Collaboration in Civic Spheres

Risks drop from prescription opioids for WA injured workers

by Matt Rosenberg January 25th, 2012

According to a new federally-funded study by University of Washington researchers, cautionary guidelines developed by Washington state agencies on physician-prescribed painkilling opiates for patients suffering from chronic pain preliminarily appear to be correlated with important overall risk reductions among one large sub-group of patients: injured workers seeking compensation through the state’s Department of Labor and Industries. Prime among these are reductions in related deadly overdoses; drops in number of claimants who were prescribed opioids; and a steady decline in the percent of workers who were being compensated for disability while using prescribed opioids, sometimes with little improvement, for pain treatment. Because of the potential for abuse and dependence, public health experts increasingly want to foster greater oversight of prescription opiates. The “yellow flag” educational program directed at physicians may very well help explain the measured changes although more data is needed in coming years to strengthen the connections.

These are the key findings of the new study published late last month in the American Journal of Industrial Medicine by researchers at the University of Washington’s School of Medicine, the university’s departments of Environmental and Ocupational Health Sciences, and Psychiatry and Behavioral Sciences, and the Washington State Department of Labor and Industries (DLI). The study was funded by the U.S. Centers For Disease Control and the National Center For Injury Prevention and Control.

Worried about rising deaths from prescription opioids in Washington and nationally, Washington state health and medical “payer” agencies (including Medicaid, DLI’s workers comp division, and the state departments of corrections and health) convened an expert group to develop a Web-based educational pilot program launched in April 2007. It emphasized to doctors that before continuing to prescribe 120 mg per day or more of opioids to non-cancer chronic pain patients whose condition had not been improving, they should consult with a pain medicine expert about other treatments combined with lower daily doses of opioids. The program also included a Web-based tool allowing physicians to easily calculate the total daily morphine-equivalent dosages (MED) ingested by a patients from all three classes of opioids.

To evaluate possible benefits for patients of the new guidelines, researchers focused on historical data in several categories both before and after the pilot program began, among claimants for workers’ compensation through DLI, which covers two-thirds of the non-federal workforce in the state for work-related injury claims.

After lenient state prescribing guidelines were established in 1999 for prescription opioids, fatal overdoses of injured workers covered through Washington State’s workers’ compensation plan from painkillers such as morphine, oxycodone, methadone and fentanyl rose at an alarming rate through 2005, dropped slightly in 2006 and 2007, rose markedly in 2008, and then spiked again in 2009, according to data gathered for the study. But the troubling occurrences declined markedly in 2010 – for the first year since implementation of a new educational pilot program in April 2007 which warned prescribing doctors to consider lowering their prescription opioid dosages in certain cases.

After that program roll-out, other improvements occurred even sooner, the study reports. Paid prescriptions for Schedule 2 opioids for workers’ comp claimants – which had risen sharply since 1996 – leveled off through 2008 then declined markedly over 2009 and 2010. Paid prescriptions among the same pool of claimants for Schedule 3 opioids such as codeine and hydrocodone were relatively steady from 1996 through 2008 but dropped to a 14-year low over 2009 and 2010. And beginning in the first quarter of 2008, the percentage of workers being paid disability claims by the state for lost work hours due to injury, who were also taking prescription opioids, began a steady and robust decline through year-end 2010.

The research team which authored the study emphasizes more data is needed in coming years to confirm the preliminary correlations between risk reduction and the dosing guidelines educational program. They also say there is room for improving awareness levels of Washington state doctors on safe guidelines for prescribing opioids and that this could yield greater improvements in the areas measured. They urge “wider and more effective use of State-based prescription monitoring programs…including ‘pushing’ evidence-based educational content to providers…” A new Washington state law approved by the legislature in 2010 and finalized with key specifics last year makes mandatory the 120 mg per day opioid dosage oversight provisions of the 2007 guidelines.

The authors write that “diversion” or unauthorized pilfering of prescription opioids from medical or pharmaceutical facilities, may – along with “shopping” for doctors known for liberal prescribing of opioids – account for most of the fatal prescription opioid overdoses in predominantly rural areas. But they stress it’s a different story in urban and suburban settings where dosage levels and monitoring are especially important and a raft of studies show risks of a serious adverse event or death are significantly less likely if total daily dosages of prescription opioids per patient are closer to 20 mg than 100 or 120.

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