opioid use in work-related injuries pacific northwest chapter - association of occupational health...
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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
4
5
6
7
8
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006A
ge a
dju
ste
d r
ate
per
100,0
00
-12345678910
Op
ioid
sale
s m
g/p
ers
onDeaths/100,000 mg/person
Source: Washington State Department of Health
Washington Hospitalizations from Opioid Overdose 1987 - 2008
Source: Washington State Department of Health
0
100
200
300
400
500
199
5
199
7
199
9
200
1
200
3
200
5
200
7
# o
f ho
spit
aliz
atio
ns
Overdose in Primary Diagnosis
Alcohol Diagnosis Present
Abuse or Dependence Diagnosis Present
L&I Prescription Opioid-related Deaths
0
5
10
15
20
25
30
Opio
id-re
late
d D
eath
Possible Probable Definite
L&I Schedule Opioid Utilization Trend
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
100000
Nu
mbe
r of O
pioi
d P
resc
riptio
ns
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-
97
Q1-
98
Q3-
98
Q1-
99
Q3-
99
Q1-
00
Q3-
00
Q1-
01
Q3-
01
Q1-
02
Q3-
02
Q1-
03
Q3-
03
Q1-
04
Q3-
04
Q1-
05
Q3-
05
Q1-
06
Q3-
06
Q1-
07
Q3-
07
Q1-
08
Q3-
08
Aver
age
MED
(m
g/da
y)
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