other”	  Drugs	  as	       a	  Percentage	  of	  All	  Pharmacy	  Claims,	          ...
Number	  of	  Prescrip@ons	  for	  “Other”	      Drugs,	  by	  Injury	  Year	  (Sept-­‐Feb)	            250000	           ...
“Other”	  Drugs,	  as	  a	  Percentage	  of	  All	  Prescrip@ons,	  by	  Injury	  Year	  (Sept-­‐Feb)	            120.0%	 ...
“Other”	  Drug	  Costs,	                            by	  Injury	  Year	  (Sept-­‐Feb)	            $12,000	                ...
“Other”	  Drug	  Costs	  as	  a	  Percentage	  of	  Total	  Drug	             Costs,	  by	  Injury	  Year	  (Sept-­‐Feb)	 ...
“Other”	  Drug	  Generic	  Subs@tu@on	  Rate,	         by	  Injury	  Year	  (Sept-­‐Feb)	                                 ...
Average	  Number	  of	  Prescrip@ons	  per	  Claim,	              by	  Injury	  Year	  (Sept-­‐Feb)	            N-drug pre...
Transi@on	  of	  Legacy	  Claims	  to	  Pharmacy	  Closed	                           Formulary	                           ...
Open	  Formulary	  for	  Legacy	  Claims	  •  Applies	  to	  both	  network	  and	  non-­‐network	     claims	  with	  dat...
Open	  Formulary	  for	  Legacy	  Claims	  How	  are	  drugs	  prescribed	  in	  an	  open	  formulary?	    Non-­‐Network	...
Open	  Formulary	  •  Drugs	  included	  in	  an	  open	  formulary	  do	  not	     require	  preauthoriza@on,	  but	  are...
TransiBon	  of	  Legacy	  Claims	  	  To	  facilitate	  the	  transi@on,	  the	  prescribing	  doctor	      or	  the	  ins...
TransiBon	  of	  Legacy	  Claims	  	  Beginning	  no	  later	  than	  March	  1,	  2013,	  the	      insurance	  carrier	 ...
TransiBon	  of	  Legacy	  Claims	  The	  wriXen	  no@fica@on	  will	  contain:	     •  Date	  the	  closed	  formulary	  wi...
TransiBon	  of	  Legacy	  Claims	  Agreement:	  	  	       	  	  	  During	  the	  discussion	  the	  insurance	  carrier	...
TransiBon	  of	  Legacy	  Claims	  Agreement	  requirements:	  •  Must	  be	  documented	  by	  the	  carrier	  and	  shar...
Medical	  Interlocutory	  Order	  	                               “MIO”	  •  When	  the	  preauthoriza@on	  denial	  of	  ...
Number	  of	  Legacy	  Claims	  Receiving	  N-­‐ Drugs,	  by	  Prescrip@on	  Year	  (Sept-­‐Nov)	            18000	       ...
Contact	  Us	  •  www.tdi.texas.gov/wc/indexwc.html	  •  Medicalbenefits@tdi.texas.gov	  •  512-­‐804-­‐4000	  or	  800-­‐3...
Guidelines	  for	  Prescribing	  opioids	  to	  Treat	             Pain	  in	  Injured	  workers	  	          -­‐NaBonal	 ...
"To	  write	  prescrip@ons	  is	  easy,	  but	  to	  come	  to	  an	  understanding	  with	  	  people	  is	  hard."	  -­‐...
“We can’t solve problems byusing the same kind ofthinking we used when wecreated them”                              !
Change in National Norms for Use of Opioids           for Chronic, Non-cancer Pain  By the late 1990s, at least 20 states...
Similarities Between Illicit & Prescription Drugs
  	  Portenoy	  and	  Foley	               	  	  	  	  	  Pain	  1986;	  25:	  171-­‐186	    Retrospective case series ch...
Limitations of Long-term (>3 Months)                       Opioid Therapy  Overall,	  the	  evidence	  for	  long-­‐term	...
Risk/Benefit	  of	  Opioids	  for	  Chronic	  Non-­‐Cancer	  Pain	  
Dentists and Emergency Medicine Physicians were the main          prescribers for patients 5-29 years of age           5.5...
Opioid-Related Deaths,Washington State Workers Compensation, 1992–2005       14                                   Definite...
UnintenBonal	  and	  Undetermined	  Intent	  Drug	  Overdose	                 Death	  Rates	  by	  State,	  2007	         ...
UnintenBonal	  Poisoning	  Fatality	  Rate,	  1999-­‐2010,	                                       WISQARS	  NCHS	  data	  ...
Evidence	  linking	  specific	  doses	  to	  morbidity	                          and	  mortality	  Dunn et al, Ann Int Med ...
Evidence linking specific doses to morbidity                    and mortalityBohnert	  et	  al,	  JAMA	  2011;	  305:	  13...
Unintentional Overdose Deaths Involving       Opioid Analgesics Parallel Opioid Sales               United States, 1997–20...
Washington Agency Medical Directors                    Opioid Dosing Guidelines•     Developed with clinical pain experts ...
Washington Agency Medical Directors              Opioid Dosing Guidelines•  Part I – If patient has not had clear improvem...
Guidance for Primary Care Providers on Safe andEffective Use of Opioids for Chronic Non-cancer Pain  Establish	  an	  opi...
Open-source Tools Added to June 2010   Update of Opioid Dosing Guidelines  Opioid	  Risk	  Tool:	  Screen	  for	  past	  ...
Washington	  State	  Primary	  Care	  Survey	  2009:                                                                      ...
Washington	  State	  Primary	  Care	  Survey	  2009:	                   Adherence	  to	  State	  Guidelines	              ...
2009 CDC recommendations For practitioners, public payers, and  insurers Seek help at 120 mg/day MED if pain  and functi...
Franklin et al, Natural History of Chronic Opioid UseAmong Injured Workers with Low Back Pain-Clin J Pain,•  694/1843	  (3...
Randomized	  trial	  Re	  effec@veness	  of	  escala@ng	  dose	  •  RCT	  of	  “hold	  the	  line”	  vs	  escala@ng	  dose	...
New	  state	  policies	  ConnecBcut	  WC	  policy-­‐7/1/2012	     The	  total	  daily	  dose	  of	  opioids	  should	  not...
Yearly Trend of Scheduled Opioids                                           (Franklin et al, Am J Ind Med 2012; 55: 325-31...
Percent of Timeloss Claimants on Opioids                       2000 - 201040.0%35.0%30.0%25.0%20.0%15.0%10.0% 5.0% 0.0%   ...
Q1                                                                                                                     10-...
WA Workers Compensation Opioid-related                                   Deaths 1995-2010                       35        ...
Unintentional Prescription Opioid Overdose Deaths                                             Washington 1995-2010        ...
There	  is	  substanBal	  clustering	  among	  providers	  on	                              dosing	  and	  mortality	  	  ...
Early	  opioids	  and	  disability	  in	  WA	  WC.	  	  Spine	                        2008;	  33:	  199-­‐204	   Popula@o...
38% Increase since 2001
What can PCP do to safely and effectively use           opioids for CNCP?  Opioid treatment agreement  Screen for prior ...
Concrete steps to take•  Track high MED and prescribers•  Reverse permissive laws and set dosing and best practice standar...
Nov,	  2012	  	  WA	  Workers	  Compensa@on	                               Opioid	  Guideline	  •  Adop@on	  of	  the	  20...
Proper	  and	  	                                                               Necessary	  Care	      Stop	  and	  Take	  ...
Disability Prevention is the Key                             Health Policy Issue	                               100       ...
Opioid	  Use	  in	  Workers’	  Compensa@on	     •  Measuring	  the	  Impact	  of	  Opioid	  Use	           –  Beyond	  acu...
THANK	  YOU!	  For electronic copies of thispresentation, please e-mail        Laura Black        ljl2@uw.eduFor questions...
A tale of_two-states-final
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A tale of_two-states-final

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Third-Party Payer Track, National Rx Drug Abuse Summit, April 2-4, 2013. Presentation by Amy Lee and Dr. Gary Franklin

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Transcript of "A tale of_two-states-final"

  1. 1. A  Tale  of  2  States   Amy  Lee  Special  Deputy  Commissioner,  Policy   and  Research,  Texas  Department  of   Insurance,  Division  of  Workers’   Compensa@on   Dr.  Gary  Franklin    Medical  Director,  Washington  State  Department  of  Labor  and  Industries      
  2. 2. Learning  Objec@ves  1.  State  what  is  needed  to  pass  regula@ons   and  legisla@ons  to  control  opioid  use.  2.  Analyze  different  approaches  to  determine   what  would  work  in  their  jurisdic@on.  3.  Formulate  ideas  you  can  implement  in  your   home  states.   2  
  3. 3. Disclosure  Statement  •  Amy  Lee  has  no  financial  rela@onships  with   proprietary  en@@es  that  produce  health  care   goods  and  services.    •  Gary  Franklin  has  no  financial  rela@onships   with  proprietary  en@@es  that  produce  health   care  goods  and  services.     3  
  4. 4. Third-­‐Party  Payer  Track:   A  Tale  of  Two  States   Amy  Lee   Texas  Department  of  Insurance,  Division  of  Workers’  Compensa@on  
  5. 5. Presenta@on  Highlights  •  Overview  of  Texas  WC  system  •  Pharmacy  Closed  Formulary  –  how  it  works  •  Preliminary  impact    •  Transi@on  of  legacy  claims,  next  steps   5  
  6. 6. Overview  of  Texas  WC  System  •  More  than  270  insurance  companies  ac@vely  wri@ng  WC  •  $2  billion  in  direct  wriXen  premium  •  Including  self-­‐insured  employers  and  governmental  en@@es,  more   than  800  insurance  carriers  with  WC  claims  •  67%  of  private  year-­‐round  employers  have  WC  and  all  governmental   en@@es  have  WC  •  About  225,000  new  claims  filed  each  year  (including  medical  only   claims)  and  about  340,000  claims  receiving  medical  and/or  indemnity   benefits  each  year  •  Pharmacy  accounts  for  14%  of  medical  payments   –  Opioids  account  for  4.6%  of  medical  payments   6  
  7. 7. Overview  of  Texas  WC  System  •  U@lizes  evidence-­‐based  medicine  treatment  guidelines,  Official  Disability   Guidelines  (ODG)  and  return-­‐to-­‐work  guidelines  (Medical  Disability   Advisor)  •  Requires  certain  services  to  be  pre-­‐authorized  by  the  insurance  carrier/ u@liza@on  review  agent  and  allows  retrospec@ve  u@liza@on  review  of  any   service  that  is  not  pre-­‐authorized  •  Sets  fee  guidelines  for  professional,  inpa@ent/outpa@ent  hospital,  ASC  and   pharmacy  services  and  allows  pharmacy  contractual  discounts  •  Has  administra@ve  dispute  resolu@on  process  for  medical  necessity  and   medical  fee  disputes  •  Collects  medical  charges,  payments  and  u@liza@on  data  via  EDI  •  Allows  cer@fied  networks,  which  require  employees  to  select  network   trea@ng  doctors,  but  allows  employees  choice  of  pharmacy   7  
  8. 8. Pharmacy  Formulary  Rules  28  TAC  Chapter  134    Benefits—Guidelines  for  Medical   Services,  Charges  and  Payments   Subchapter  F,  Pharmaceu=cal  Benefits   8  
  9. 9. Insert  open  formulary  reference  here   9  
  10. 10. DefiniBons  Exclusions  from  the  Closed  Formulary:   –  drugs  with  “N”  status  iden@fied  in  the  current  edi@on   of  the  Official  Disability  Guideline  (ODG)  Treatment  in   Workers’  Comp/  Appendix  A,  ODG  Workers’   Compensa=on  Drug  Formulary  and  any  updates   –  any  compounded  drugs  that  contains  a  drug  iden@fied   with  an  “N”  status  in  ODG;  and   –  inves@ga@onal  or  experimental  drugs  as  defined  in   Texas  Labor  Code  §413.014(a)   10  
  11. 11. “N”  Status  Drugs  •  ODG’s  appendix  A  is  the  most  current  publica@on   for  “N”  status  drugs    www.worklossdata.com  •  TDI-­‐DWC  will  post  the  “N”  status  drugs  from  ODG’s   Appendix  A  on  its  website:    hXp:// www.tdi.state.tx.us/wc/dm/index.html  •  “N”  status  drugs  is  updated  monthly   11  
  12. 12. Texas Department of Insurance Division of Workers’ Compensation This table is provided as a convenience only and is not a substitute for the current edition of ODG Treatment in Workers Comp / Appendix A: ODG Workers Compensation Drug Formulary (see memo). ODG Texas Workers’ Compensation Status "N" Drugs (Excluded from the Closed Formulary as of May 31, 2012) Generic Drug Class Generic Name Brand Name Equivalency Status N (forOpioids Buprenorphine Suboxone® No pain) BuprenorphineOpioids (transdermal) Butrans™ No N Butalbital (aOpioids barbiturate) Fioricet® Yes NOpioids Fentanyl buccal Fentora® No NOpioids Fentanyl buccal film Onsolis™ No NOpioids Fentanyl lollipop Actiq® Yes N Fentanyl nasalOpioids spray Lazanda No N Fentanyl sublingualOpioids spray Subsys® No N FentanylOpioids transmucosal Abstral No N Hydrocodone/Opioids ibuprofen Vicoprofen® Yes NOpioids Hydromorphone ER Exalgo No N 12  
  13. 13. Preliminary  Impact  of  Closed  Pharmacy   Formulary   13  
  14. 14. Data  and  Methods  •  Injury months: September – February•  Injury years: 2009 – 2011•  Injury year 2011 (Sept 2011 – Feb 2012): new injuries that occurred after the implementation of the pharmacy closed formulary•  Nine months maturity per claim•  N-drug list: approximately 150 drugs that require carrier preauthorization. 14  
  15. 15. Number  of  Claims  Receiving  an  N-­‐Drug,   by  Injury  Year  (Sept-­‐Feb)   10000   8,957 9,104 9000   8000   7000   6000   5000   4000   3,616 3000   2000   -­‐60%   1000   0   2009 2010 2011Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research  and  Evalua@on  Group,  2013.   15  
  16. 16. N-­‐drug  Claims,  as  a  Percentage  of  All  Pharmacy   Claims,  by  Injury  Year  (Sept-­‐Feb)   20.0%   18.9% 18.2% 18.0%   16.0%   14.0%   12.0%   10.0%   8.0%   7.4% 6.0%   4.0%   -­‐59%   2.0%   0.0%   2009 2010 2011 Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research   and  Evalua@on  Group,  2013.   16  
  17. 17. Number  of  N-­‐drug  Prescrip@ons,   by  Injury  Year  (Sept-­‐Feb)   25000   20,473 20,895 20000   15000   10000   6,467 5000   -­‐69%   0   2009 2010 2011Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research  and  Evalua@on  Group,  2013.   17  
  18. 18. N-­‐drugs  as  a  Percentage  of  All  Prescrip@ons   by  Injury  Year  (Sept-­‐Feb)   10.0%   9.5% 9.0% 9.0%   8.0%   7.0%   6.0%   5.0%   4.0%   3.0% 3.0%   2.0%   1.0%   -­‐67%   0.0%   2009 2010 2011 Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research   and  Evalua@on  Group,  2013.   18  
  19. 19. N-­‐drug  Costs,   by  Injury  Year  (Sept-­‐Feb)   $3,000   $2,404 (000) $2,309 $2,500   (000) $2,000   $1,500   $1,000   $470 (000) $500   -­‐80%   $0   2009 2010 2011Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research  and  Evalua@on  Group,  2013.   19  
  20. 20. N-­‐drug  Costs  as  a  Percentage  of  Total  Drug  Costs,   by  Injury  Year  (Sept-­‐Feb)   25.0%   20.1% 20.0%   18.8% 15.0%   10.0%   4.6% 5.0%   0.0%   -­‐76%   2009 2010 2011 Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research   and  Evalua@on  Group,  2013.   20  
  21. 21. N-­‐drug  Generic  Subs@tu@on  Rate,   by  Injury  Year  (Sept-­‐Feb)   Brand Generic 5,150 4,821 2,595 48%   52%   1,214 32%   68%   2010 2011Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research  and  Evalua@on  Group,  2013.   21  
  22. 22. Other  Drugs  •  Key measures:   Claim counts   Prescription utilization patterns   Prescription costs   Generic substitution rates   Most prescribed drugs 22  
  23. 23. Number  of  Claims  with  Prescrip@ons  for  “Other”  Drugs,  by  Injury  Year  (Sept-­‐Feb)   60000   46,265 48,827 48,406 50000   40000   30000   20000   10000   -­‐1%   0   2009 2010 2011Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research  and  Evalua@on  Group,  2013.   23  
  24. 24. Claims  with  Prescrip@ons  for  “Other”  Drugs  as   a  Percentage  of  All  Pharmacy  Claims,   by  Injury  Year  (Sept-­‐Feb)   100.0%   93.6% 90.0%   81.1% 81.8% 80.0%   70.0%   60.0%   50.0%   40.0%   30.0%   20.0%   14%   10.0%   0.0%   2009 2010 2011 Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research   and  Evalua@on  Group,  2013.   24  
  25. 25. Number  of  Prescrip@ons  for  “Other”   Drugs,  by  Injury  Year  (Sept-­‐Feb)   250000   211,099 210,593 195,111 200000   150000   100000   50000   -­‐<.1%   0   2009 2010 2011Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research  and  Evalua@on  Group,  2013.   25  
  26. 26. “Other”  Drugs,  as  a  Percentage  of  All  Prescrip@ons,  by  Injury  Year  (Sept-­‐Feb)   120.0%   97.0% 100.0%   90.5% 91.0% 80.0%   60.0%   40.0%   20.0%   7%   0.0%   2009 2010 2011Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research  and  Evalua@on  Group,  2013.   26  
  27. 27. “Other”  Drug  Costs,   by  Injury  Year  (Sept-­‐Feb)   $12,000   $9,998   $9,874   $9,558   (000)   (000)   $10,000   (000)   $8,000   $6,000   $4,000   $2,000   $0   -­‐  <1%   2009 2010 2011Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research  and  Evalua@on  Group,  2013.   27  
  28. 28. “Other”  Drug  Costs  as  a  Percentage  of  Total  Drug   Costs,  by  Injury  Year  (Sept-­‐Feb)   100.0%   95.4% 90.0%   79.9% 81.2% 80.0%   70.0%   60.0%   50.0%   40.0%   30.0%   20.0%   10.0%   0.0%   17%   2009 2010 2011 Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research   and  Evalua@on  Group,  2013.   28  
  29. 29. “Other”  Drug  Generic  Subs@tu@on  Rate,   by  Injury  Year  (Sept-­‐Feb)   Brand Generic 85,360 82,231 (91%) (94%) 8,600 5,290 (9%) (6%) 2010 2011Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research  and  Evalua@on  Group,  2013.   29  
  30. 30. Average  Number  of  Prescrip@ons  per  Claim,   by  Injury  Year  (Sept-­‐Feb)   N-drug prescriptions per claim Other-drug prescriptions per claim 5 4.4 4.2 4.3 4 3 2.3 2.3 1.8 2 +2%   1 -­‐22%   0 2009 2010 2011 Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research   and  Evalua@on  Group,  2013.   30  
  31. 31. Transi@on  of  Legacy  Claims  to  Pharmacy  Closed   Formulary   31  
  32. 32. Open  Formulary  for  Legacy  Claims  •  Applies  to  both  network  and  non-­‐network   claims  with  dates  of  injury  prior  to  September  1,   2011  •  A  legacy  claim  is  any  date  of  injury  prior  to   September  1,  2011  •  Subject  to  the  open  formulary  un@l  September   1,  2013   32  
  33. 33. Open  Formulary  for  Legacy  Claims  How  are  drugs  prescribed  in  an  open  formulary?   Non-­‐Network   •  According  to  the  ODG  treatment  guidelines   Network   •  According  to  the  cer@fied  network’s   treatment  guidelines   33  
  34. 34. Open  Formulary  •  Drugs  included  in  an  open  formulary  do  not   require  preauthoriza@on,  but  are  subject  to   retrospec@ve  review  •  However,  inves@ga@onal  or  experimental  drugs   require  preauthoriza@on   34  
  35. 35. TransiBon  of  Legacy  Claims    To  facilitate  the  transi@on,  the  prescribing  doctor   or  the  insurance  carrier  may:   •  Contact  each  other  to  discuss  ongoing  pharmacological   management  of  the  injured  employee’s  claim   •  When  the  par@es  contact  each  other,  they  must  provide   a  name,  phone  number,  date  and  @me  to  discuss   ongoing  pharmacological  management  of  the  injured   employee’s  claim   35  
  36. 36. TransiBon  of  Legacy  Claims    Beginning  no  later  than  March  1,  2013,  the   insurance  carrier  shall:   •  Iden@fy  legacy  claims  where  an  excluded   drug  has  been  prescribed  aqer  September   1,  2012   •  Provide  wriXen  no@fica@on  to  the  injured   employee,  prescribing  doctor  and   pharmacy,  if  known   36  
  37. 37. TransiBon  of  Legacy  Claims  The  wriXen  no@fica@on  will  contain:   •  Date  the  closed  formulary  will  apply   •  Name,  telephone  number,  and  date  and  @me   to  discuss  ongoing  pharmacological   management  of  the  injured  employee’s  claim   37  
  38. 38. TransiBon  of  Legacy  Claims  Agreement:            During  the  discussion  the  insurance  carrier  and   a  prescribing  doctor  may  enter  into  an   agreement  on  the  applica@on  of  the  closed   formulary  on  an  individual  claim-­‐by-­‐claim  basis   38  
  39. 39. TransiBon  of  Legacy  Claims  Agreement  requirements:  •  Must  be  documented  by  the  carrier  and  shared   with  the  prescribing  doctor  and  injured  employee  •  Health  care  provided  as  a  result  of  the  agreement   is  not  subject  to  retrospec@ve  review  If  an  agreement  is  not  reached:  •  A  denial  of  a  request  for  an  agreement  is  not   subject  to  dispute  resolu@on  •  Closed  formulary  applies  as  of  9/1/2013   39  
  40. 40. Medical  Interlocutory  Order     “MIO”  •  When  the  preauthoriza@on  denial  of  a  drug   excluded  from  the  closed  formulary;  •  Poses  an  unreasonable  risk  of  medical   emergency  to  the  injured  employee;    •  Provides  a  means  for  an  injured  employee  to   con@nue  use  of  the  previously  prescribed  and   dispensed  drug(s)  throughout  the  dura@on  of   the  appeals/dispute  process.   40  
  41. 41. Number  of  Legacy  Claims  Receiving  N-­‐ Drugs,  by  Prescrip@on  Year  (Sept-­‐Nov)   18000   15,682   16000   14000   12000   10000   8,032   8000   6000   4000   -­‐49%   2000   0   2011 2012Source:  Texas  Department  of  Insurance,  Workers’  Compensa@on  Research  and  Evalua@on  Group,  2013.   41  
  42. 42. Contact  Us  •  www.tdi.texas.gov/wc/indexwc.html  •  Medicalbenefits@tdi.texas.gov  •  512-­‐804-­‐4000  or  800-­‐372-­‐7713   42  
  43. 43. Guidelines  for  Prescribing  opioids  to  Treat   Pain  in  Injured  workers     -­‐NaBonal  Rx  Drug  Abuse  Summit-­‐   Orlando,  FL   Wed  April  3,  2013   Gary  M.  Franklin,  MD,  MPH   Medical  Director   WA  Dept  of  Labor  and  Industries   Research  Professor   University  of  washington  
  44. 44. "To  write  prescrip@ons  is  easy,  but  to  come  to  an  understanding  with    people  is  hard."  -­‐-­‐  Franz  Kaua,   A  Country  Doctor  
  45. 45. “We can’t solve problems byusing the same kind ofthinking we used when wecreated them” !
  46. 46. Change in National Norms for Use of Opioids for Chronic, Non-cancer Pain  By the late 1990s, at least 20 states passed new laws, regulations, or policies moving from near prohibition of opioids to use without dosing guidance   WA law: No disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opioids prescribed. (WAC 246-919-830, 12/1999)  Laws were based on weak science and good experience with cancer pain WAC-Washington Administrative Code46
  47. 47. Similarities Between Illicit & Prescription Drugs
  48. 48.    Portenoy  and  Foley            Pain  1986;  25:  171-­‐186    Retrospective case series chronic, non-cancer pain  N=38; 19 Rx for at least 4 years  2/3 < 20 mg MED/day; 4> 40 mg MED/day  24/38 acceptable pain relief  No gain in social function or employment could be documented  Concluded: Opioid maintenance therapy can be a safe, salutary and more humane alternative…
  49. 49. Limitations of Long-term (>3 Months) Opioid Therapy  Overall,  the  evidence  for  long-­‐term  analgesic  efficacy  is  weak    PutaBve  mechanisms  for  failed  opioid  analgesia  may  be   related  to  rampant  tolerance    The  premise  that  tolerance  can  always  be  overcome  by  dose   escalaBon  is  now  quesBoned    100%  of  paBents  on  opioids  chronically  develop  dependence     More  than  50%  of  paBents  on  opioids  for  3  months  will   sBll  be  on  opioids  5  years  later   Ballantyne J. Pain Physician 2007;10:479-91; Martin BC et al. J Gen Intern Med 2011; 26: 1450-5749
  50. 50. Risk/Benefit  of  Opioids  for  Chronic  Non-­‐Cancer  Pain  
  51. 51. Dentists and Emergency Medicine Physicians were the main prescribers for patients 5-29 years of age 5.5  million  prescripBons  were  prescribed  to  children  and  teens  (19  years  and  under)  in  2009   900   800   700   600   Rate  per  10,000  persons   GP/FM/DO   500   IM   400   DENT   300   ORTH  SURG   EM   200   100   0   0-­‐4                 5-­‐9                 10-­‐14             15-­‐19             20-­‐24             25-­‐29             30-­‐39   40-­‐59   60+   Age  Group  Source:  IMS  Vector  ®One  Na@onal,  TPT  06-­‐30-­‐10  Opioids  Rate  2009  
  52. 52. Opioid-Related Deaths,Washington State Workers Compensation, 1992–2005 14 Definite Probable 12 10 8 Deaths 6 4 2 0 95 96 97 98 99 00 01 02 Year Franklin GM, et al, Am J Ind Med 2005;48:91-9 52
  53. 53. UnintenBonal  and  Undetermined  Intent  Drug  Overdose   Death  Rates  by  State,  2007   MD   12.5   MA   12.5   NH   11.7   RI   11.1   CT   11.1   DE   9.8   DC   8.8     VT   7.9   NJ   7.5   Age-­‐adjusted  rate  per     100,000  populaBon   National Vital Statistics System, http://wonder.cdc.gov53
  54. 54. UnintenBonal  Poisoning  Fatality  Rate,  1999-­‐2010,   WISQARS  NCHS  data   16   14  Deaths/100,000   12   10   8   California  n=3580   6   Ohio  n=1678   4   2   Utah  n=273   0   Washington  n=754   Year  
  55. 55. Evidence  linking  specific  doses  to  morbidity   and  mortality  Dunn et al, Ann Int Med 2010; 152: 85-92 Risk of morbidity and mortality increased 8.9 fold at 100 mg MED Editorial-McLellan-White House Office of National Drug Control Policy   Smarter, more responsible (prescribing) practices are the only hope to avoid tragic, avoidable deathsBraden et al, Arch Int Med 2010; 170: 1425-32 Opioid doses >120 mg/day MED and use of long acting Schedule II opioids associated with incresed risk of alcohol- or drug- related ER visit*
  56. 56. Evidence linking specific doses to morbidity and mortalityBohnert  et  al,  JAMA  2011;  305:  1315-­‐21  •  Risk  of  mortality  7.18  (chronic  pain),  6.64  (acute  pain)  Gomes  et  al,  Arch  Int  Med  2011;  171:  686-­‐91  •  Risk  of  mortality  2.04  at  100  mg  and  2.88  at  200  mg  
  57. 57. Unintentional Overdose Deaths Involving Opioid Analgesics Parallel Opioid Sales United States, 1997–2007  Distribution by drug Opioid sales * (mg/ companies person)   96  mg/person  in  1997   627%     698  mg/person  in  2007   increase       Enough  for  every  American to take 5 mg Vicodin every 4 hrs for 3 weeks   Year  Overdose deaths Opioid deaths   2,901  in  1999   296%  increase       11,499  in  2007   Year National Vital Statistics System, multiple cause of death data set and Drug Enforcement Administration ARCOS system;57 2007 opioid sales figure is preliminary
  58. 58. Washington Agency Medical Directors Opioid Dosing Guidelines•  Developed with clinical pain experts in 2006•  Implemented April 1, 2007•  First guideline to emphasize dosing guidance•  Educational pilot, not new standard or rule•  National Guideline Clearinghouse –  http://www.guideline.gov/content.aspx?id=23792&search=wa+opioids 58 www.agencymeddirectors.wa.gov  
  59. 59. Washington Agency Medical Directors Opioid Dosing Guidelines•  Part I – If patient has not had clear improvement in pain AND function at 120 mg MED (morphine equivalent dose) , take a deep breath –  If needed, get one-time pain management consultation (certified in pain, neurology, or psychiatry)•  Part II – Guidance for patients already on very high doses >120 mg MED 59 www.agencymeddirectors.wa.gov  
  60. 60. Guidance for Primary Care Providers on Safe andEffective Use of Opioids for Chronic Non-cancer Pain  Establish  an  opioid  treatment  agreement    Screen  for     Prior  or  current  substance  abuse       Depression    Use  random  urine  drug  screening  judiciously     Shows  pa@ent  is  taking  prescribed  drugs     Iden@fies  non-­‐prescribed  drugs    Do  not  use  concomitant  sedaBve-­‐hypnoBcs    Track  pain  and  funcBon  to  recognize  tolerance    Seek  help  if  dose  reaches  120  mg  MED,  and  pain  and  funcBon  have   not  substanBally  improved     http://www.agencymeddirectors.wa.gov/opioiddosing.asp MED, Morphine equivalent dose60
  61. 61. Open-source Tools Added to June 2010 Update of Opioid Dosing Guidelines  Opioid  Risk  Tool:  Screen  for  past  and  current              substance  abuse    CAGE-­‐AID  screen  for  alcohol  or  drug  abuse    PaBent  Health  QuesBonnaire-­‐9  screen  for  depression    2-question tool for tracking pain and function  Advice on urine drug testing Available  as  mobile  app:  hXp:// www.agencymeddirectors.wa.go v/opioiddosing.asp  61 hXp://www.agencymeddirectors.wa.gov/opioiddosing.asp#DC  
  62. 62. Washington  State  Primary  Care  Survey  2009:   Physician  Concerns   Please  check  the  statement  that  most  accurately  reflects     your  experience  when  prescribing  opioids     for  chronic,  non-­‐cancer  painNO  concerns  about  development  of  psychological  dependence,   2%addicBon,  or  diversion  OCCASIONAL  concerns  about  development  of  psychological   45%dependence,  addicBon,  or  diversion  FREQUENT  concerns  about  development  of  psychological   54%dependence,  addicBon,  or  diversion   Interim  Evalua@on  of  the  Opioid  Dosing  Guidelines.  hXp://www.agencymeddirectors.wa.gov   62  
  63. 63. Washington  State  Primary  Care  Survey  2009:   Adherence  to  State  Guidelines   Always  or   Never  or   Guidance   SomeBmes Olen almost   almost  never alwaysUse  treatment  agreement 10% 22% 20% 49%Screen  for  substance  abuse <1% 3% 15% 81%Screen  for  mental  illness <1% 12% 30% 58%Use  random  urine  screen 30% 32% 18% 20%Use  paBent  educaBon 34% 38% 19% 9%Track  pain   40% 31% 15% 15%Track  physical  funcBon 69% 20% 7% 5% Interim  Evalua@on  of  the  Opioid  Dosing  Guidelines.  hXp://www.agencymeddirectors.wa.gov   63  
  64. 64. 2009 CDC recommendations For practitioners, public payers, and insurers Seek help at 120 mg/day MED if pain and function not improving http://www.cdc.gov/ HomeandRecreationalSafety/pdf/poision- issue-brief.pdf
  65. 65. Franklin et al, Natural History of Chronic Opioid UseAmong Injured Workers with Low Back Pain-Clin J Pain,•  694/1843  (37.6%)  received  opioid  early   Dec, 2009•  111/1843  (6%)  received  opioids  for  1  yr  •  MED  increased  sign  from  1st  to  4th  qtr  •  Only  minority  improved  by  at  least  30%  in  pain  (26%)   and  funcBon  (16%)  •  Strongest  predictor  of  long  term  opioid  use  was  MED   in  1st  qtr  (40  mg  MED  had  OR  6)  •  Avg  MED  42.5  mg  at  1  yr;  Von  Korff  55  mg  at  2.7  yrs  
  66. 66. Randomized  trial  Re  effec@veness  of  escala@ng  dose  •  RCT  of  “hold  the  line”  vs  escala@ng  dose  strategies  •  N=135,  parallel  group  pragma@c  study  •  No  change  in  any  primary  pain  or  func@on  outcome  •  27%  discharged  due  to  misuse/non-­‐compliance  *Naliboff  et  al,  2011  (FEB);  12:  288-­‐96  
  67. 67. New  state  policies  ConnecBcut  WC  policy-­‐7/1/2012   The  total  daily  dose  of  opioids  should  not  be  increased  above  90mg  oral  MED/day   (Morphine  Equivalent  Dose)  unless  the  pa@ent  demonstrates  measured   improvement  in  func@on,  pain  or  work  capacity.  Second  opinion  is  recommended  if   contempla@ng  raising  the  dose  above  90  MED/day.  MaineCare  (Medicaid)-­‐4/1/2012   Total  45  day  maximum  for  non-­‐cancer  pain  New  Mexico-­‐Rule  16.10.14-­‐Proposed  rules  Aug,  2012    A  health  care  prac@@oner  shall,  before  prescribing,  ordering,   administering  or  dispensing  a  controlled  substance  listed  in  schedule  II,  III   or  IV,  obtain  a  pa@ent  PMP  report  for  the  preceding  twelve  (12)  months  
  68. 68. Yearly Trend of Scheduled Opioids (Franklin et al, Am J Ind Med 2012; 55: 325-31 ) 100,000Number of Opioid Prescriptions 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 Schedule II Schedule III Schedule IV
  69. 69. Percent of Timeloss Claimants on Opioids 2000 - 201040.0%35.0%30.0%25.0%20.0%15.0%10.0% 5.0% 0.0% Opioids Highdose Opioids
  70. 70. Q1 10- Q3 09- Q1 09- Q3 08- Q1 08- 2010 Q1 Q3 2009 Q3Washington Workers Compensation, 1996–2010 07- 2009 Q1 Q1 07- 2008 Q3 Q3 2008 Q1 06- 2007 Q3 Average Daily Dosage for Opioids, Q1 06- 2007 Q1 Q3 2006 Q3 05- 2006 Q1 Q1 Long-acting opioids 05- 2005 Q3 Short-acting opioids 2005 Q1 Q3 04- 2004 Q3 Q1 2004 Q1 04- 2003 Q3 Q3 03- 2003 Q1 Year/Quarter Q1 2002 Q3 03- 2002 Q1 Q3 02- 2001 Q3 Q1 2001 Q1 02- 2000 Q3 Q3 01- 2000 Q1 Q1 1999 Q3 01- 1999 Q1 Q3 00- 1998 Q3 Q1 1998 Q1 00- 1997 Q3 Q3 1997 Q1 99- 1996 Q3 Q1 99- 1996 Q1 Q3 98- 140 120 100 80 60 40 20 0 70 Q1 98- MED (mg/day) Q3 97- Q1 97- Q3 96- Q1 96-
  71. 71. WA Workers Compensation Opioid-related Deaths 1995-2010 35 30Opioid-related Death 25 20 15 10 5 0 Possible Probable Definite
  72. 72. Unintentional Prescription Opioid Overdose Deaths Washington 1995-2010 600 500 420 Number of deaths 400 300 200 100 24 0 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 Prescription Opioid + alcohol or illicit drug Prescription Opioid +/- Other Prescriptions* Tramadol only deaths included in 2009, but not in prior years.Source: Washington State Department of Health, Death Certificates
  73. 73. There  is  substanBal  clustering  among  providers  on   dosing  and  mortality    CA  CWCI  study-­‐Swedlow  et  al,  March,  2011:  3%  of  prescribers   account  for  55%  of  Schedule  II  opioid  Rxs: hXp://www.cwci.org/research.html  Dhalla  et  al,    Clustering  of  opioid  prescribing  and  opioid-­‐related   mortality  among  family  physicians  in  Ontario.  Can  Fam   Physician  2011;  57:  e92-­‐96    Upper  quin@le  of  frequent  opioid  prescribers  associated  with   last  opioid  Rx  in  62.7%  of  public  plan  beneficiary  uninten@onal   poisoning  deaths  DLI  sent  leXers  to  all  prescribers  with  any  pa@ent  on  opioid  doses  at  or  above  120  mg/day  MED-­‐ONLY  N=60  •  Call  their  aXen@on  to  AMDG  Guidelines  and  new  WA  state   regula@ons  •  Associate  medical  director  will  meet  with  these  docs   personally  
  74. 74. Early  opioids  and  disability  in  WA  WC.    Spine   2008;  33:  199-­‐204   Popula@on-­‐based,  prospec@ve  cohort   N=1843  workers  with  acute  low  back  injury  and  at   least  4  days  lost  @me   Baseline  interview  within  18  days(median)     14%  on  disability  at  one  year   Receipt  of  opioids  for  >  7  days,  at  least  2  Rxs,  or    >  150   mg  MED  doubled  risk  of  1  year  disability,  aqer   adjustment  for  pain,  func@on,  injury  severity  
  75. 75. 38% Increase since 2001
  76. 76. What can PCP do to safely and effectively use opioids for CNCP?  Opioid treatment agreement  Screen for prior or current substance abuse/ misuse (alcohol, illicit drugs, heavy tobacco use)  Screen for depression  Prudent use of random urine drug screening (diversion, non-prescribed drugs)  Do not use concomitant sedative-hypnotics or benzodiazepines  Track pain and function to recognize tolerance  Seek help if MED reaches 120 mg and pain and function have not substantially improved  Use PDMP!
  77. 77. Concrete steps to take•  Track high MED and prescribers•  Reverse permissive laws and set dosing and best practice standards for chronic, non-cancer pain•  Implement AMDG Opioid Dosing Guidelines ( http://www.agencymeddirectors.wa.gov/opioiddosing.asp)•  Implement effective Prescription Monitoring Program; check the PDMP on every new injured worker who receives opioid Rx•  Encourage/incent use of best practices (web-based MED calculator, use of state PMPs)•  DO NOT pay for office dispensed opioids•  ID high prescribers and offer assistance•  Incent community-based Rx alternatives (activity coaching and graded exercise early, opioid taper/multidisciplinary Rx later)•  Offer assistance (academic detailing, free CME,ECHO)
  78. 78. Nov,  2012    WA  Workers  Compensa@on   Opioid  Guideline  •  Adop@on  of  the  2010  AMDG  Interagency   Guideline  on  Opioid  Dosing  for  Chronic  Non-­‐ cancer  Pain    •  This  Supplement  provides  addi@onal   informa@on  and  guidance  for  trea@ng  work-­‐ DOH  pain  management  rules,  2010  AMDG  Guideline  and   related  injuries   reflec@ve  of  the  prac@ce  standard  for   this  Supplement  are   prescribing  opioids  for  a  work-­‐related  injury  or   occupa@onal  disease.   79  
  79. 79. Proper  and     Necessary  Care   Stop  and  Take  a  Deep   for     Breath  at  6  weeks  and   Clinically  Meaningful   Opioid   before  COT   Improvement  in   Prescribing     Func@on   Case  Defini@on    Managing  Surgical   &     Addic@on  Treatment   Pain  in     Workers  on  COT   Algorithms   for     Discon@nuing     COT   80  
  80. 80. Disability Prevention is the Key Health Policy Issue   100 80%  of  cases  on   Bme  loss 60 40 20 0 0 1 2 3 4 5 6 7 8 9 10 11 12 Time  loss  duraBon  (months) Adapted from Cheadle et al. Am J Public Health 1994; 84:190–196.!
  81. 81. Opioid  Use  in  Workers’  Compensa@on   •  Measuring  the  Impact  of  Opioid  Use   –  Beyond  acute  phase,  effec@ve  use  should  result  in   clinically  meaningful  improvement  in  func@on   (CMIF)   –  CMIF  is  an  improvement  in  func@on  of  at  least  30%   compared  to  start  of  treatment  or  in  response  to  a   dose  change    Con@nuing  to  prescribe  opioids  in  the  absence  of  CMIF  or  aqer  the  development  of   –  Evalua@on  of  clinically  meaningful  improvement  a  severe  adverse  outcome  is  not  proper  and  necessary  care.  In  addi@on,  the  use  of   escala@ng  doses  to  tccur  at  3dcri@cal  phases  (acute,  subacute   and   should  o he  point  of     eveloping  opioid  use  disorder  is  not  proper   and  during  COT)   necessary  care.   1  
  82. 82. THANK  YOU!  For electronic copies of thispresentation, please e-mail Laura Black ljl2@uw.eduFor questions or feedback, please e-mail Gary Franklin meddir@u.washington.edu
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