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Joseph Paduda


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Compliance with Narcotics Guidelines …

Compliance with Narcotics Guidelines
National Rx Drug Abuse Summit 4-11-12

Published in: Economy & Finance, Business
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  • 1. Compliance withNarcotics Guidelines April 10-12, 2012 Walt Disney World Swan Resort
  • 2. Learning Objectives:1.  Describe how managed care programs, employers, health care providers and insurers are susceptible to increased workers compensation costs due to prescription drug abuse.2.  Identify strategies employers and medical professionals can use to help drug-dependent and addicted employees regain control of their lives and return to work using results of CompPharma’s survey, “Prescription Drug Management in Workers’ Compensation – The Eighth Annual Survey.”3.  Describe how Washington State has addressed the over use of opioids in workers’ compensation.
  • 3. Disclosure Statement•  Joseph Paduda has disclosed that he has a relationship with Reckitt Benckiser’s Suboxone Sublingual Film and Millennium Laboratories.•  Dr. Richard A. Victor has disclosed no relevant, real or apparent personal or professional financial relationships.
  • 4. Agenda•  The problem•  The impending disaster•  Efforts to prevent the disaster
  • 5. California Workers Comp Institute, Preliminary ResultsPharmaceutical Utilization & Cost - Schedule-II Opioid Drugs1 25% 20% 383.3% 15% 10% 5% 355.8% 0% 2002 2003 2004 2005 2006 2007 2008 2009 2010 Pcnt Scripts 1.2% 1.4% 1.9% 1.4% 1.8% 3.3% 5.5% 5.7% 5.8% Pcnt Pymts 4.3% 4.6% 6.5% 3.7% 4.2% 10.0% 17.7% 19.0% 19.6%1 Calculations are on a calendar year basis Exhibit 5
  • 6. Analysis of Prescribing Patterns Schedule II Opioids Top Injury Categories w/ Schedule II Opioids Pcnt of S-II Pcnt of S-II Pcnt of S- Opioid Opioid II Opioid Diagnostic Category Claims Scrips Pymnts Medical Back w/o Spinal Cord Invlvmnt 35.7% 47.1% 50.2% Spine Disorders w/ Spinal Cord or Root Invlvmnt 11.3% 15.1% 16.1% Cranial & Peripheral Nerve Dis 5.0% 6.8% 6.5% Degen, Infect & Metabol Joint Dis 9.3% 6.1% 5.4% Other Injuries, Poisonings & Toxic Effects 5.5% 5.9% 6.8% Ruptured Tendon, Tendonitis, Myositis & Bursitis 6.0% 3.6% 2.7% Sprain of Shoulder, Arm, Knee or Lower Leg 6.8% 3.2% 2.8% Wound, FX of Shoulder, Arm, Knee or Lower Leg 6.3% 2.7% 1.6% Other Mental Disturb 1.2% 1.7% 1.5% Other Diagnoses of Musculoskeletal Sys 1.5% 1.4% 1.1% CWCI 3/2011 Exhibit 6
  • 7. Pain Management and the Use of Opioids Exhibit 7
  • 8. Background on Pain ManagementOpioids are often used to treat pain Exhibit 8
  • 9. CWCI - Pain Mgt and the Use of Opioids Distribution by Primary Diagnosis Percent ofICD-9 Primary Diagnosis Claims Sample847.2 Sprain Lumbar Region 59,738 35.9%846 Sprain Lumbosacral 25,334 15.2%847 Sprain of Neck 24,950 15.0%847.1 Sprain Thoracic Region 15,681 9.4%724.2 Lumbago 9,449 5.7%847.9 Sprain of Back NOS 4,935 3.0%724.5 Backache NOS 5,208 3.1%722.52 Lumbar/Lumbosacral Disc 3,542 2.1% Degeneration846 Sprain Lumbosacral 3,040 1.8%723.1 Cervicalgia 2,963 1.8%Sub-Total 154,840 93.1% Exhibit 9
  • 10. Pain Mgt and the Use of OpioidsDistribution by Category of Number of Morphine Equivalents Average Range of Number of Number of Morphine Morphine Equivalents in Equivalents in Category Category Category No MEs 0 0 Category 1 124 3-240 Category 2 406 241-650 Category 3 1,207 651-2100 Category 4 14,870 2,101 and up Exhibit 10
  • 11. Pain Mgt and the Use of Opioids Exhibit 11 Average Benefit Cost Outcomes$25,000 +203%$20,000$15,000 +196% +209%$10,000 $5,000 $0 Total Benefits Medical IndemnityNo MEs $6,733 $3,207 $3,526Level 1 $6,499 $2,938 $3,561Level 2 $10,550 $4,411 $6,139Level 3 $14,950 $6,356 $8,594Level 4 $20,389 $9,488 $10,901
  • 12. Relationship Between Early Opioid Prescribing for Acute Occupational Low Back Pain and Disability Duration Webster B Spine: September 2007•  8443 claimants from a large WC database with new-onset, disabling LBP•  Pts > 450 mg MEA were, on average, disabled 69 days longer than those who received no early opioids•  Risk for surgery was 3 times greater and the risk of receiving late opioids was 6 times greater in the highest MEA group•  Given the negative association between receipt of early opioids for acute LBP and outcomes, it is suggested that the use of opioids for the management of acute LBP may be counterproductive to recovery.
  • 13. Narcotics – NCCI Study
  • 14. Opioids and Claim Outcomes•  Those who received more than 450 mg MEA were, on average, disabled 69 days longer than those who received no early opioids… (Webster et al, Spine 2007)•  For the small group of workers with compensable back injuries who receive opioids longer-term (111/1843, 6%), opioid doses increase substantially and only a minority shows clinically important improvement in pain and function. The amount of prescribed opioid received early after injury strongly predicts long-term use. (Franklin et al, Clin J Pain 2009)•  Average claim costs of workers receiving seven or more opioid prescriptions were three times more expensive than those of workers who receive zero or one opioid prescription, and these workers were 2.7 times more likely to be off work and had 4.7 times as many days off work… (Swedlow et al CWCI Special Report 2008)
  • 15. Early opioids and disability in WA WC Spine 2008; 33: 199-204•  Population-based, prospective cohort•  N=1843 workers with acute low back injury and at least 4 days lost time•  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, after adjustment for pain, function, injury severity
  • 16. Cost of Addiction  Drug cost - $1000 - $12,000/month  Associated drug costs for treating depression, constipation, alertness, insomnia  Associated medical costs  Extended disability duration  Settlement expense…
  • 17. The impending disaster•  Large regional insurer –  48,000 claimants on opioids >180 days•  Rating agencies and actuaries haven’t fully grasped the impact•  These claimants: –  aren’t going back to work –  are likely addicted/dependent –  won’t settle their claims
  • 18. 2011 Survey of Pharmacy Management in Workers Comp•  20 payers, in-depth survey of decision makers and implementers•  Ranged from very large national players to state funds to TPAs –  Covering 19% of total WC premium and equivalents•  Focused on –  assessing awareness and level of concern –  defining the problem –  identifying solutions –  assessing program results
  • 19. Respondents views on narcotics (1-5 scale)•  Rated a 4.8 - very significant problem –  (highest score recorded in eight years of the Survey)•  Concern about risk of addiction/dependency - 4.4, very concerned –  60% rated this a 5, extremely concerned•  Over a quarter said opioids are the single biggest problem in work comp pharmacy management•  Level of concern is higher than last year…
  • 20. Narcotics - Respondent Quotes•  It is not curing the problem, just temporary relief and it is being used as long- term treatment causing major dependency and death in some cases•  Because they are addictive and opioids dont necessarily control pain; long term use is not efficacious; once addicted, they become the pain generator; too much influence / pressure on docs to prescribe; utilization is a problem; our programs have been built on pricing, yet utilization is the real driver of cost, not price; so the more the doc does, the more he gets paid; it is a never ending cycle; we are not getting good quality medicine; only 15-20% docs are aware of evidence based protocols
  • 21. Respondent quotes•  Partly nature of the business; in an injury-driven line of insurance, that increases the potential exposure to opiates; also related to a certain mentality that exists among providers that equates comp with a difference in how they manage pain vs. a non comp patient; there is a misperception on what the expectations are for treatment (by injured worker) that the absence of pain means will go back to a pre-injury status; often that is not realistic in terms of the injury; there is a high demand for opiates because they expect to get back to a pain-free state; often that is not possible
  • 22. Respondent Quotes•  Socially driven; providers trying to get claimants out of their office; think wc is a very pain- focused environment and wanting to relieve pain, but dont understand whats driving the pain...too many factors out of control involving all parties - providers, injured workers, wc environment•  Too many claimants are treating with physicians that dont really understand how to deal with pain management; there are too few pain management experts in the industry; seldom discontinue usage of opioids without looking at functionality of injured workers; disconnect between functionality and what they are prescribing; so it is a physician - driven problem - dont know how to deal with ongoing pain
  • 23. Respondent quotes•  Most work comp injuries are going to include a script for pain; you have people who never get off of [their pain drugs and payers] continue to fill them, they become dependent on them; the longer the injured worker is on a narcotic, the less likely they are to RTW; many jobs cant return to if on narcotics•  Our concern is that it may increase disability as well risk associated with chronic use of opioids; sleep apnea, risk of abuse and addiction, and possibly death
  • 24. Pharmacy Management Programs•  >75% had implemented significant changes to their pharmacy management programs in 2010•  Primarily clinically oriented; identification of potentially problematic claimants, physicians, medications•  Tighter formularies•  Improved tracking of narcotics, coordination of efforts around narcotics especially for long term users
  • 25. New programs/initiatives•  Every single clinical utilization management tool that our PBM offers•  Developed a program called "[proprietary]" that looks at people who are first time narcotic users; chronic narcotic users; high dollar cost products being used; antidepressants and anti-psychotic meds controlling our formulary and utilization; re: utilization•  Hired a nurse for our precertification dept; dedicated to pain management program; also a separate nurse works with PBM to review every request for pre-authorization; these nurses are on our staff
  • 26. New programs/initiatives•  Implemented a narcotic focus program; doing a lot of work re: injured workers taking narcotic meds; also did some work re: looking at utilization of drugs within work injury claims and doing some work with utilization review•  Increased custom reporting to fraud; clinical escalation alerts when drugs fall outside of formulary; enhanced our process with handling on clinical side for long acting opioids in first dispense; approved alert to adjuster to notify them of an of aforementioned conditions / issues
  • 27. One state’s solution•  Washington developed pilot dosing guidelines in 2007•  Opioid dosing guidelines signed into law in 2010, effective in 2011•  PDMP began 1/1/2012
  • 28. WA Agency Medical Directors’ Opioid Dosing 28
  • 29. Guidance for Primary Care Providers on Safe and Effective 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 patient is taking prescribed drugs   Identifies non-prescribed drugs   Do not use concomitant sedative-hypnotics   Track pain and function to recognize tolerance   Seek help if dose reaches 120 mg MED, and pain and function have not substantially improved MED, Morphine equivalent dosec 29
  • 30. Yearly Trend of Scheduled Opioids 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
  • 31. 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 2000Q1 2000Q2 2000Q3 2000Q4 2001Q1 2001Q2 2001Q3 2001Q4 2002Q1 2002Q2 2002Q3 2002Q4 2003Q1 2003Q2 2003Q3 2003Q4 2004Q1 2004Q2Opioids 2004Q3 2004Q4 2005Q1 2005Q2 2005Q3 2005Q4 2000 - 2010 2006Q1Highdose Opioids 2006Q2 2006Q3 2006Q4 2007Q1 2007Q2 2007Q3 2007Q4 2008Q1 Percent of Timeloss Claimants on Opioids 2008Q2 2008Q3 2008Q4 2009Q1 2009Q2 2009Q3 2009Q4 2010Q1 2010Q2 2010Q3 2010Q4
  • 32. 10-Q3 2010 Q1 10-Q1Washington Workers Compensation, 1996–2010 2009 Q3 09-Q3 2009 Q1 09-Q1 2008 Q3 08-Q3 2008 Q1 08-Q1 2007 Q3 07-Q3 Average Daily Dosage for Opioids, 2007 Q1 07-Q1 2006 Q3 06-Q3 2006 Q1 06-Q1 Long-acting opioids 2005 Q3 05-Q3 Short-acting opioids 2005 Q1 05-Q1 2004 Q3 04-Q3 2004 Q1 04-Q1 2003 Q3 03-Q3 Year/Quarter 2003 Q1 03-Q1 2002 Q3 02-Q3 2002 Q1 02-Q1 2001 Q3 01-Q3 2001 Q1 01-Q1 2000 Q3 00-Q3 2000 Q1 00-Q1 1999 Q3 99-Q3 99-Q1 1999 Q1 98-Q3 1998 Q3 98-Q1 1998 Q1 97-Q3 1997 Q3 97-Q1 1997 Q1 96-Q3 1996 Q3 96-Q1 1996 Q1 32 140 120 100 80 60 40 20 0 MED (mg/day)
  • 33. WA Workers Compensation Opioid-related Deaths 1995-2010 35 30Opioid-related Death 25 20 15 10 5 0 Possible Probable Definite