By Julie Black, R.Ph., Product Director, Coventry Workers’ Comp
Overutilization of prescription narcotics has been termed a national epidemic by the Centers of Disease Control and Prevention (CDC) and now causes more deaths per year than cocaine and heroin combined.1 Over the last 20 years, the treatment of pain has been aggressive and the use of narcotics has become more acceptable than it had been historically. Chronic pain due to work-place injuries has resulted in a sizeable increase in narcotic utilization. According to the National Council on Compensation Insurance (NCCI), in 2009, OxyContin, a long-acting narcotic medication, was the most utilized medication within workers’ compensation.2 In response to the rising use of narcotics and fatalities in the state of Washington, in 2010, the Washington Agency Medical Directors Group (AMDG) published a revised guideline for dosing narcotics for patients with chronic non-cancer related pain. The guideline recognizes 120 mg Morphine Equivalent Dose (MED) per day as the threshold for seeking consultation with a pain specialist if improvement in pain or function is not evident. A recent cohort study illustrated that doses above 100 mg MED per day result in a 9-fold increase in risk of overdose with 12% of overdoses being fatal. The creation of the Washington narcotic guideline has transformed the clinical management of patients taking narcotics due to the lack of a published ceiling dose by the majority of narcotic manufacturers or compendia.
Converting Narcotic Dosing to MED for Patient Risk Stratification
Using morphine as the gold standard for comparing narcotic doses, the daily MED is calculated with the assistance of a conversion table and the known daily dose of the narcotic utilized by the patient. The following narcotic conversation table taken from the 2010 AMDG Guidelines3 demonstrates how varying doses translate into a morphine equivalent dose:
Table 5. MED for Selected Narcotics
| Narcotic | Approximate Equianalgesic Dose (oral & transdermal) * |
| Morphine (reference) | 30mg |
| Codeine | 200mg |
| Fentanyl transdermal | 12.5mcg/hr |
| Hydrocodone | 30mg |
| Hydromorphone | 7.5mg |
| Methadone | Chronic: 4mg† |
| Oxycodone | 20mg |
| Oxymorphone | 10mg |
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* Adapted from VA 2003 & FDA labeling † Equianalgesic dosing ratios between methadone and other opioids are complex, thus requiring slow, cautious conversion (Ayonrinde 2000) |
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Implications for Workers’ Compensation
The importance of the 120 mg MED per day threshold in workers’ compensation is considerable as clinicians now have a measuring stick, of sorts, with which to analyze injured worker prescription data and then stratify claims by level of risk to the patient. In addition, the threshold of narcotic utilization is now a point of discussion with prescribers who exceed it. Information on safe and effective doses of narcotics now exist allowing prescribers to be presented with an accepted ceiling dose and supporting safety data. Prior to exceeding a narcotic dose of 120 mg MED per day, the AMDG recommends a consultation with a pain management specialist in order to address possible alternatives to narcotics, the risks and benefits of high dose narcotics, appropriate pain and function measurements, and the need for intervention with additional specialists. Although the AMDG recommendations are specific to providers in Washington State, the MED guidelines are gaining acceptance across the country and should be adopted as the norm for Pharmacy Benefit Managers (PBMs) to identify cases warranting prescriber outreach and utilization management.
In the current environment of increasing narcotic use, it is important that clinicians recognize that narcotic doses above 120 mg MED per day jeopardize the health and safety of the injured worker. As doses increase, adverse events such as central nervous system depression, addiction, and death become more prevalent. The increased morbidity and mortality associated with high doses of narcotics results in added costs to the workers’ compensation system and is a grim reminder that a ceiling dose, does in fact, exist for these medications and should be considered in every narcotic therapy regimen.
About Julie Black
Julie Black is a registered pharmacist in Arizona, California, and Missouri. She is responsible for the development of new and enhanced clinical pharmacy programs for First Script, the Coventry Workers’ Comp Services Pharmacy Benefit Management Program. Julie’s 6 years with Coventry include her previous management of the clinical pharmacy operations team. Julie has worked for a group health PBM, several chain settings, a closed staff long-term care pharmacy, and has performed both adverse event reporting and patient education programs throughout the pharmaceutical industry. Julie received her Bachelor of Science in Pharmacy from the University of Missouri at Kansas City.
About Coventry Workers’ Comp Services
Coventry Workers’ Comp Services, a division of Coventry Health Care, Inc. (NYSE: CVH), is the leading provider of cost and care management solutions for property and casualty insurance carriers, (workers’ compensation and auto insurers), third-party administrators and self-insured employers. We design best-in-class products and services to help our partners restore the health and productivity of injured workers and insureds as quickly and as cost effectively as possible. We accomplish this by developing and maintaining consultative, trusting partnerships with our clients and stakeholders, built on a foundation of innovative and customized solutions that support the claims management process.
Notes
1 CDC Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999—2008; Retrieved from the Centers for Disease Control and Prevention website on 8/17/12 at http://www.cdc.gov/media/releases/2011/t1101_prescription_pain_relievers.html.
2 Narcotics in Workers Compensation; Retrieved from the National Council on Compensation Insurance website on 8/17/12 at https://www.ncci.com/nccimain/IndustryInformation/ResearchOutlook/Pages/Narcotics-WorkComp.aspx
3 Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain; Retrieved from the Agency Medical Directors’ Group website on 8/17/12 at http://www.agencymeddirectors.wa.gov/opioiddosing.asp