By Roberto Ceniceros
Oct. 6, 2011
The guideline recommends that doctors curb prescribing large doses of the opioid painkillers, which the federal government blames for a nationwide public health epidemic of addiction and deaths paralleling a rise in the number of prescriptions written along with an increase in dosage amounts prescribed.
Medical experts say Washington state’s guideline for chronic, noncancerous pain could serve as a model for other states looking to reduce deaths and addiction among workers’ compensation claimants and the general population.
They say such guidelines are called for because workers with relatively minor workplace injuries are ending up addicted or dying from overdoses.
“It’s one of the most tragic outcomes in work comp,” said Robert Malooly, former assistant director for the Washington State Department of Labor & Industries’ Insurance Services Division and current CEO of Claim Maps in Olympia, Washington. “Someone comes in with a back sprain that otherwise would have resolved on its own and they wind up dying of an overdose.”
Although Washington’s efforts are not without detractors, the state’s efforts also get high praise.
Washington state “should be commended for taking action where many other states have done nothing,” said Andrew Kolodny, president of Physicians for Responsible Opioid Prescribing and chairman of the Department of Psychiatry at Maimonides Medical Center in New York.
Among other measures, Washington’s guideline recommends that doctors not increase opioid doses beyond an average daily morphine equivalent of 120 milligrams when a patient does not demonstrate improved functionality and decreased pain at lower doses or without first consulting with a pain management expert.
Colorado has had a workers’ compensation chronic pain prescription guideline for several years. It calls for measures such as testing claimants’ urine to help ensure they are not diverting painkillers, said Kathryn Mueller, an advocate of such guidelines and a professor in the department of emergency medicine at the University of Colorado Denver’s medical campus.
But unlike Washington, Colorado’s guideline does not suggest a specific opioid dosage that should trigger extra precautions by prescribing doctors. Studies on the detrimental impact of higher opioid doses available now did not exist when Colorado adopted its guideline, Mueller said.
It is anticipated, however, that an updated version of the Colorado Division of Workers’ Compensation chronic-pain guideline now under development will suggest a dose at which doctors should be particularly cautious, Mueller said. Many medical experts believe that patients are being put at risk when opioid dosages reach 100 milligrams to 120 milligrams per day, she added.
According to the White House Office of National Drug Control Policy, the milligram-per-person use of prescription opioids increased 402 percent to 369 milligrams from 1997 to 2007.
Like Washington, Colorado’s new guideline dose amount would only recommend that prescription writers take certain steps, such as getting other doctors involved in making such decisions, when considering prescribing high doses of painkillers.
The guidelines are not a mandate. But Washington state was the first in the nation to suggest a specific dose at which doctors should take certain precautions and its guideline applies to all medical care, sources said.
The guideline was introduced in 2007 as an “educational pilot,” said Gary Franklin, a physician who is the medical director for the Department of Labor and Industries, which administers the state’s workers’ compensation insurance fund. The guideline was updated in June 2010.
Franklin told the audience at sister publication Business Insurance‘s recent Workers Comp Cost Control Strategies virtual conference that “there is now very strong evidence in at least three studies linking specific doses of opioids to increased morbidity and mortality.”
Meanwhile, research has found that patients given larger and larger doses merely increase their tolerance for the drugs without achieving improvements in function or decreased pain.
Data show Washington state’s death rate from unintentional opioid poisoning now exceeds the death rate from car crashes.
But since the 2007 implementation of Washington’s dosing guideline, the state’s workers’ comp system has experienced a 25 percent decline in average daily doses of morphine equivalence for opioid prescriptions, Franklin said.
In 2010, the state saw a 50 percent reduction in deaths related to opioid use among its workers’ compensation claimants vs. 2009, he said.
“For the first time in over a decade we have had a marked decline in [opioid] deaths in Washington state workers compensation,” he told the conference. “This is only one year [of data] and I won’t be really happy unless we see it again next year, but it’s hopeful.”
Not everyone thinks Washington state is on the right track.
The 120 milligram dose at which the guideline suggests that primary-care doctors consult a specialist is an arbitrary level, said Lynn Webster, a physician who is an officer for the Glenview, Illinois-based American Academy of Pain Medicine.
Additionally, the guideline suggests a dosage without appropriately considering why certain patients need higher doses, Webster said.
Dose puts patients at a greater risk of harm, he added, “but more important than dose is the reason why physicians have patients at 120 milligrams or more.”
“When we see guidelines that are somewhat arbitrary and don’t take into account individual responses to medications or their needs, to me its not addressing the appropriate issue.”
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