Comparing Two Programs to Reduce Unsafe Opioid Prescribing and Improve Outcomes among People Who Are Injured at Work -- The WOW Study

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What was the research about?

A type of medicines called opioids can help ease acute pain caused by an injury. But long-term opioid use can lead to addiction, overdose, or death. One way to prevent these problems is to reduce unsafe prescribing. Unsafe prescribing includes taking high-dose opioids or taking opioids for longer than 60 days.

In this study, the research team compared a workers’ compensation program for injured workers in Washington State with a program in Ohio:

• Washington State. This program used prior authorization. Insurance doesn’t pay for opioids unless doctors get approval first. Then doctors must agree to follow safe prescribing practices.
• Ohio. This program used retrospective review. A nurse reviews patients’ health records. If they find signs of unsafe prescribing, they mail a letter to the doctor asking them to explain. If the doctor can’t explain, then the health insurer stops paying for the opioids.

The research team looked at how well the programs worked to reduce unsafe opioid prescribing.

What were the results?

After one year, the two programs didn’t differ in unsafe opioid prescribing. Compared with patients in Ohio, patients in Washington were:

• More likely to receive time-loss benefits, which provide patients with wages while they can’t work
• More satisfied with the care they received for their pain

The two programs didn’t differ in patient reports of:

• Pain
• Symptoms of anxiety or depression
• Activity levels
• Income
• Use of opioids
• Quality of life

What did the research team do?

The research team looked at workers’ compensation claims for patients with opioid prescriptions. The data included 4,632 patients in Washington and 779 patients in Ohio. Of these, 75 percent were men and 23 percent were 35–44 years old.

The research team also surveyed 1,965 workers in Washington and 319 workers in Ohio. These workers had received workers’ compensation and had an opioid prescription. They completed surveys one year after their injury. Surveys asked about workers’ health and their ability to work after they received opioids.

Patients with chronic pain and pharmacy managers provided input during the study.

What were the limits of the study?

The research team may not have had data on all the opioid prescriptions each patient received. Results may have been different if the team had had data on all prescriptions. The study looked at two states’ programs for workers with injuries. Results may differ in other states.

Future research could use more data sources on opioid prescriptions. Studies could also look at other states’ workers’ compensation programs to reduce unsafe opioid prescribing.

How can people use the results?

Workers’ compensation policy leaders can use these results when considering ways to promote safe opioid prescribing for workplace injuries.

Objective

To compare the effectiveness of two opioid prescribing programs in reducing unsafe opioid prescribing and improving patient-reported outcomes among patients who were injured on the job and receiving workers’ compensation

Study Design

This prospective observational cohort study compared the effectiveness of two opioid prescribing programs in Washington and Ohio in reducing unsafe opioid prescribing and improving patient-reported outcomes. The programs were:

• Prior authorization. Washington requires prescribers to seek approval for opioid prescriptions beyond six weeks after injury. Prescribers must submit documentation showing that they followed opioid-prescribing best practices and that taking opioids resulted in clinically meaningful pain reduction for the patient. Workers’ compensation insurance in Washington only pays for opioid prescriptions with prior authorization.
• Retrospective review. Six weeks after a patient’s injury, Ohio requires that a nurse review opioid prescription claims to look for documentation that prescribers followed opioid-prescribing best practices. If missing, Ohio workers’ compensation mails up to three requests for prescribers to provide documentation. If prescribers do not provide documentation, workers’ compensation insurance stops paying for opioid prescriptions.

Researchers reviewed workers’ compensation claims data for 4,632 patients with a new injury from Washington and 779 patients from Ohio. Among patients in Washington, 75% were male and 24% were 35–44 years old. Among patients in Ohio, 75% were male and 20% were 35–44 years old.

For patient-reported outcomes, at one year, researchers surveyed 1,965 patients in Washington and 319 patients in Ohio receiving workers’ compensation within six weeks of their injury. The survey asked about pain, anxiety, depression, activity limitations, and whether the patient was working for pay or receiving time-loss benefits, which are wage replacement payments for people who cannot work. The survey also asked about self-reported opioid use, quality of life, satisfaction with overall treatment, and if patients were earning less than before their injury.

Patients with chronic pain, a patient with a work-related injury, and workers’ compensation insurance or pharmacy managers provided input during the study.

Results

After one year, the two programs did not differ significantly in unsafe opioid prescribing. Compared with patients in Ohio, patients in Washington were more likely to receive time-loss benefits (odds ratio [OR]=1.97; 95% confidence interval [CI]: 1.12, 3.47) and were more satisfied with their pain treatment (OR=0.22; 95% CI: 0.05, 0.38). The two programs did not differ significantly in other patient-reported outcomes.

Limitations

Because workers’ compensation claims only include opioid prescriptions paid through workers’ compensation, the analyses did not include opioid prescriptions from other sources. The study only looked at two state-funded workers’ compensation systems. Results may differ for other workers’ compensation systems.

Conclusions and Relevance

The study did not find significant differences in unsafe opioid prescribing when comparing prior authorization with retrospective reviews. Compared with patients in Ohio, patients in Washington reported more time-loss benefits and more satisfaction with their care.

Future Research Needs

Future research could use other data sources like prescription drug monitoring to obtain more complete opioid prescribing information or examine other states’ workers’ compensation programs to reduce unsafe opioid prescribing.