Opioids and the Injured Worker Tools for Successful Outcomes

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1 Opioids and the Injured Worker Tools for Successful Outcomes Tim Pokorney, RPh Director, Clinical Express Scripts Workers' Compensation Division

2 Goals and Objectives Alarming statistics for narcotic utilization, fraud, and abuse How did we get here? Work Comp pharmacy landscape Best Practices for Opioid prescribing Industry Tools and Solutions Best Practices Q & A

3 Opioid Prescribing Trends in U.S. U.S. citizens consume 80% of world s opioid supply despite being only 4.6% of the world s population Opioid sales * (mg/person) 627% increase U.S. population consumes 99% of world s Hydrocodone supply 0 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07

4 Prevalence of Narcotic Use and Abuse

5 Accidental Deaths are Staggering Heroin Cocaine

6 Unintentional and Undetermined Intent Drug Overdose Death Rates by State, 2007 MD MA NH RI CT DE DC VT NJ Age-adjusted rate per 100,000 population National Vital Statistics System, 6

7 Aren t Prescription Drugs Safe?

8 Opioids and the Injured Worker Expenditures for opioids increased 423% in treatment of LBP WITHOUT an improvement in outcomes or disability rates Workers on opioids miss up to 69 more days than workers not treated with opioids Recent Study demonstrates associated risks and costs when prescribing opioids 8

9 How Did We Get Here? 1986: Pain panel 1997: Better pain control encouraged Low grade studies showed low risk of addiction Advocacy of pain treatment by lobbying groups and physicians Disciplining and monitoring of physicians decreased Pain Management and Chemical Dependency: Evolving Perspectives JAMA 1997, Portenoy et al. Pain the Fifth Vital Sign: 1999 VA Initiative PAIN VICTIMS' CARE FAULTED BY PANEL By PHILIP M. BOFFEY, Special to the New York Times Published: May 22, 1986 WASHINGTON, May 21 A Federal advisory panel today called for improved treatment of pain after hearing testimony that millions of Americans are cared for inadequately. 9

10 Change in National Norms for Use of Opioids for Chronic, Non-cancer Pain By the late 1990s, at least 20 states passed new laws, regulations, or policies moving from near prohibition of opioids to use without dosing guidance WA law: No disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opioids prescribed. (WAC , 12/1999) Laws were based on weak science and good experience with cancer pain WAC Washington Administrative Code 10

11 Where are Rx Costs Going? Pharmacy Costs- 19% of Medical Costs Narcotics- Extreme Cost Driver & Increasing Drug Trends Newer Drugs to Market Opana, Nucynta, Exalgo, Butrans, etc.

12 Prescription Drug Cost Breakdown 2011 Utilization Data Other 22% Hypnotics 3% Muscle Relaxants 5% Antidepressants8% Anticonvulsants 9% Opioid Analgesics 38% Anti-Inflammatories 8% Opioid Analgesics Anti-Inflammatories Dermatologicals Anticonvulsants Antidepressants Muscle Relaxants Hypnotics Other Dermatologicals7%

13 Ripe Market for Fraud Opportunity for Diversion and Foul Play Street Values of Common Narcotics OxyContin- up to $1/mg Hydrocodone- $6-$15/pill Morphine ER- up to $1/mg Opana- $35-$50/pill Actiq- $20/dose Duragesic- $100/patch

14 When are Opioids Appropriate? Key is Improving Functionality Most studies show little to no change in functional improvement when prescribing opioids In fact, some studies show that opioid use can delay an employee s return to work, not to mention increasing costs. Opioids should be only part of treatment plan Ask initial questions: Are there reasonable alternatives? Have alternatives been tried? Is the patient likely to improve? Pain relief & Functional improvement Risks of dependency, abuse and misuse

15 Best Practices for Opioid Prescribing Full evaluation of medical history and physical examination Determine the lowest effective dose Set and agree upon goals. Use Pain Treatment Agreement Use Step Therapy approach Actively monitor with Urine Drug Screening (UDS) The purpose of UDS is to reveal not only the presence of illicit substances, but also the absence of the prescribed medication Stop use if pain is not at least partially relieved One provider, one pharmacy

16 Urine Drug Screening Start with baseline and determine risk level with ORT, then repeat randomly based on level of risk

17 Morphine Equivalent Dosages (MED s) Comparison tool for opioid dosing 120 mg MED- established threshold as an indicator of risk Patients receiving 100 mg or more per day MED had a 9-fold increase in overdose risk New trends and initiatives Key management tool for managing risk and improving outcomes

18 Red Flags for Narcotic Utilization No Pain Relief or Functional Improvement in acute/sub-acute phases Inappropriate Utilization in 1 st 30 days of therapy MED Escalation Side Effects outweigh benefits Non-Adherence (Regimen, Pharmacy, or MD) Violation of Pain Contract Evidence of Diversion or Forgery with opioids or illicit drugs

19 Long-Term Risks of Opioids Tolerance Higher dose needed to achieve same effect Physical dependence Addiction Abrupt withdrawal of a drug will induce withdrawal syndrome Compulsive disorder Preoccupation with obtaining/using a substance Continued use results in decreased quality of life

20 Industry & Legislative Initiatives State Legislation and Regulatory Updates Washington guidelines TX formulary NY Pain Guidelines Abuse-Resistant Formulations FDA Regulations Dose Limitations for Acetaminophen Removal of Propoxyphene from market Newer Drugs for Detox Prescription Drug Monitoring Programs REMS initiatives

21 Why is Clinical Management Important? Increase safety and clinical effectiveness Ensure appropriate utilization Deter fraud and abuse Decrease wasteful Rx spending Generics Channel management 21

22 Comprehensive Clinical Tools Formulary Management Drug Utilization Reviews POS clinical intervention Step Therapy Outreach Programs Reporting and Analysis MED and APAP calculations Home Delivery opportunities 22

23 Best in Class PBM Opportunities Early Intervention Reporting MED alerts At-Risk predictors Fraud, Waste, and Abuse Monitoring & advanced analytics Outreach programs Physician Peer to Peer Drug Testing capabilities Patient Education initiatives 23

24 Identify Injured workers on opioid medications Early Intervention is Key Calculate Morphine Equivalent Dosage and daily Acetaminophen dosage Tools to help identify patients for further investigation and intervention Highlight Patients taking greater than 120mg Morphine Equivalents per day Patients taking long acting opioids or high doses in first month of injury Patient still taking opioids three to twelve months after injury Patients receiving Acetaminophen (Tylenol ) doses greater than 4000 mg. per day 24

25 Why Should You Be Concerned About Pain Management? Chronic pain is a leading cause of disability Cost of opioid medications are one of the main cost drivers for workers compensation claims Increased use of opioids in management of chronic non-cancer pain in the past 20 years Increase in abuse, misuse, and mortality associated with opioid use Concerns for injured-worker safety & education

26 What Can the Risk Manager Do? Start active management of Opioids now it s already too late! Short AND Long-term risks Requires hands-on management Seek proper tools from your PBM & partners Overall program performance Drug Trends Top Injured Worker reporting Physician patterns Program offerings At-Risk claim opportunities 26

27 Questions?

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