Since the late 1990s, the United States has seen an epidemic of mortality, overdose, and addiction related to the use of prescription opioids for chronic pain. This has led to over 200,000 deaths and millions addicted. Workers’ compensation systems have been hit particularly hard by the opioid epidemic because the populations most likely to receive longer-term opioid prescriptions have been those with routine musculoskeletal conditions, which are the most common disabling conditions among injured workers. For example, nearly one-third of injured workers with low back injuries in Washington state receive opioids, and receipt of just three prescriptions, or over seven days of opioids in the first six weeks, after injury is associated with a doubling of the likelihood that a worker will become disabled long term. Preliminary data suggest that reducing acute prescribing for injured workers could reverse this disability trend associated with acute prescribing of opioids. The Centers for Disease Control and Prevention have recently also emphasized the potential importance of avoiding opioids if possible in favor of alternative treatments and limiting the number of days opioids can be prescribed for acute pain to three to seven days in most cases.
Washington and Ohio offer a unique opportunity to study interventions to reduce unsafe opioid prescribing in the workers’ compensation system because these are the two largest states that insure workers through population-based exclusive state funded insurance (not private workers’ compensation insurers). Both states have regulatory authority over healthcare delivery to all injured workers in the state. Furthermore, both states have opioid review procedures related to opioid prescribing during the subacute pain period, between six weeks and three months after injury. This offers a unique opportunity to compare the effectiveness of these two different procedures in reducing unsafe opioid prescribing. The Washington and Ohio systems use similar opioid prescribing guideline-concordant principles but differ substantially in how the authorization procedures are implemented.
We will assess whether use of such insurer-based opioid authorization methods is associated with decreases in unsafe opioid prescribing and with improved health outcomes important to patients and their families (e.g., pain, function, quality of life, ability to work, disability). We will also assess whether a coordinated, stepped care management system for pain in Washington leads to better patient-reported outcomes among patients affected by the opioid review decisions.
For this study, we will form a Study Advisory Committee that includes a broad spectrum of stakeholders from both within and beyond Washington and Ohio, for ongoing and coordinated advice and assistance in all aspects of this study. The Study Advisory Committee will consist of representatives from key stakeholder groups and perspectives, including patients/injured workers, healthcare providers/opioid prescribers, workers’ compensation pharmacy managers, and workers’ compensation insurance leaders who have been nationally influential in workers’ compensation opioid policy. Patient/injured worker representatives will include those who have at least three types of patient experience: chronic pain, opioid use disorder, and difficulty terminating opioid treatment after being prescribed short-term opioids for an injury. The President of the American Chronic Pain Association has agreed to be a member. Key stakeholders who could also be affected by insurer authorization procedures (e.g., prescribing providers) and large public and commercial payers, insurers, and employers who would be most effective in wider dissemination and implementation of prior authorization procedures are also formally engaged.