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

1. Compliance with
Narcotics 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 Results
Pharmaceutical 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 Management
Opioids are often used to treat pain
Exhibit 8

9. CWCI - Pain Mgt and the Use of Opioids
Distribution by Primary Diagnosis
Percent of
ICD-9 Primary Diagnosis Claims Sample
847.2 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%
Degeneration
846 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 Opioids
Distribution 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 Indemnity
No MEs $6,733 $3,207 $3,526
Level 1 $6,499 $2,938 $3,561
Level 2 $10,550 $4,411 $6,139
Level 3 $14,950 $6,356 $8,594
Level 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 don't 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 don't understand what's 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 don't 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 -
don't 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 can't 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 Guidelines
www.agencymeddirectors.wa.gov
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
http://www.agencymeddirectors.wa.gov/opioiddosing.asp
MED, Morphine equivalent dosec
29

30. Yearly Trend of Scheduled Opioids
100,000
Number 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
2004Q2
Opioids
2004Q3
2004Q4
2005Q1
2005Q2
2005Q3
2005Q4
2000 - 2010
2006Q1
Highdose 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-Q1
Washington 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
30
Opioid-related Death
25
20
15
10
5
0
Possible Probable Definite