According to the study, "Bending the Prescription Opioid Dosing and Mortality Curves: Impact of the Washington State Opioid Dosing Guideline," published in the Dec. 27, 2011, edition of the American Journal of Industrial Medicine, Washington's efforts are paying off with the gross total number of prescriptions for opioids down and a corresponding drop in prescription drug-related deaths.
The Washington Agency Medical Director's Group convened an advisory group in 2006 to develop dosing guidelines and in April 2007, the Medical Director's Group launched a web-based educational pilot program that included guidelines listing a "yellow-flag" warning for opioid dosages of 120 milligrams of morphine-equivalent doses per day. The guidelines recommended providers obtain a consultation with a pain-management specialist for patients with chronic non-cancer pain who were receiving dosages of opioids in excess of 120 mg per day before writing more prescriptions for the drugs at the same strength.
The number of prescriptions for Schedule II opioids increased 191% from 22,867 in 1996 to 66,544 in 2006, according to the study's authors, who include Dr. Gary Franklin, medical director for the Washington State Department of Labor and Industries, which runs the state's workers' compensation system. Prescription rates held steady from 2006 through 2008, before dropping to 54,484 in 2009 and 44,209 in 2010.
The number of prescriptions for Schedule III opioids increased from 76,935 in 1996 to 93,550 in 1999. The number of Schedule III prescriptions totaled 79,882 in 2008 and dropped to 63,808 in 2009 and 52,499 in 2010.
Expressed in terms of lost-time claims, there were 2,365 opioid prescriptions per lost-time claim in 1997 and 3,222 in 2002. That fell to 2,666 per 1,000 claims in 2009 and 2,245 in 2010.
The study found the number of deaths increased from 0 in 1996 to a 15-year high of 35 in 2009, corresponding to the increase in prescriptions and dosages. When prescriptions and dosages started dropping in 2009, the number of deaths also declined more than 50% to just 15 deaths in 2010.
Interest in Washington's results may migrate to the other side of the nation. The Workers Compensation Research Institute (WCRI) in its just released CompScope Benchmarks for Florida, 12th Edition, concludes that Florida worker's compensation costs are increasing across the board – driven largely by increases in payments for prescription drugs and outpatient hospital services.
WCRI said prescription costs per lost-time claim increased by 7% per year between October 2005 and March 2008. From 2006 through 2009, Florida ranked second – behind Louisiana – for prescription payments per lost-time claim. Florida payments averaged $500 per claim, while payments in Louisiana averaged $700.
The research group said physician-dispensing of repackaged drugs was the prime driver behind the pharmacy cost increases. WCRI reported earlier this year that physician dispensing accounted for 46% of all drug costs in the Florida workers' compensation system and noted physicians were paid more than pharmacies for most drugs.
WCRI's conclusions are supported independently by rate making agency NCCI.
In September of 2011 NCCI reported that more than half of the money spent on drugs dispensed to Florida's injured workers in 2009 went to doctors. Florida has gained the notorious reputation as the pill-mill of the South.
Former Gov. Charlie Crist vetoed legislation passed in 2010 that could have capped the price of drugs sold by repackagers at the average wholesale price (AWP) established by the drugs' original manufacturer plus a $4.18 dispensing fee.
The Florida Senate passed a similar bill last session. But the bill stalled in a House-Senate conference committee that passed a ban on physician dispensing of drugs on Schedules II and III of the U.S. Drug Enforcement Agency's controlled substances list.
But according to the NCCI report, nine of the 10 drugs dispensed by Florida doctors to injured workers in 2009 were not on the DEA's schedules. NCCI was concerned that the ban would have very little effect on workers' compensation cases.
In the middle of the country the Texas Association of Business (TAB) is organizing the Texas Alliance for Responsible Prescription Drug Use to combat what the association calls an “epidemic … sweeping across the state and nation.”
The Texas Prescription Program was created by the Legislature in 1982 to monitor Schedule II controlled substance prescriptions. Effective Sept. 1, 2008, the Texas Legislature expanded the program to include the monitoring of Schedule III through Schedule V controlled substance prescriptions. The schedules were established by the federal Drug Enforcement Administration and are based on the addictive nature of a drug and its use in medical treatment.
A report by the Texas Department of Insurance Workers’ Compensation Research and Evaluation Group released last fall on pharmacy costs in the Texas workers' compensation system shows prescription payments for 2010 exceeded $138 million, with long-standing claims of injured workers having significantly higher average costs than in more recent claims.
Payments for pharmacy services represented 13% of the medical costs in the Texas workers' compensation system for the year, a rate consistent with previous years, the researchers said. But so-called "legacy claims," which represent ongoing claims by injured workers (for injury years 1991 through 2005 in the study) had significantly higher average pharmacy costs than more recent claims. Many of those long-term claims involve potentially addictive painkillers, the report said.
The alliance could decide to take a look at prescribing practices as part of its work.
The take-away is that the issue of prescription drugs in workers' compensation is multi-faceted, ranging from education and dosing guidelines to outright bans on certain activities. The industry is tackling issues related to prescription drugs in an aggressive and dramatic fashion. I have no doubt that these efforts will pay off ... until the next crisis intervenes.workers compensation, work comp, injured worker