National and Industry Response
From a national perspective, the prescription opioid and heroin epidemic cannot be detached from each other. Four out of five new heroin users report abusing prescription opioids prior to moving on to heroin. The primary reason for the transition to heroin was that heroin is cheaper and easier to obtain than prescription opioids. The progression from prescription opioid addiction to heroin use is a devastating component of this epidemic and will need to be addressed on a national level.
As an industry, workers’ compensation has responded to the opioid prescription epidemic. State legislation has been passed with Utah and Washington leading the way early in the crisis. In addition, independent organizations like the Official Disability Institute (ODG) published by the Work Loss Data Institute and The American College of Occupational & Environmental Medicine (ACOEM) have released industry specific guidelines for prescribers in the appropriate use of opioids for the treatment of pain specific to workplace injuries.
In some instances, these guidelines have been adopted into state regulation, providing not only recommendations for appropriate treatment of pain, but the legislative backed leverage to enforce it. Pharmacy Benefits Managers (PBMs) are almost universally utilized by payors as partners in controlling inappropriate opioid prescribing.
Outside of the workers’ compensation system, several states have passed legislation limiting the daily allowable dose and days supply of opioid prescriptions. On a national basis, President Obama’s attendance at the 2016 National Rx Drug Abuse and Heroin Summit was a call to establish the first federal guidelines for opioid prescribing and provide funding for opioid addiction treatment.
The Comprehensive Addiction and Recovery Act of 2016 was signed, providing state support for expanding Prescription Drug Monitoring Programs (PDMPs), providing funding for Naloxone use to treat emergency opioid overdose, and increasing education and prevention efforts. However, many stakeholders feel the bill failed to provide for extensive opioid addiction treatment.
CDC Guideline for Prescribing Opioids for Chronic Pain
In March of 2016, the CDC published the CDC Guideline for Prescribing Opioids for Chronic Pain. The CDC‘s stated goal was to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose. The guidelines apply only to adults and do not apply to patients experiencing cancer related pain, palliative care, or end of life care.
Although the guidelines were written for the use of opioid therapy in treating chronic pain, many patients experiencing acute pain are treated with opioids. For many patients, acute pain typically precedes chronic pain. Therefore, portions of the CDC Opioid Guidelines are applicable to acute pain and some components are specifically written for the treatment of acute pain. Prescriber education materials were also produced in conjunction with the guideline release. Reminders for prescribers in these materials include:
- Opioids are not first-line or routine therapy for chronic pain
- Establish and measure goals for pain and function
- Discuss benefits and risks and availability of non-opioid therapies with patient
- Use immediate-release opioids when starting
- Start low and go slow
- When opioids are needed for acute pain, prescribe no more than needed
- Do not prescribe ER/LA opioids for acute pain
- Follow-up and re-evaluate risk of harm; reduce dose or taper and discontinue if needed
In addition to the reminders above, specific quantifiable recommendations are provided relating to the choice of opioid agents, dosing ranges to adhere to, cautions against certain drug combinations, and the duration of therapy (i.e. the number of days supply).
Prescribe No More Than Needed
Opioid therapy is frequently initiated for the treatment of acute pain. When beginning opioid therapy, the shortest duration necessary should be used. The CDC states that a three-day supply of opioids is often adequate and it is rare that more than seven days are required.
Use Immediate Release Formulations to Start
When beginning opioid therapy, immediate release opioids should be used first. Immediate release formulations include Lortab and Percocet. These agents can be taken for breakthrough pain, allowing patients to take only as needed when the pain is intolerable. Long acting opioids such as OxyContin and Zohydro, release a steady dose over long periods of time resulting in delivery of opioid long after the breakthrough pain has subsided.
Use the Lowest Effective Dose
When initiating opioids, the lowest possible dose resulting in relief should be used. The CDC provides recommendations on daily dose thresholds based on the Milligrams of Morphine Equivalent per Day (MME/day), sometimes referred to as Morphine Equivalent Dosing (MED) or Morphine Equivalent Daily Dose (MEDD). The CDC states that risks should be carefully assessed before increasing total daily dosing above 50 MME/day and to avoid prescribing more than 90 MME/day
Do Not Prescribe Long Acting Opioids for Acute Pain
Long Acting Opioids should only be used in patients experiencing chronic pain and only after carefully assessing the associated risk.
Avoid Concurrent Prescribing of Benzodiazepines and Opioids
The concurrent use of Benzodiazepines (Xanax, Ambien) and Opioids are associated with significant risk of overdose and death. 30% of opioid overdose deaths in recent years were associated with concurrent use of benzodiazepines.
Unlike recommendations intended to facilitate discussion between provider and patient concerning risks and establishing goals around opioid therapy, the above recommendations are distinctly measurable by insurers, PBMs, and managed care organizations within the workers’ compensation industry. Identifying opioid prescribing outside of the CDC recommendations and intervening with prescribing physicians presents an opportunity to avoid unnecessary risks and promote better outcomes for injured workers.
Clinical guidelines are recommendations to guide the medical community, insurers, and other stakeholders in the healthcare delivery system toward appropriate treatment and optimal outcomes. Guidelines by themselves are not enforceable and do not ensure appropriate treatment. However, many state regulations reference guidelines such as ODG and ACOEM in their legislations which is enforceable.
Considering the current national focus on the opioid epidemic, it is possible that the CDC Opioid Guidelines could, at some point, become enforceable on a national level. If the Guidelines were enforceable, what impact could be expected to the workers’ compensation industry? How compliant was opioid prescribing at the time of CDC Opioid Guidelines publication? Has there been any measurable change since the CDC Opioid Guidelines were introduced? What impact would enforcing the CDC Opioid Guidelines have on injured workers currently being treated, treating physicians, insurers, PBMs, and managed care organizations?
To answer these questions, Mitchell conducted a retroactive analysis of more than 815,000 workers’ compensation claims with a date of injury after 1/1/2011. This included a corresponding 3.9 million prescriptions.
The study population was further limited to claimants receiving an opioid prescription resulting in a final study population of greater than 417,000 claimants receiving more than 1,059,000 prescriptions.
Compliance to CDC Opioid Guidelines were assessed against the five aforementioned, measurable CDC recommendations, with the following criteria for evaluation:
- Prescribe no more than needed – Percentage of claimants whose first opioid prescription was for a duration:
- <3 days
- 3-7 days
- >7 days
- Use Immediate Release Formulations to Start – Evaluate the percentage of claimants that received a long-acting opioid as the first prescription
- Use the Lowest Effective Dose – Percentage of claimants receiving a daily opioid dose within the following ranges:
- <50 MME/day
- 50-90 MME/day
- >90 MME/day
- Do Not Prescribe Long Acting Opioids for Acute Pain – Percentage of claimants receiving a long acting opioid within the first 30 days after the date of injury (DOI)
- Avoid Concurrent Prescribing of Benzodiazepines and Opioids – The percentage of claimants that were prescribed an opioid and a benzodiazepine concurrently
Compliance with the above criteria were analyzed for two distinct groups, claimants with dates of injury prior to release of the CDC Opioid Guidelines and those with date of injury after release of the CDC Opioid Guidelines. In this evaluation, the release of the CDC Opioid Guidelines was considered to be March 17, 2016.