Study Shows Variations in Narcotics-Prescribing Patterns

Employers may want to take a close look at a new report on the use of pain medications by injured workers. The lack of consistency among states reveals the knowledge gap in treating patients with chronic pain.

Wednesday, August 24, 2011
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A new report that compares the use of pain medications among injured workers in 17 large states points to the wide variations in the use of narcotics -- and coincides with one state's new rules that may help solve some of the growing concerns about opioid use in the workers' comp system.

"I think this study is one of the more important ones," says Richard A. Victor, executive director of the Workers Compensation Research Institute in Cambridge, Mass., which produced the report entitled Interstate Variations in Use of Narcotics. "It shows there are some large opportunities to manage better."


Nearly one in six injured workers who received any narcotics in Louisiana were identified as longer-term users of narcotics, compared to one in 20 in the typical state. Other states with higher numbers of long-term narcotics users were New York, Pennsylvania, Texas, California, Massachusetts, and North Carolina.

The amount of narcotics per claim also varied substantially. The average injured worker in New York received more than 4,000 milligrams of morphine equivalent narcotics per claim. Also high were Louisiana, Massachusetts, and Pennsylvania.

Tied in with the amount of narcotics per claim was the type of narcotics prescribed. Injured workers in Massachusetts, New Jersey, Maryland, Minnesota, North Carolina, Pennsylvania and Wisconsin were more likely to have stronger, Schedule II narcotics prescribed.

The report notes that most experts recommend careful screening of patients for chronic opioid therapy as well as close monitoring and management.

However, "few ...longer-term users of narcotics received those recommended services," the report states.

"Only 7 percent of the longer-term users in the median state had urine drug screening tests... . Similarly, few longer term users of narcotics had the psychological evaluation and treatment recommended by guidelines," it states.

Victor says he is surprised by the wide variations in the length of use of narcotics among the states. "In certain states, such as Louisiana, there's a relatively high likelihood [that] if you start narcotics, you will be taking them six months later," he says.

The authors note, however, that more frequent prescribing of Schedule II narcotics did not always imply an overuse of narcotics.

In Wisconsin and Minnesota, even though physicians were more likely to prescribe Schedule II narcotics, the average morphine equivalent amount of narcotics per claim was lower than the 17-state median.

Talking about Need for Action

The results signal the need for further research, according to the authors, who also hope the findings spark discussions and, perhaps, action among the following stakeholders:

* Injured workers. "If my physician said to me, 'I'm going to prescribe narcotics and you should know that data shows you have a one-in-six chance of being on them six months from now,' I'd think long and hard," Victor says.

* Physicians. "If I'm a clinician and I'm in the Northeast or Mid-Atlantic states where I have a preference for prescribing Schedule II narcotics, I'd want to know whether my counterparts in states that have a preference for Schedule III narcotics are getting good outcomes," Victor says.

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* Employers and insurers. "If I'm a payer in states where workers get high amounts of narcotics, I'd want to focus my utilization management there," he says.

* Elected representatives. "If I'm a public official in a state with high narcotics use, I'd want to take a look at the effectiveness of public policies in place and look at what other states do to see if they get different results," Victor says.

* Public-sector action. In Washington state, officials are taking actions to stem the potential overuse of narcotics. A state law adopted last year requires healthcare regulatory boards and commissions to develop rules for the management of chronic non-cancer pain by this summer.

"The law was very direct about what needed to be in the rules in terms of setting up a daily threshold for dosage," says Kristi Weeks, director of legal services for the Washington Department of Health. "If the patient exceeds the daily dosage, they have a consultation with a pain-management specialist."

The rules also cover evaluating and monitoring patients who are prescribed narcotics. "The idea was, 'Let's not just keep giving somebody more drugs, but let's assess if it's helping them and, if not, let's look at other things," she says.

Under the rules, physicians are required to evaluate chronic patients for current and past treatment, comorbidities and any history of substance abuse. Also required is a physical evaluation, "not just hearing subjective complaints," Weeks says.

Finally, the rules require periodic reviews of patients. Included must be whether the patient is complying with the treatment plan.

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