Efforts to track opioid dispensation across the nation show many state workers’ compensation systems produce significantly varied data. What factors are currently at play in these state-to-state differences? Returning guest Dr. Vennela Thumula joins host Alan Pierce to discuss the study she co-authored, Interstate Variations in Dispensing of Opioids, 5th Edition. Dr. Thumula describes the research questions addressed in the study and offers insight into the effect certain state policies may have on opioid use.
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Workers Comp Matters
Examining State Variations in Opioid Dispensation with WCRI’s Dr. Vennela Thumula
Intro: This is Workers Comp Matters, hosted by attorney Alan S. Pierce, the only Legal Talk Network program that focuses entirely on the people and the law in workers’ compensation cases. Nationally recognized trial attorney, expert, and author, Alan S. Pierce, is a leader committed to making a difference when Workers Comp Matters.
Alan S. Pierce: Welcome once again to Legal Talk Network and Workers Comp Matters. This is your host Alan Pierce. I am an attorney at Pierce, Pierce & Napolitano in Salem, Massachusetts practicing in the field of Workers’ Compensation, and we are happy to bring you another edition of Workers Comp Matters with a returning guest.
We’ve had Dr. Vennela Thumula with us once before and I am going to be having a discussion with Dr. Thumula on a recent project that she completed for the Workers Comp Research Institute entitled, ‘Interstate Variations in Dispensing of Opioids’.
But before we get to the subject of today’s show, we would like you to visit our sponsor, PInow.com, find a local qualified private investigator anywhere in the United States. Visit pinow.com to learn more.
As I mentioned, Dr. Thumula is associated with the Workers Compensation Research Institute located in Cambridge, Massachusetts and we have had the benefit of having guests from WCRI on workers’ comp matters in the past and just to acquaint our listeners WCRI is an independent not-for-profit research organization based in Cambridge, Massachusetts. It was organized in 1983. The Institute does not take positions on the issues it researches, rather it provides information obtained through studies and data collection efforts which conformed to recognize scientific methods. Objectivity is further ensured through rigorous, unbiased peer review procedures.
WCRI’s diverse membership includes employers, insurers, government entities, managed care companies, healthcare providers, insurance regulators, state labor organizations and state administrative agencies such as Industrial Accident Boards and the like, not only in the United States, but Canada, Australia, and New Zealand.
WCRI does perform an amazing service to the workers’ comp industry and they really approach issues in a way that some of us who practice law don’t fully appreciate or understand. They get deep into the details.
And getting deep into the details, again, as I mentioned before, we have a returning guest, Dr. Vennela Thumula, she is a Policy Analyst for WCRI. She conducts research on pharmaceutical use in the workers’ comp system. She’s the author of several studies evaluating, prescribing patterns of opioids, drug formularies, physician dispensing, and Dr. Thumula received her Ph.D. from the University of Mississippi School of Pharmacy.
So, having said all of that, Dr. Thumula again, let me welcome you to Workers Comp Matters.
Dr. Vennela Thumula: Thank you for having me, Alan. I’m happy to be here.
Alan S. Pierce: Okay, needless to say, I don’t think we have to spend very much time talking about the issue of opioids, opioid prescriptions and chronic pain and pain management in the workers’ comp system. Not only have we done several shows on this very hot topic over the last several years, but you can hardly go anywhere in the United States and attend any workers comp seminar, forum, panel discussion without the issues surrounding opioids, opioid misuse, opioid deaths and the effect both in terms of financial costs as well as costs in human life and appreciation of life and the difficulties in trying to control this problem.
And I know WCRI has done a lot of work studying how different jurisdictions, different states deal with the dispensing and the utilization of opioids and in fact, your research brief that we are going to discuss this afternoon is ‘Interstate Variations in Dispensing of Opioids’.
So, first of all, what prompted this study, why is it important to look across State boundaries to look at how different states do things?
Dr. Vennela Thumula: Opioids as you mentioned are a hot topic not just in workers’ compensation but in the nation, and in workers’ compensation injured workers are commonly prescribed opioids for work-related injuries.
So this particular study is the fifth edition of our opioid benchmarking studies that track how opioid use varies across states and overtime in the workers’ compensation system.
And as states differ in terms of prescribing practices and pain management practices in the study we track which states had higher or lower utilization of opioids, and in more recent years many states are implementing legislation and regulation to combat the opioid epidemic, and so doing the study, it provides us an opportunity to monitor the results of these ongoing policy changes, whether there are reductions in opioids following the implementation of these reforms, which is one of the reasons we updated this study to track the changes and to see where states are at the end of the study period, if there are states where opioid use continues to be higher.
Alan S. Pierce: So, as I gave a review of your study it seemed to me there were states that were still on the high side of opioid dispensing others on the low side and some rationale as to why there may be differences. So may I assume it might be helpful for those states that are doing a better job than others for you to be able to isolate who those states are and perhaps the methods that they’ve employed to improve the opioid situation? So this I assume can provide a basis for improvement in some of those states that you’ve studied or perhaps the states that weren’t studied to improve their systems, is that a fair goal?
Dr. Vennela Thumula: That is correct. So we do demonstrate which states have higher and lower use, which states had the largest reductions and what policies were implemented in states that had large reductions so that others may have a description of all these policy tools that may be used for a reduction of opioid dispensing.
Alan S. Pierce: Okay. So let’s get into it. What period of time was covered? I’m looking at the results of your research, it certainly is not a set of data that occurred over just a particular year, so give us the range of time and perhaps even some of the other numbers of how many cases or claims and numbers of prescriptions that were looked at that went into your conclusions?
Dr. Vennela Thumula: Okay, so in the fifth edition of ‘Interstate Variations in Dispensing of Opioids’, we tracked trends from 2012 to 2016 injuries and the prescriptions that were filled by these injured workers on an average 24-month period post-injury. So we include prescriptions filled up to March 2018 in the study.
And in terms of the total number of claims, we have roughly half a million non-surgical claims that had more than 7 days of lost time across 27 states and these 27 states are diverse in terms of their geographic location and the sample that we have included represents 37% to 72% of workers compensation claims in each State.
Alan S. Pierce: Okay, so you have roughly a little over half the 50 states and just — let me just run down very quickly for our listening audience the particular states studied. Obviously states that aren’t included in the study can certainly extrapolate from your data, but just for those of you out there who may want to look more deeply into the study, those states, and I’ll read them relatively quickly are Arkansas, California, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Jersey, New York, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas, Virginia and Wisconsin, and clearly you do have a geographical as well as a population and economic diversity here.
So now that we know what the study was looking for, in the period of time it covered and who was studied, what are the particular variations that stuck out at you as you research the dispensing of opioids across these State jurisdictions?
Dr. Vennela Thumula: So we do see large interstate variation in overall dispensing of opioids. One of the measures that we look at is how many, what proportion of injured workers with a prescription, with any prescription paid under workers’ compensation receive at least one opioid and we do see large interstate variations on this measure, from roughly one-third of injured workers in New Jersey receiving at least one opioid prescription to 70% in Arkansas and Louisiana.
And another measure that we look at into quantified opioid dispensing variation across states is the average amount of opioids reclaim in the State and we see that the highest State had five times the average amount compared to the lowest State in our study.
So, in terms of the opioid dispensing, amount of opioids dispensed, we do see quite a bit of interstate variations. We also in the study examine what are the types of opioids or what are the type of pain medications that are prescribed for injured workers across the states and while in the most recent study period, we start to see that non-opioid pain medications such as NSAIDs, anticonvulsants, those form the majority of pain medication prescriptions.
There is quite a bit of a variation in what percent of pain medications are for these non-opioid analgesics. It varies from 50% to 70%, and if even when we look at the type of opioids that are prescribed we again see variation. In some states, doctors more likely prescribe oxycodone. For example in Massachusetts, oxycodone is the most prescribed opioid and in several other states hydrocodone is more frequently prescribed, and in some others tramadol is more frequently prescribed.
So we try to present for each State the types of opioids that are prescribed, the amount of opioids that are prescribed, what percent have chronic opioids, what percent have opioid levels that exceed guideline recommended amounts. We also look at concomitant exposure of opioids to opioids and other central nervous system depressants such as benzodiazepines. And we do again see interstate variations in many of the measures that I touched on today.
Alan S. Pierce: Okay, and in fact looking at the summary of your findings, I think for example, the percentage of injured workers with prescriptions receiving opioids range from 32% to 70% across the 27 states, which is pretty wide variance, we can discuss perhaps some of the reasons in a moment.
But you identified by MME, which is Morphine Milligram Equivalent, that the states that had the highest MME per worker were Delaware, Louisiana, Pennsylvania and New York, and in fact Delaware and Louisiana, I think your study indicates that their Morphine Milligram Equivalent per claim was over 3,200 milligrams, more than three times the median and five times the State with the lowest amount, which was Missouri.
You identified I think New York and Pennsylvania is having had a higher average amounts of opioids dispensed in the first two years of a claim up to a 110% higher than the median. So there is wide variety or variation between and among the states.
Would you say that there were certain policy measures adopted by the states that might be doing a better job in controlling the frequency and dosage of opioids, and if so, what would some of those changes in the way states handled it be.
Dr. Vennela Thumula: That’s a great question. In fact, I see two questions in there, because some of these states like New Jersey they were lower on to begin with at the beginning of the study period and we saw reductions in this in the states further, which brought them to the lowest in terms of the percentage of injured workers with prescriptions receiving opioids.
So I want to answer that question in two parts, one is, why are there variations across the states even before some of these changes were implemented and then what are the changes that were implemented in these states with large reductions, right? So with respect to the first point, why states vary on opioid dispensing?
We discussed several potential factors that might explain the variation in the study but we did not examine empirically how much each of these factors contribute to the variation. One thing we did examine was whether do these states really differ a lot on demographic characteristics of claimants, the injury and industry composition of the workers compensation claimant, and we do not see that that’s a major factor.
We adjusted for the differences across the states in demographics and injury industry mix and this did decrease the range across the states by a little, but the large interstate variations persisted even after controlling for these differences.
So even if you put similar workers in different states, the frequency of opioid dispensing still varies a lot. So what are some of the factors that might explain this variation?
One of them that we didn’t explore in this study, but some of the previous WCRI studies looked at it and looked at local practice norms have a major role in explaining whether an injured worker residing in an area is likely to get an opioid prescription for their work-related injury.
We see that if the injured worker resides in an area where the general prescribing norms of opioids are higher, then they are more likely to get an opioid prescription. That’s one of the factors.
Then, there are state policies such as PDMPs and other pain policies that may explain why injured workers in some states have higher rate of opioids compared to those residing in other states and within workers’ compensation.
Alan S Pierce: Dr. Thumula, PDMPs, that’s Prescription Drug Monitoring Program, so that’s a program that involves both a contract with the provider and the patient as well as a variety of other things that go into that, such as random or required drug tests and pledges not to secure drugs from more than one provider, etc. So your reference to a PDMP would be in jurisdictions that require a prescription drug monitoring program, so I just want to clarify what a PDMP was.
Dr. Vennela Thumula: Yeah, you are right. So it’s not just about whether the state has a Prescription Drug Monitoring Program, but all the other policies surrounding the Prescription Drug Monitoring Programs, which vary from state to state. As of now all 50 states have a Prescription Drug Monitoring Program, but they differ in terms of whether they require unsolicited reporting, whether doctors are required to check the PDMP.
So it’s one of the factors that might explain as to how if there are a lot of policies that improve the utility of the PDMP in a state that might be associated with the opioid prescribing practices in the state.
Alan S Pierce: Okay, we are going to take a break right here and then when we resume our discussion, we will be talking about some of these other policies that have been adopted in various states that have begun to help control the epidemic of overuse of opioids. So after a couple of minutes we will be right back with Dr. Vennela Thumula.
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Alan S Pierce: We are resuming our discussion with Dr. Vennela Thumula about interstate variations in the dispensing of opioids, and one of the things we ended the last segment on was while many states, if not all states, have PDMPs or Prescription Drug Monitoring Programs, there are other methodologies within these type of programs or even outside these programs that have played a role in beginning to reduce the frequency, duration and chronicity of long-term or even short-term opioid use.
So in addition to that, what other processes or programs have different states within the workers’ comp system, such as Industrial Accident Boards, done to address this problem?
Dr. Vennela Thumula: One of the policies that we see that were implemented in a lot of states that had reductions in opioid dispensing were the limits on the amount and duration of initial opioid prescriptions for acute pain, and half of the study states this particular type of legislation was implemented during a study period and most of these limit the duration of initial opioid prescriptions to a 7 or up to 14 days of supply, which is in line with the recommendations of the CDC Chronic Pain Guidelines.
Alan S. Pierce: Are there situations where a workers’ comp claimant can exceed those guidelines in exceptional circumstances or in these jurisdictions it is pretty rigid, you get the 7 days or 14 days only post-surgery or post-acute injury, are there exceptions?
Dr. Vennela Thumula: Yes, there are. These laws do have exceptions. These are for — some of these are associated with acute pain just in emergency or urgent care settings, but for surgery, these are not related to ongoing use or chronic pain and they also have surgical exceptions in most cases.
Alan S. Pierce: Okay. And let’s talk about chronic pain, because obviously if you can control the initial utilization of opioids, you are going to be less likely to find a physical and/or psychological dependency setting in over a period of time, and I know from my clients, I have clients that are in pain and chronic pain which depending on how it’s defined is pain over a six-week period or some arbitrary period before it’s termed chronic, and it’s the dealing with my clients, the injured workers who have been in chronic pain as they report for months, in fact even years. So how do you begin to address the issue or how have different jurisdictions addressed the issue of the ongoing open-ended use of opioids in chronic pain?
I know in Massachusetts we have Chronic Pain Guidelines and we have other modalities that are listed in our guidelines as substitutes for pills and opioid medications. What are some of your findings in terms of how different jurisdictions are dealing with the chronic use of opioids over the months and years long-term?
Dr. Vennela Thumula: You have mentioned one of the policy levers to address chronic opioid treatment and as you said, we do see treatment guidelines for prescribing opioids and chronic pain management that were implemented during the study period in several states, not just by workers’ comp agencies, but also the state medical boards.
In this study, because a lot of these guidelines call for a broader adoption of non-pharmacologic treatment and non-opioid pain medications prior to or along with opioids, and we did in the study track how frequently injured workers are receiving some of these non-opioid pain medications and non-pharmacologic treatments such as active physical medicine, passive physical medicine modalities, acupuncture, chiropractic care, interventional pain management services and behavioral treatments.
Alan S. Pierce: And we have discussed this on past shows and I can tell you from my practice, and again, I have always found it somewhat difficult. Before we have had treatment guidelines here in Massachusetts outlining this sort of palliative of additional non-pharmaceutical remedies such as acupuncture, such as massage therapy, psychological intervention, I think we all can agree that a lot of pain is psychologically based, that’s not to say that it’s made up, but it is — there is a component to that, there are some people that can deal with pain differently than others.
And it’s been in my view the recognition over the last several years from insurers, claims adjusters, claims reps, I find they are more willing to authorize and approve non-pharmacological or pills or opioids in exchange for some of these other modalities, where in prior years they wanted to stay as far away as possible from psychological intervention or even things that are considered to be a little bit less than mainstream medicine, such as acupuncture or massage, biofeedback and things like that.
And I think your study bears out that those jurisdictions that seem to recognize the need to not just simply put limits on pills that can be habituating, but there must of necessity be some other mechanisms that can control pain.
You have also mentioned the implementation of drug formularies and that gets into another sort of interesting area of debate that we are not going to get into today, but just for the audience and for me, what is a drug formulary and the implementation of same and how does that impact the prescription patterns of opioids?
Dr. Vennela Thumula: Drug formularies are a list of medications in workers’ compensation. The way they are enforced is, some of the drugs would require a prior authorization before they can be prescribed and some of them would not require a preauthorization. So it’s a limited list that can be prescribed without preauthorization and the rest, medical necessity for those drugs needs to be established before prescribing them.
And they address opioids to different extents. I mean it’s not that many workers’ compensation jurisdictions have drug formularies at this point, I think it’s about a dozen states that have implemented them and how opioids are addressed differs across these states, but again, it’s one of the many policies that were implemented during the study period in states that we see large reductions in. In fact, about half of the states had Prescription Drug Monitoring Program prescriber mandates, about half implemented limits on the initial opioid prescriptions for acute pain and I think about five states formularies were implemented in five states and in one of them it was towards the end of the study period.
Alan S. Pierce: And I can tell you as a claimant attorney and somebody who speaks with and works with claimant attorneys and for that matter insurer attorneys around the country, the concept of a drug formulary in general and specifically for pain is a hot button topic from our perspective, on behalf of our clients, it allows somebody other than the treating doctor to dictate the type of medications that could be available. And that the other modalities that you had mentioned, such as drug monitoring, Chronic Pain Guidelines and other modalities can work independent of establishing a formulary, which reduces choice and oftentimes leaves outliers from a drug formulary really without appropriate pain medication or chronic pain control.
So where do you see this study going further? Now that it’s been published, is this something that the various states can take a look at and what can they hope to glean from it and improve their performance and what comes next from WCRI? I am sure this is a work in progress.
Dr. Vennela Thumula: It is an ongoing series of studies tracking opioids and better opioid dispensing is changing as more policies are being implemented. And opioids continue to be an area with a lot of policy debates still ongoing, so we will hopefully conduct research on this topic as long as there is opioid utilization dispensing in workers’ compensation.
Alan S. Pierce: Okay. So if somebody would like further information about WCRI or for that matter this particular study, and again, it’s ‘Interstate Variations in Dispensing of Opioids’, 5th Edition, where could they find further information?
Dr. Vennela Thumula: The study and all our studies; we have several other studies related to opioids, you can find them on our website, wcrinet.org, and specifically with respect to this topic, we have a webinar coming up on September 12 at 2:00 p.m. We will be taking a deeper dive into the findings of the study, so all the measures that we include and which states had the largest reductions, we will be covering that during the webinar, and if you are interested in that webinar, you can also sign up for it on our website.
Alan S. Pierce: Okay. And since many people may be listening to this particular podcast after September 12, will that webinar be archived and available on your website or is it a live and done event?
Dr. Vennela Thumula: Yes, the webinar will be available on our website and it’s going to be free for our members and everybody else can get it for a nominal fee.
Alan S. Pierce: Okay. Well, that again brings us to the conclusion of another Workers Comp Matters show. I want to thank our guest Dr. Vennela Thumula and WCRI for their good work in studying a most pressing and vexing problem in the area of workers’ comp, and as our guest has said, it’s not just limited to workers’ comp, but it is a problem across society and across the nation.
So until our next show, thank you for listening and go out and make it a day that matters. Bye-bye.
Outro: Thanks for listening to Workers Comp Matters today on the Legal Talk Network, hosted by attorney Alan S. Pierce, where we try to make a difference in workers’ comp legal cases for people injured at work. Be sure to listen to other Workers Comp Matters shows on the Legal Talk Network, your only choice for legal talk.