Opioid Use in Work-related Injuries

Pacific Northwest Chapter - Association of Occupational Health Professionals (AOHP)

January 4, 2011

Jaymie Mai, PharmDPharmacy Manager

A Historical Perspective

Prior to 1996, prohibition on opioid use for chronic non-cancer pain led to under-treatment

New permissive regulations allow more aggressive treatment of pain with opioids– WA DOH Guidelines for Management of Pain1998– L&I Guidelines for Outpatient Prescription of Oral

Opioids for Injured Workers with Chronic, Non-cancer Pain 2000

L&I 2000 Guideline - Oral Opioids for Injured Workers Payment as long as there is substantial

reduction in pain & ongoing improvement in function (WAC 296-20-03022)

Emphasizes use of best practices and focuses on rehabilitation (WACs 296-20-03019 through 03024)

Documentation Requirements for Opioids

Initiating opioids for chronic, non-cancer pain– Initial report (billing code 1064M)– Opioid progress report (billing code 1057M)– Treatment agreement

Ongoing opioid treatment– Opioid progress report every 60 days– Treatment agreement every 6 months – Functional progress form (optional)

Emerging data on mortality, morbidity & dose-related risk with chronic opioid use

Unintentional & Undetermined Opioid Overdose Death Rates by State 2007

Source: Centers for Disease Control and Prevention

3.1-9.0 9.1-11.4 11.5-21.1

Age-adjusted rate per 100,000 population

Washington Opioid Deaths & Sales of Rx Opioids

0

1

2

3

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8

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1998

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Source: Washington State Department of Health

Washington Hospitalizations from Opioid Overdose 1987 - 2008

Source: Washington State Department of Health

0

100

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500

199

5

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7

199

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Overdose in Primary Diagnosis

Alcohol Diagnosis Present

Abuse or Dependence Diagnosis Present

L&I Prescription Opioid-related Deaths

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30

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Possible Probable Definite

L&I Schedule Opioid Utilization Trend

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Schedule II Schedule III Schedule IV

L&I Dosing Trend of Long-acting Opioids (morphine equivalent dose)

40

60

80

100

120

140

160

Q1-

96

Q3-

96

Q1-

97

Q3-

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Aver

age

MED

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Group Health Study 1st to validate association between specific

dose levels and severe overdose events Risk of morbidity and mortality increased 8.9

fold at 100mg/d of morphine equivalent dose (MED)

7 non-fatal overdose events for each death Editorial by Dr. McLellan (White House Office

of National Drug Control Policy):– “Smarter, more responsible (prescribing) practices

are the only hope to avoid tragic, avoidable deaths”

Source: Dunn et al. Ann Int Med 2010;152:85-92

Severe Opioid Complications

Sleep apnea – 92% prevalence of ataxic or irregular breathing during NREM

sleep at >/= 200 mg MED (Walker et al. J Clin Sleep Med 2007;3:455-61)

Endocrine dysfunction – testosterone deficiency Addiction

– Rate up to 18.9% (Fishbain et al. Clin J Pain 1992;8:77-85)

Hyperalgesia – Abnormal pain sensitivity with chronic opioid use (Ballantyne

J. Pain Physician 2007;10:479-91)

Disability

Early Opioid Use and Low Back Disability

During the first 6 weeks of low back injury:– Opioids >7 days significantly associated with

disability in 1 year– ≥2 opioid prescriptions doubled the odds of 1-year

disability– >150mg total morphine equivalent dose (MED)

prescribed was associated with doubling of 1-year disability

Source: Franklin et al. Spine 2008;33(2):199-204

Strategies for safe and effective opioid prescribing

Best Practices When Prescribing Opioids

Do initial evaluation & assessment– Physical examination, comprehensive assessment

Screen for risk– Addiction, abuse or aberrant behavior; psychiatric status– Check state’s prescription monitoring program (PMP) if available or

other systems such as the emergency department information exchange (EDIE)

Establish treatment goals or plans– Define effectiveness (improve function & pain); monitor risks,

adverse effects, complications; single prescriber & pharmacy

Sign treatment agreement or informed consent– Discuss risks, benefits, complications; patient expectations; random

urine drug testing

Best Practices When Prescribing Opioids

Monitor treatment– Ongoing assessment of effectiveness by tracking pain and function

and adverse effects or complications; random urine drug testing; psychiatric co-morbidities

– Periodically check the state’s PMP if available and other systems such as EDIE

Dosing guidance– Know how to calculate total morphine equivalent dose– Reassess at 100 - 120mg/d MED if pain and function have not

improved; consider alternative treatment or consultation

Taper or discontinue treatment– When function or pain does not improve after trial; significant

adverse effects; misuse, addiction or diversion

Additional Tools Available Through AMDG

Opioid dose calculator Screening tool for alcohol and substance

abuse 2-question tool for tracking pain and function Patient education aids Detailed advice on using urine drug testing to

screen risk and monitor compliance

For more on the AMDG Opioid Dosing Guideline, go to http://www.agencymeddirectors.wa.gov/default.asp

New efforts to reduce opioid-related mortality and morbidity

New CDC Recommendations Health Care Providers Use opioids only after alternatives failed and lowest effective dose In addition to behavioral screening and use of patient contracts,

consider random, periodic, targeted urine testing If a patient’s dosage has increased to ≥120 morphine milligram

equivalents per day without substantial improvement in pain and function, seek a consult from a pain specialist

Do not prescribe long-acting or controlled-release opioids for acute pain

Periodically request a report from your state prescription drug monitoring program

For complete recommendations, go to http://www.cdc.gov/HomeandRecreationalSafety/pdf/poision-issue-brief.pdf

FDA Risk Evaluation and Mitigation Strategies (REMS) for Opioids Ensure benefits of drug outweigh risks All extended release oral opioids (hydromorphone,

morphine, oxycodone, oxymorphone); methadone for pain; transdermal fentanyl

Proposed REMS include (July 2010) – Medication guides– Elements to Assure Safe Use (EASU) for prescribers education– Mandatory sponsor-developed patient educational materials

available to providers for voluntary use with patients

Advisory committee did not agree with the FDA proposed REMS

AMDG Opioid Dosing Guideline

Collaboration with clinical and academic pain experts

Improve care and safety with opioid treatment through use of “best practices”

Consult before exceeding 120mg/d MED if pain and function have not improved

Assist provider in optimizing opioid treatment for patients who are above the dosing threshold

For more on the AMDG Opioid Dosing Guideline, go to http://www.agencymeddirectors.wa.gov/default.asp

ESHB 2876 – Pain ManagementChapter 209, Laws of 2010 Repeals existing WACs New WACs by June 2011 with guidance on

Dosing criteria Consultations and ways for electronic consultation Tracking clinical progress with tools (pain

interference, physical function, overall risk for poor outcome)

Tracking use of opioids

Exempt acute pain, palliative, hospice or other end-of-life care