Monday, January 23, 2012

OH Rules Will Provide Good Comparison to WA Drug Program

Ohio is toying with a different approach to the issue of prescription drug abuse in workers' compensation.

The Ohio Bureau of Workers’ Compensation (BWC) will be reviewing at its January 27 meeting of directors a pharmacy “lock-in” rule, called the Coordinated Services Program, aimed at combating prescription drug abuse.

The program will allow BWC to require an injured worker to use a single pharmacy to dispense all non-emergency prescriptions that are reimbursed under the bureau’s prescription benefit plan.

House Bill 93, which took effect last May 20, requires that the bureau adopt such a program and rule by July 1, 2012. The legislation also provides that the bureau’s effort be developed in cooperation with the Department of Job and Family Services.

Under the proposed rule, the bureau could place an injured worker in the “lock-in” program based on the injured worker meeting one or more of the following criteria in a three-month time frame:

--Use of three or more different prescribers to obtain prescriptions of the same or comparable medications.

--Receipt of prescription drugs from more than two different pharmacies.

--Monthly receipt of three or more prescriptions, including refills for drugs identified as narcotic analgesics.

--Monthly receipt of more than two concurrent narcotic analgesics in the same therapeutic drug class.

--Monthly receipt of more than two narcotic analgesics in the same therapeutic drug class, more than one benzodiazepine, and more than one sedative-hypnotic.

The proposed rule also would allow the bureau to restrict an injured worker convicted of a drug offense to the use of a single prescribing physician, selected by the injured worker from bureau-certified physicians, in order to receive reimbursement from the agency for non-emergency prescriptions.

Ernie Boyd, executive director of the Ohio Pharmacists Association, told WorkCompCentral on Friday that he thinks the rule will help deter abuse of prescription drugs. Boyd said the only concern raised by pharmacists on the rule was that when an injured worker is required to select a single pharmacy, "it has to be the worker's choice."

Compare Ohio's plan with Washington's pharmaceutical controls.

Washington requires medical practitioners to perform a full evaluation to document a patient's health history for past treatment of pain and substance abuse problems. Practitioners must also review any available information about past prescriptions and current prescriptions through prescription drug monitoring programs before prescribing opioids.
Doctors are required to prepare a treatment plan, discuss the risks associated with opioids with patients and have the patient sign an agreement for treatment that outlines how the drugs should be taken. The contract can also include language saying the patient could be cut off from medication for violating the contract.

Other provisions in Washington's rules say whenever possible, a single prescriber and single pharmacy should dispense opioids, and that treating doctors should review the treatment plan and patient's progress at least every six months.

Doctors in Washington are required to seek a consultation for any prescription in excess of the equivalent of a 120 mg dose of orally administered morphine per day. Exceptions to the consultation requirement apply when a patient is being tapered off opioids, a patient requires only a temporary increase in dosage for acute pain, the doctor documents reasonable attempts to obtain a consultation with a pain management specialist or the doctor documents that the patient's pain and function is stable and the patient is on a non-escalating dosage of opioids.

Ohio is one of the few completely state-run systems. This allows the state to implement rules, such as the Coordinated Services Program, much more easily than a competitive open market state, because coordination of state agency services is more consolidated and streamlined.

Because Washington is also a state-run system, the effectiveness of the Coordinated Services Program can be measured directly against Washington's program for controlling prescription drugs providing the rest of the nation with valuable insight into better ways to manage this current source of abuse and concern. I assume at some point one of the workers' compensation research organizations will do this comparison and also compare against other states with, and without, adopted pharmaceutical control guidelines.workers compensation, work comp, injured worker 


  1. David - I thought you'd find my blog post on the WA rules interesting. There are a few additional (and notable) nuances to the WA program.

    Much has been made of the public policy initiatives of the state of Washington in the area of prescription narcotics. To quote from a workcompcentral article (subscription required) this week: “The CDC held out Washington as an example of a state that is aggressively tackling problems with excessive opioid prescriptions. Five medical boards and commissions passed measures requiring a provider to perform a full assessment of a patient’s health history and past treatment of pain when prescribing opioids. Doctors are required to prepare a treatment plan, and also seek a consultation for any prescription that exceeds the equivalent of a 120 mg dose of orally administered morphine per day.”
    And another article appears to indicate that the state’s 2007 dosage guidelines may, in fact, have led to a drop in both the dosage levels and overdose deaths associated with opioids.
    I applaud these efforts as a necessary step toward mitigating the public health crisis of prescription drug over-utilization. In particular, I’m appreciative of the efforts of Dr. Gary Franklin, Medical Director for the Washington State Department of Labor and Industries, who has served as a voice of reason on this issue.
    But I also want to make sure we collectively understand the fine print on the new rules, effective January 2, 2012. For instance:
    Washington is a single payer state (i.e., the state essentially operates as a monopolistic work comp carrier). This is a well-known fact and not exactly “fine print”, but it’s important to note because this makes translating public policy initiatives to other, non-monopolistic states a potentially more complicated proposition.
    The rules provide for an exemption from the mandatory consultation requirement for the following: pain management specialists, doctors who have completed at least 12 hours of CE in chronic pain management (with at least 2 hours focused on long acting opioids), physicians who are “pain management practitioners” working in a multidisciplinary pain program or academic medical center, or any physician with at least 3 years of experience in a chronic pain management setting with at least 30% of current care being delivered in the area of chronic pain management. Did you get all that? In our experience, the presumption that “pain management specialists know better” is a dangerous one.
    The rules do not require doctor/patient narcotics contracts unless the patient is deemed “at high risk for medication abuse, or has a history of substance abuse, or psychiatric comorbidities.” This conflicts with the ACOEM guidelines, which suggest initiation of such a contract for any patient being prescribed an opioid for chronic non-cancer pain.
    And what happens if a doctor doesn’t follow these rules? The commission goes out of its way to state, within rule set itself (WAC 246-919-850), that “physicians should not fear disciplinary action from the commission for ordering, prescribing, dispensing, or administering controlled substances, including opioid analgesics, for a legitimate medical purpose…” Until the commission intervenes with punitive action for non-compliant physicians, I’m not convinced the rules will have their intended (and much needed) effect.
    I don’t mean to be overly critical. These rules are an excellent start and a good step in the right direction. But for employers and insurers in other states waiting for legislation to fix the problem of opioid abuse in work comp, don’t hold your breath. Get to work on a market-driven solution.

  2. Thanks for the additional information Michael.