Transcript Assessing Impairment from Opioids and Polypharmacy

NARCOTICS:
WHO’S DRIVING?
Paul D. Dykstra
Ganan & Shapiro, P.C.
411 Hamilton Boulevard, Suite 1006
Peoria, Illinois 61602
June 4, 2012
NARCOTICS
“DRIVERS”
1. Employee/patient
2. Treating doctor
3. Employer / insurance provider
4. Drug
Top 15 Prescription Drugs in WC for Service Year 2009
1. OXYCONTIN® (Ox i KON tin) is a controlled-release narcotic painkiller prescribed for around-the-clock relief of moderate to severe pain.
2. LIDODERM® (LYE doe derm) is used to relieve the pain associated with sunburn; insect bites; poison ivy; poison oak; poison sumac; minor cuts,
scratches, and burns; sores in the mouth; dental procedures; hemorrhoids; and shingles (herpes infection).
3. HYDROCODONE W/ACETAMINOPHEN (hye droe KOE done)/(ah see ta MIH no fen) (generic form of Vicodin®) is a narcotic analgesic used to
relieve moderate to severe pain.
4. LYRICA® (LEER i kah) is an anticonvulsant and neuropathic pain agent used for treating fibromyalgia or nerve pain caused by certain conditions
(e.g., shingles, diabetic nerve problems). It is also used in combination with other medicines to treat certain types of seizures.
5. CELEBREX® (SELL eh breks) is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain or inflammation caused by many conditions
such as arthritis, ankylosing spondylitis, and menstrual pain. It is also used in the treatment of hereditary polyps in the colon.
6. GABAPENTIN (ga bah PEN tin) (generic form of Neurontin®, approved in 2003) is used in the treatment of some types of seizures and the
management of postherpetic neuralgia (nerve pain caused by the herpes virus or shingles).
7. SKELAXIN® (skell AX in) is a muscle relaxant used to treat skeletal muscle conditions such as pain or injury.
8. CYMBALTA® (sim BALL ta) is used to treat major depression—a disorder marked by continuing, serious, and overwhelming feelings of
depression that interfere with daily functioning. It is used to treat diabetic peripheral neuropathy, a painful nerve disorder associated with diabetes
that affects the hands, legs, and feet.
9. MELOXICAM (mell OX ih kam) (generic form of Mobic®) is used to relieve the pain and stiffness of osteoarthritis and rheumatoid arthritis.
10. CYCLOBENZAPRINE HCL (sye kloe BEN za preen)/(HYE droe KLOR ide) (generic form of Flexeril®) is a muscle relaxant used to treat skeletal
muscle conditions such as muscle spasms resulting from injuries such as sprains, strains, or pulls.
11. TRAMADOL HCL (TRA ma dol)/(HYE droe KLOR ide) (generic form of Ultram®) is prescribed to relieve moderate to moderately severe pain.
12. OMEPRAZOLE (oh MEP ra zole) (generic form of Prilosec®) is prescribed for the short-term treatment (four to eight weeks) of the following:
stomach ulcer, duodenal ulcer (near the exit of the stomach), erosive esophagitis (inflammation of the esophagus), and heartburn and other symptoms
of gastroesophageal reflux disease (also known as GERD, which occurs when stomach acid backs up into the tube connecting the throat to the
stomach).
13. FENTANYL (FEN ta nil) (generic form of Duragesic®) prescribed for chronic pain when short-acting narcotics and other types of painkillers fail
to provide relief.
14. FLECTOR® is a patch that is placed on the skin to apply pain medication directly to the source. It is used to treat pain caused by minor strains,
sprains, and bruises.
15. OXYCODONE HCL (ox i KOE done)/(HYE droe KLOR ide) (generic form of Roxicodone® or OxyContin® if extended release) is a narcotic pain
reliever used to treat moderate to severe pain. The extended-release form of this medication is for around-the-clock treatment of pain.
1. EMPLOYEE /
PATIENT:
WHO IS GETTING THE
DRUGS?
AMA GUIDES NEWSLETTER
MARCH/APRIL 2011
-
Narcotic medications are most often prescribed for low-back pain
-
Prescription narcotics are extremely addictive, becoming so often
shortly after first consumption, and have a diminishing effect with the
same dosage over time.
-
Over the past five years, expenditures for prescription narcotics for lowback symptoms have increased 423%, with no appreciable effect or
improvement on symptom or disability outcomes.
-
The two largest studies on narcotic prescription consumption show that
noncompliance (misuse, overuse, nonconsumption) occurred in more
than 70% of patients.
AMA GUIDES NEWSLETTER
MARCH/APRIL 2011
-
The nature of the diagnosis and length of time experiencing pain did not
correlate with who will be prescribed narcotic drugs.
-
Narcotic prescriptions most often correlated with the patient’s less
education, lower income, mental illness, smoking, obesity, and ethnicity,
most often Caucasian.
-
The primary risk factor for chronic benign pain are psychological and
social, so prescribing narcotics bears little chance of successfully
addressing that pain.
CDC DATA
-
The quantity of prescribed narcotics in 2010 was 4 times
larger than in 1999.
-
Per capita prescribed narcotics were 3 times higher in
Florida (highest rate) than Illinois (lowest rate).
- 33 million Americans over age 12 misuse narcotics.
-
Nearly 500,000 emergency room visits in 2009 were due to
misuse or abuse of prescription narcotics.
-
Misuse or abuse of prescribed narcotics costs health
insurers $72.5 billion each year.
CDC DATA
-
Men are much more likely than women to misuse or abuse
prescription narcotics.
-
Middle-aged adults have the highest prescription narcotics
abuse rates.
-
People in rural counties are almost twice as likely to misuse
or abuse prescription narcotics as those in urban areas.
-
Whites are more likely to abuse prescribed narcotics than
any other race demographic.
2. TREATING
DOCTOR
Top Physician-Dispensed Drugs in Florida
(NCCI)
2005
2009
Drug Name
Price Per Script
Drug Name
Price Per Script
1 CARISOPRODOL
2 NAPROXEN
3 CEPHALEXIN
4 TRAMADOL HCL
5 SKELAXIN®
6 IBUPROFEN
7 RANITIDINE HCL
8 ETODOLAC
9 CYCLOBENZAPRINE HCL
10 DICLOFENAC SODIUM
$118
$35
$52
$35
$50
$12
$92
$52
$28
$56
MELOXICAM
CARISOPRODOL
TRAMADOL HCL
OMEPRAZOLE
RANITIDINE HCL
LIDODERM®
NAPROXEN
HYDROCODONE-ACETAMINOPHEN
CYCLOBENZAPRINE HCL
ETODOLAC
$192
$272
$80
$279
$175
$502
$57
$50
$63
$126
Top Physician-Dispensed Drugs in Georgia
(NCCI)
2005
2009
Drug Name
Price Per Script
Drug Name
Price Per Script
1 IBUPROFEN
2 CYCLOBENZAPRINE HCL
3 DICLOFENAC SODIUM
4 ETODOLAC
5 RANITIDINE HCL
6 CEPHALEXIN
7 TRAMADOL HCL
8 NAPROXEN SODIUM
9 SKELAXIN®
10 NAPROXEN
$13
$35
$45
$67
$65
$45
$32
$25
$80
$32
MELOXICAM
LIDODERM®
HYDROCODONE-ACETAMINOPHEN
TRAMADOL HCL
CARISOPRODOL
RANITIDINE HCL
GABAPENTIN
NAPROXEN
OMEPRAZOLE
CYCLOBENZAPRINE HCL
$199
$419
$48
$63
$171
$121
$167
$60
$231
$47
NCCI Study August, 2011
1. Narcotics account for nearly one-quarter of all workers compensation
prescription costs.
2. In 2009, prescriptions accounted for 19% of total medical costs, rising
roughly 1% per year since 2004.
3. Prescription distribution and utilization, not price increase, accounts for
global cost increase.
4. Per-claim prescription costs grew 12% from 2008 to 2009.
5. Narcotics share of drug costs increases as claims age.
6. Narcotics are used mostly for back injuries in workers compensation.
NCCI STUDY AUGUST, 2011
Percentage of prescriptions dispensed by physicians (versus by pharmacies)
Nationally
Florida
California
Georgia
Maryland
Pennsylvania
Illinois
2007
2008
2009
19%
22%
50%
20%
14%
22%
18%
23%
44%
46%
33%
29%
27%
22%
28%
50%
48%
44%
35%
33%
31%
NCCI STUDY AUGUST, 2011
Reasons for physician dispensation of
prescriptions
1. Having the patient begin taking the medication
immediately.
2. Getting the medication dosage properly calibrated.
3. Providing convenience for the patient.
4. Bypassing medical fee schedules by repackaging and
repricing the medications (giving the doctor a vested
interest in prescribing narcotic medication).
3. EMPLOYER /
INSURANCE
PROVIDER
Top 50 Drugs for Service Year 2009 Paid Share
Rank by Service Year (NCCI)
2009
Drug Name
2009
2008
2007
6.1%
5.2%
5.1%
4.4%
3.7%
3.4%
2.8%
2.7%
2.3%
2.3%
2.1%
2.0%
1.8%
1.5%
1.4%
1.4%
1.3%
1.3%
1.3%
1.2%
1.1%
1.1%
1.1%
1.1%
1.1%
1.0%
OXYCONTIN®
LIDODERM®
HYDROCODONE-ACETAMINOPHEN
LYRICA®
CELEBREX®
GABAPENTIN
SKELAXIN®
CYMBALTA®
MELOXICAM
CYCLOBENZAPRINE HCL
TRAMADOL HCL
OMEPRAZOLE
FENTANYL
FLECTOR®
OXYCODONE HCL
ULTRAM® ER
OXYCODONE HCL-ACETAMINOPHEN
CARISOPRODOL
NAPROXEN
KADIAN®
ZOLPIDEM TARTRATE
OPANA® ER
AMRIX®
TIZANIDINE HCL
AMBIEN CR®
PERCOCET®
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
3
2
1
4
5
6
7
8
11
9
10
15
12
28
13
17
19
16
14
23
18
31
47
22
26
27
8
2
1
4
3
5
7
13
15
9
10
18
14
>1000
6
23
21
12
11
24
30
57
266
20
27
25
Top 10 Therapeutic Classes by Amount Billed–2010
(Coventry First Script Drug Trends 2011)
Therapeutic Class
Analgesics, Narcotic Sustained-Release
Analgesics, Narcotic Short-Acting
Anticonvulsants
NSAIDs
Muscle Relaxants
Dermatological/Topical Preparations
Antidepressant Medications, Non-TCA
Sedative/Hypnotics
Antiulcer Medications
Antipsychotics
% Total Rx
6.0%
30.2%
8.5%
11.1%
10.3%
3.6%
6.1%
3.4%
2.6%
0.6%
% Total Billed
20.3%
17.5%
10.6%
7.5%
7.3%
7.0%
6.7%
3.5%
3.2%
2.0%
Top 10 Total
All Other Total
82.4%
17.6%
85.6%
14.4%
Top 10 Therapeutic Classes by Amount Billed–2011
(Coventry First Script Drug Trends 2011)
Therapeutic Class
Analgesics, Narcotic Sustained-Release
Analgesics, Narcotic Short-Acting
Anticonvulsants
NSAIDs
Dermatological/Topical Preparations
Antidepressant Medications, Non-TCA
Muscle Relaxants
Antiulcer Medications
Sedative/Hypnotics
Antipsychotics
% Total Rx
5.7%
29.8%
8.5%
11.9%
3.9%
6.0%
10.3%
2.6%
3.1%
0.7%
% Total Billed
19.4%
17.5%
10.7%
7.7%
7.3%
6.8%
6.7%
3.3%
3.1%
2.3%
Top 10 Total
All Other Total
82.5%
17.5%
84.8%
15.2%
4. DRUG
AMA GUIDES NEWSLETTER
MARCH/APRIL 2011
-
In a recent study, 100% of patients demonstrated increased vulnerability
to pain after one month of taking prescribed narcotics.
-
Pain thresholds in those patients decreased 16%, and pain tolerance
dropped 24%, in that time.
-
Narcotics cause a phantom pain, called “hyperalgesia,” that often
accounts for unexplained symptoms.
-
Narcotics may aggravate the pain that they were designed to address.
-
These effects were found not to be permanent, as 21 of 23 patients in
the study reported a significant decrease in pain after detoxification.
AMA GUIDES NEWSLETTER
MARCH/APRIL 2011
-
Narcotics produce severe pain that hinders functional ability and
accurate impairment assessments.
-
The AMA Guides for Impairment include subjective claims of functional
impairment as a factor in the impairment rating.
-
Narcotic consumption delays attainment of maximum medical
improvement because of the related hyperalgesia and lack of
effectiveness in addressing the true organic symptoms that relate to the
injury.
-
Several studies prove that consumption of narcotics made no difference
in pain control versus consumption of a placebo.
AMA GUIDES NEWSLETTER
MARCH/APRIL 2011
-
Side effects of prescription narcotics -
-
Endocrine disruption (87% of men reported erectile dysfunction after
ingestion of narcotics).
-
Sleep abnormalities.
-
Immune system compromise.
-
Cognitive impairment.
-
Abuse of other substances (56% of patients taking narcotics abuse other
substances).
SOLUTIONS:
THE EMPLOYER
TAKES THE WHEEL
1.
Encourage treating doctors who prescribe narcotic medications to
frequently have the patient tested to ensure that the drug is in the
patient’s system and in the intended amount.
2.
Develop a system within your program to trigger Utilization Review of a
prescribed medication after a designated number of refills.
3.
Use independent medical examinations and peer records reviews to
obtain opinions on the necessity of narcotics prescriptions.
4.
Bring the employee back to work in order to break the dependence
psychology that many times drives the “need” for narcotic medication
and in order for you to be able to monitor the employee’s behavior and
ongoing status.
THANK YOU TO THOSE OF YOU WHO
ATTENDED THIS PRESENTATION.
I THANK THE NATIONAL COUNCIL FOR
THE INVITATION AND THE
OPPORTUNITY TO SPEAK.