Thursday, January 17, 2013

New Opioid Guidelines: Well Done Washington

Washington State's Department of Labor & Industries (L&I) has issued new, and quite comprehensive, guidelines for prescribing opioids to treat injured workers.  Yes, Washington is a monopolistic state.  Yes, I've been critical in the past of certain L&I measures that gained widespread praise, but fell short when one looked closely at the details.  But the new guidelines represent a bold, clinically-focused, evidence-based, administratively-tight step that will lead to material changes in opioid use for the state.  The document is dense and covers a lot of ground: the prevalence of opioid use, the impact of the drugs - both clinically and socially, the appropriate uses of the drugs by stage of injury, and best practices regarding discontinuation.  Not enough room here to cover everything, but here are a few highlights:

Let's start with my favorite sentence in the entire 20 page document: "If opioids are to be prescribed beyond 12 weeks post-injury or post-surgery, the provider must have received prior authorization from the department."  (By the way, the bold font for "must" is not my doing... L&I wrote it that way).  Further, in order to receive such prior authorization, several important conditions must be documented, including:
- Clinically meaningful improvement in function (greater than or equal to 30%) has been established with opioid use in the acute or subacute phase.
- Failure of trials of reasonable alternatives to opioids.
- Signed treatment agreement (pain contract).
- A time limited treatment plan, addressing whether chronic opioid therapy is likely to improve the worker's vocational recovery.
- Consultation with a pain management specialist if the worker's dose is above 120 mg per day MED.

Good stuff.  If every state, every carrier, every employer enforced (or, perhaps were allowed to enforce) such guidelines, we could eliminate a significant portion of the opioid problem in comp. 

One concern (and I'd be happy to get some input here, particularly from Washington readers): Is L&I prepared for the administrative burden of the prior authorization process they've created here?  While taking a slightly different form, Texas has effectively created a similar requirement (through its closed formularly rules).  We've performed sufficient analysis and looked at enough cases in Texas to know that enforcing a pre-auth requirement takes a lot of resources, a lot of planning, and (optimally) a remediation period to address chronic opioid therapy on legacy claims.  Washington appears to plan to "flip a switch" on July 1, 2013.   I hope they're ready.

On Twitter @PRIUM1


  1. We'll be ready. We are also working on accompanying regs.

    Thanks for the coverage-these guidelines, along with the 2010 WA Agency Medical Director Opioid
    dosing Guidelines, and the new state rules, should be a huge boost to prevent harm and improve outcomes.

    Gary Franklin

  2. I think that is great, there are too many people being overprescribed opiodes and a lot of issues that come out of it, great that washington is doing that to protect people and have tighter guidelines.