RI Law Restricts Opioid Prescriptions – Initially

Providence, RI (WorkersCompenstion.com) – Workers’ compensation stakeholders in Rhode Island have a new tool to help prevent unnecessary prescribing of opioids: state law. H5537, which was signed into law by the governor last week, restricts initial prescribing of opioids to a 7-day supply and no more than 30 morphine milligram equivalents per total daily dose. Because it does not exclude workers’ compensation, the measure pertains to prescriptions for inured workers.

“When a state enacts broad mandates like this, unless they explicitly exclude workers’ comp they are applicable to work comp; which means when a prescriber/payer/pharmacy benefit manager is trying to figure out what is and is not allowed, oftentimes you need to look in multiple places (and not just the work comp statutes),” said Mark Pew, senior VP of Product Development & Marketing for Preferred Medical.

Pew points out that the 30 MMEs per day in Rhode Island’s law is even more restrictive than the 50 suggested under the Centers for Disease Control and Prevention’s opioid prescribing guidelines, which also call for justifying the need to increase the dosage to more than 90 MMEs per day.

The new law almost negates the need for Rhode Island to enact a workers’ compensation drug formulary, at least for initial opioid prescriptions. But what Rhode Island’s law fails to address, like many in the country, is long-term opioid users.

“Part of the dialogue that’s been going on with the opioid epidemic is people who’ve been using them chronically and can no longer access them,” Pew said. “Most states that have passed legislation are focused purely on initial prescriptions.”

The workers’ compensation system in particular has made great strides in combatting the unnecessary use of opioids. But it has “abandoned” a subset of injured workers.

“Opioid prescribing has been down for 6 or 7 years, in terms of both cost and utilization,” Pew said. “But we’ve got these people we didn’t treat right when we didn’t apply what we should have known and created a cadre of injured workers on these drugs; but for a variety of reasons we can’t get them to move to something different.”

Chronic Opioid Users

The workers’ compensation industry has not developed an overall strategy to deal with injured workers who have been taking opioids long-term. Instead, the industry is doing it on a piecemeal basis, with each case individualized and stakeholders trying to do the right thing to create a plan to taper them off the drugs.

“For example, a number of claims in California have been ongoing for a while and payers have consistently gotten utilization review decisions saying it does not pass review of the medical treatment utilization schedule and [the drugs] should be stopped,” Pew said. “Even though [payers] have the statutory right to stop payment for them … they’ve chosen not to because they don’t want to create medical emergencies. Payers are bending over backward to create an individualized tapering plan.”

While there are not a lot of cases of long-term injured workers suddenly being denied access to opioids, the problem is that not all stakeholders are willing to do what is necessary to get them off the medications. Some are reluctant to push for cognitive behavioral therapy, mindfulness meditation, functional restoration or other alternatives to treat chronic pain.

“So for all the best intentions for tapering, it doesn’t happen and the person continues to get ‘inappropriate drug regimens,’” Pew said. “It’s frustrating. You see appropriate regimens and a path forward and options provided, but then you see nothing happens. At some point it breaks down because a stakeholder digs in and doesn’t want to go down that path.”

Pew said it will take education and “a lot of humbling of attitudes” to persuade stakeholders to be open to pain treatment alternatives.

“It needs to change,” he said. “It’s been frustrating in a variety of jurisdictions that [there is a] small subset of patients nobody can make any headway on. It’s in best interests of injured workers to change it. So it is the major story.”

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