Ohio Self-Insurers Association 2013

Sedgwick © 2013 Confidential – Do not disclose or distribute.
JUNE 12-13, 2013

Narcotic Medication
Strategies
Teresa Bartlett, MD
Senior Vice President
Medical Quality

Sedgwick © 2013 Confidential– Do not disclose or distribute. 3Sedgwick © 2011 Confidential– Do not disclose or distribute. 3
Objectives
• Provide background information regarding opioids
• Provide education
• Provide tools to assist in the assessment of cases
• Screening tools
• Opioid Agreement
• Timing of follow up
• Board of pharmacy reporting
• Assessment considerations
• Drug Screening guidance
• Calculations of Morphine dosages

Education
• First step toward Prescription Drug optimization
• Addresses:
• Overuse
• Underuse
• Misuse
• Drug to drug interactions
• Medication reconciliation process
• Overall health safety concerns
• lab studies

Statistics
• Every hour in the USA one baby is born suffering from in opioid withdrawal
(NIDA)
• 40% increase in employees testing positive for prescription narcotics from
2005-2009 (Quest)
• A November 18, 2010 report post-accident drug tests are four-times more
likely to find narcotics than pre-employment drug tests (Quest)
• Vicodin is the most frequently found narcotic prescription drug
abused (Quest)

Background: How did we get here
•From the American Pain Society Website:
• In late 2000, Congress passed into law a
provision, which the President signed, that
declared the ten-year period that began
January 1, 2001, as the:
• Decade of Pain Control and Research
• The American Pain Society has actively
supported the Decade of Pain Control and
Research and it has been a focal point for the
development of numerous programs to advance
awareness and treatment of pain and funding
for research

Narcotic Utilization
•Fatal overdoses involving
prescribed opioids tripled in
the United States between
1999 and 2006
•A recent government study
determined that opioid poisoning was
the leading cause of death for people
aged 35-54
• This rate was higher
than motor vehicle or
firearm related deaths
for that age group
• Since 1990, the medical use of opioids has increase by a factor of 10
• According to the CDC, enough opioids were prescribed last year to
medicate every American adult with a standard pain treatment
dose of hydrocodone every 4 hours for a month

Narcotic Medication Management
• National Issue
• Creates issues for
• patients
• physicians
• employers
• * The # 1 prescribed drug in the USA in 2012 was Hydrocodone
with acetaminophen (Vicodin)
http://healthland.time.com

Prescription Drug Diversion as a National Issue

Unintended Result
• Across the country, there is an
increase in the number of ER visits
due to non-medical use of
narcotics
• Up to 89% of abused prescription
drugs are diverted from legally
written prescriptions
Problem isn’t just with narcotic
prescribing,buthowtheyare
usedonceinthehandsofthe
public

Biochemical Physiology of Narcotic Use
The way the brain reacts facilitates the process of
addiction/abuse:
• Endorphins are naturally occurring chemicals that
work on the nervous system to reduce pain
• The endorphins can act on certain parts of the brain to
produce euphoria or a natural “high”
• Addiction shuts the endorphin system down
• This leads to hyperalgia (increased pain perception)
and hypersensitivity
• The abuser then seeks higher doses or stronger drugs

Opioid Guideline for Chronic Pain
• Use opioid only after other pain relief therapies have been exhausted
• Before prescribing a risk assessment screening should be conducted
• Opioids should be started at the lowest possible dose
• If a patients dosage has increased to 120mg MED without substantial
improvement in function or pain relief a chronic pain specialist should be
consulted
• Long acting or controlled release opioids should not be used for acute pain
• Fentanyl patches, OxyContin and Methadone are examples

Opioid Contract

Importance of Communication Skills
• Medical Literacy
• Risks
• Self Care
• Lifestyle choices
Patient
Education
• Better Results
• Transfer of specific
knowledge
Consulting
Physician
Education
BetterOutcomes

Follow up Care
• Failure to progress or demonstrate functional progress or any
signs of compliance should lead to prompt discontinuance of
medication
• Dosage may need to be increased to maximize therapeutic value
not to exceed 120mg Morphine/day
• Random Urine Drug Screen
• Weaning should involve a mental health professional who
specializes in addiction
• PT, exercise and other medications such as NSAIDS are
important in this process

Morphine 120mg/day is the MAXIMUM
• An electronic dose calculator can be found and downloaded
• http://agencymeddirectors.wa.gov/mobile.html
MORPHINE (reference) 30 mg
Codeine 200 mg
Fentanyl Transdermal 12.5mcg/hr
Hydrocodone (Vicodin) 30 mg
Hydromorphone 7.5mg
Oxycodone 20mg
Oxymorphone 10mg
Methadone** 4mgj BE CAUTIOUS
COMPLICATED

Acetaminophen (Tylenol) Warning
• Causes liver toxicity
• Many narcotics are combined with acetaminophen so you must also watch
for maximum dosing
• Short-term use (<10 days) – 4000 mg/day
• Long-term use – 2500mg/day

Opioid Risk Tool ORT
Date ______
Patient Name
OPIOID RISK TOOL
Mark each
box that applies
Item Score
If Female
Item Score
If Male
1. Family History of Substance Abuse Alcohol [ ] 1 3
Illegal Drugs [ ] 2 3
Prescription Drugs [ ] 4 4
2. Personal History of Substance Abuse Alcohol [ ] 3 3
Illegal Drugs [ ] 4 4
Prescription Drugs [ ] 5 5
3. Age (Mark box if 16 – 45) [ ] 1 1
4. History of Preadolescent Sexual Abuse [ ] 3 0
5. Psychological Disease Attention Deficit
Disorder [ ] 2 2
Obsessive Compulsive
Disorder
Bipolar
Schizophrenia
Depression [ ] 1 1
TOTAL [ ]
Total Score Risk Category Low Risk 0 – 3 Moderate Risk 4 – 7 High Risk > 8

Urine Drug Testing
• Purpose
• Identify aberrant behavior
• Undisclosed drug use and/or abuse
• Verify compliance with treatment
• Frequency
• Based on risk assessment for drug abuse
• Low risk once/year
• Moderate risk twice/year
• High risk three to four times/year
• Unusual or suspicious behavior = at time of visit
• Losing prescription
• Requesting early refills
• Multiple prescribers
• Demonstrating intoxication
• Slurred, slow speech

Urine Drug Testing Result Interpretation
The following UDT results should be viewed as a “red flag”
requiring confirmation and intervention:
• Negative for opioid(s) prescribed
• Positive for drug (benzodiazepines, opioids, etc) NOT prescribed
• Positive for amphetamine or methamphetamine
• Positive for alcohol
• Positive for cocaine or metabolites
If a confirmatory drug test (MRO) substantiates a “red flag” result AND is:
• Positive for prescribed opioid(s)
• a controlled taper and a referral to an addiction specialist or drug treatment
program should be considered
• Negative for prescribed opioid(s)
• The physician should stop prescribing opioid(s) and consider a referral to an
addiction specialist or drug treatment program

Assessment of Function
• Overall Pain Management
• How well is the pain being managed?
• Pain rating when asked to consider the past month
• Should indicate pain is overall better and able to function at a higher
level
• Function
• Daily activities should be listed
• Even in WC activities that are healthy should be encouraged

Suggested Weaning Process
• Reduce Morphine mg by 10 to 20% each week
• Add Clonopine to help with withdrawal symptoms
• Addiction or Pain Management Specialist should be consulted
• May require short inpatient stay to assist with initial phase
• May require drug rehab program (inpatient and outpatient)

The Role of Claim Managers
• Help the physician stay on track
• Ask for the Risk assessment (ORT) and provide tool if necessary
• Make sure other therapies are tried first
• That first RX for opioids should be small doses and improvements
should be documented in function and pain
• Request follow up assessment of patient to see if medication is working
(allergic reaction) Does not have to be office visit
• Set next appointment with treating physician for 10 to 14 days for next
assessment
• Provide an Opioid agreement to any physician prescribing these drugs
(ACOEM or State of Washington)
• Ask for copies of screening, opioid agreement, drug test results and
OARRS report

OHIO Automated RX Reporting System (OARRS)
• Established in 2006
• Tool to assist healthcare professionals in providing better treatment for
patients with medical needs
• Quickly identifies drug seeking behaviors.
• Prescription History Report can assure a patient is getting the appropriate
drug therapy and is taking their medication as prescribed
Who can run this history report?
• Prescribers (or delegates)
• Pharmacists
• Officers of law enforcement agencies whose primary mission involves
enforcing prescription drug laws
• All must register for an OARRS account

Providers Required to Check OARRS When:
Have a drug screen result that is inconsistent with
the treatment plan or refusal to participate in a
drug screen
Forging or altering a prescription
Stealing or borrowing reported drugs
Arrest, conviction or received diversion, or
intervention in lieu of conviction for a drug related
offense while under the physician's care
Increasing the dosage of reported drugs in
amounts that exceed prescribed amount
Selling prescription drugs
Receiving reported drugs from multiple prescribers,
without clinical basis
Have a family member, friend, law enforcement
officer, or health care professional express concern
related to the patient's use of illegal or reported
drugs

Potential Claim or Clinical Actions
• Focus on quality health care and patient safety issues
• Use Clinical Resources when needed:
• Customized letters to physicians
• Request drug screen
• Ask physician for contract
• Ask Physician to run OARRS Report
• Identify red flags
• Physician Peer outreach
• Independent Medical Exam
• Seek a weaning process from the treating physician
• Potential point of sale blocks
• GOAL: Improve management of the injured workers’
medication regime and lower overall claim costs

Role of Pharmacy Benefit Management
• Identify adverse trends
• Provide point of sale alerts
• Customize according to need
• Define historic use and potential abuse
• Injury specific formulary
• Formulary different for acute and chronic phase

Success Stories
• Sometimes well intended, high quality physicians fall prey to drug seeking patients
– Got narcotic pain RX
– Called doctor and indicated they realized they had a negative reaction in the
past asked for different RX
• Injured worker who did not want narcotics after learning they may cause erectile
dysfunction
• Injured worker who did not want to risk the side effect of the medications when
nurse explained the medication

MAKE A DIFFERENCE!
Questions and Discussion

Ohio Self-Insurers Association 2013

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