1. Opioid Use in Work-related Injuries Pacific Northwest Chapter - Association of Occupational Health Professionals (AOHP) January 4, 2011 Jaymie Mai, PharmD Pharmacy Manager

2. 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

3. 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)

4. 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)

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

7. Unintentional & Undetermined Opioid Overdose Death Rates by State 2007 Source: Centers for Disease Control and Prevention 3.1-9.09.1-11.411.5-21.1 Age-adjusted rate per 100,000 population

8. Washington Opioid Deaths & Sales of Rx Opioids Source: Washington State Department of Health

9. Washington Hospitalizations from Opioid Overdose 1987 - 2008 Source: Washington State Department of Health

10. L&I Prescription Opioid-related Deaths

11. L&I Schedule Opioid Utilization Trend

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

13. Group Health Study  1 st 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

14. 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

15. 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

16. Strategies for safe and effective opioid prescribing

17. 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

18. 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

19. 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 http://www.agencymeddirectors.wa.gov/default.asp

21. New efforts to reduce opioid-related mortality and morbidity

22. 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 http://www.cdc.gov/HomeandRecreationalSafety/pdf/poision-issue-brief.pdf

23. 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

24. 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 http://www.agencymeddirectors.wa.gov/default.asp

25. ESHB 2876 – Pain Management Chapter 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