Raising the Bar to Lower Opioid Risk
While progress is being made to reduce opioid prescribing, institutions and groups are doubling down on efforts to lower the risk of opioid misuse, including more stringent guidelines.
The last couple of years have seen a decline in the number of opioids being prescribed, but evidence still shows that a significant portion of patients are receiving chronic treatment with opioids longer than 90 days. According to a recent study conducted in Rochester, New York, 1 in 4 patients receiving a new opioid prescription progressed to chronic use.1 Further, patients receiving long-term opioid treatment were more likely to have a past or current history of substance abuse, even though treatment guidelines specifically recommend that these patients should not receive opioid therapy. And while prescribing habits and rates vary by state, it remains that millions of Americans are receiving long-term opioid treatment.
While strides are being made against the pervasiveness of opioid overprescribing in workers’ compensation, there remains room for improvement, and recent guideline updates are part taking a strong stand to make this happen.
LOWER DOSING THRESHOLDS
Daily morphine equivalent dose (MED) of opioid medications directly correlate with negative outcomes ranging from abuse and overdose to increased risk of depression and other serious side effects. Increased risk for overdose has been documented at a MED as low as 20mg, with significant risk occurring at MED 100mg or higher.2 The American College of Occupational and Environmental Medicine (ACOEM) updated their Practice Guidelines at the end of 2014 with the goal of providing more detailed guidance for all phases of opioid treatment.3 The organization sets the bar for recommended daily MED thresholds at 50mg based on their analysis of studies that indicate a sharp increase in risk for overdose death at levels above 50mg.4,5 This is an aggressive target compared with other evidence-based or state-specific guidelines, which set the maximum recommended daily MED between 80-120mg.
Although the recommended MED thresholds vary depending upon the guidelines followed, the approach to prescribing remains the same: when dealing with a medication with so much potential for risk, it is always best to err on the conservative side. Care management strategies should emphasize alternative pharmacological and non-pharmacological treatment whenever possible. When opioid treatment is clinically appropriate, opioid treatment duration should be minimized, and tools that enable close monitoring and ongoing clinical assessment are critical.
Healthesystems, in concert with its customers, takes a proactive and aggressive approach to opioid risk management. Among claims managed by Healthesystems, more than 80% of injured worker claimants receiving opioid therapy fall below the ACOEM maximum recommended daily MED of 50mg, the most stringent threshold set in the industry.6
PREVENTING CHRONIC USE
Keeping MED levels low is a positive sign that opioids are being managed appropriately. However the ultimate goal is to achieve an MED level of zero – whether that means seeking alternative treatment in patients upfront, or tapering them off opioids as needed following acute treatment in favor of a more appropriate long-term treatment strategy.
The state of Washington has taken a strong stance on this approach with their recently updated opioid prescribing guidelines. The 2015 Interagency Guideline on Prescribing Opioids for Pain places a greater emphasis on decision-making in the acute stage of treatment, as well as preventing transition to chronic opioid use.7 It also includes expanded recommendations for non-opioid pain management options and stresses the importance of tracking clinically meaningful improvements in function as well as pain management to make decisions regarding opioid treatment. The previous 2010 guidelines had primarily focused on chronic non-cancer pain, and the new update represents a dramatic shift towards early intervention opportunities. And while the most recent Washington guidelines have kept the official recommended maximum daily MED at 120mg, they do acknowledge the potential risks associated with MED higher than 100mg/day. They also emphasize that there really is no “safe” opioid dose, and therefore chronic use should be avoided altogether, wherever possible.
The California Division of Workers’ Compensation (DWC) has also initiated a process to update the chronic pain section of its Medical Treatment Utilization Schedule. The updates include a new, standalone chapter for opioid guidelines that stress the exploration of alternative treatments such as physical activity, yoga and acupuncture, as well as non-opioid medications. For patients in whom opioids are appropriate, California guidelines recommend a maximum daily MED of 80mg.8
GUIDELINES AS A TOOL FOR PAYERS, PBMS
Guidelines serve not only as recommendations for prescribers in making appropriate treatment decisions; they also serve as a powerful tool for payers and PBMs to enforce clinically sound decisions. State-implemented guidelines can support claims professionals in making decisions regarding high-risk, high-cost medications such as opioid analgesics.
The application of evidence-based guidelines in treatment of the injured worker has a proven impact on both clinical and cost-related outcomes. This extends to pharmacologic and non-pharmacologic treatment – from recommendations for appropriate opioid prescribing to guidance on when physical therapy is preferred over surgery or imaging services. Healthesystems incorporates evidence-based medicine from leading guidelines into all of its solutions, ranging from automated tools to enhanced clinical decision support.