As part of an ongoing effort to ensure safe and effective care for injured workers, the department developed an opioid prescribing report to provide information on opioid prescribing practices for providers treating injured workers. Using data from the Washington State Prescription Monitoring Program, this report looks at three measures of opioid prescribing that may place injured workers at increased risk of harm. Note that even if you treated patients for issues unrelated to an industrial injury, if they had an open claim in the L&I or self-insured system at the time the opioid was prescribed, they would be included in our analysis.
Sample Report
In the sample opioid prescribing report, click on the links to learn more. A measure that appears in red accompanied by a red “X” indicates a provider’s prescribing is at or above the 90th percentile for that measure. A measure that appears in yellow accompanied by a yellow “!” indicates a provider’s prescribing is between the 85th and 89th percentile for that measure. While providers do not receive a report if their prescribing ranks below the 90th percentile, it’s a good idea to review corresponding best practices for measures that are flagged in both red and yellow.
Contact
If you have questions not addressed on this site, contact us at pharmacymanager@Lni.wa.gov. We strive to improve and would appreciate your feedback.
- Prescription Monitoring Program (PMP)
- High-dose opioids
- Clinically meaningful improvement in function (CMIF)
- Concurrent opioids and sedatives
- Chronic opioids
- Non-specific pain
Prescription Monitoring Program (PMP)
PMP is a statewide electronic database of controlled substances prescribed for your patients. The PMP is a valuable screening tool and should be checked prior to prescribing opioids to ensure controlled substance history is consistent with prescribing record and patient’s report.
Providers who prescribe opioids must register with the PMP.
Review opioid prescribing requirements.
Red flags to look for when you check the PMP:
- pattern of controlled substances prescribed by multiple providers and/or multiple pharmacies
- multiple instances of early refills
High-dose opioids
Defined as prescribing >90 mg/day morphine equivalent dose (MED) for at least 28 days for the year in question (does not have to be consecutive days).
Overdose risk increases two-fold starting at 20 mg/day MED and increases further with additional increases in dose. Prescribe the lowest effective dose to minimize serious adverse outcomes. While the Opioid Prescribing Rules require consulting a pain specialist before exceeding 120 mg/day MED, the CDC Guideline recommends avoiding doses above 90 mg/day MED. The method used for MED calculations is consistent with the Agency Medical Directors' Group MED calculator.
Clinically meaningful improvement in function (CMIF)
Defined as an improvement in function of at least 30% compared to the start of opioid therapy or a dose change.
For consistency, use the same validated instrument to assess, such as the Two Item Graded Chronic Pain Scale or PEG. Note that a decrease in pain in the absence of improved function is not considered CMIF.
Concurrent opioids and sedatives
Defined as any overlap in an opioid prescription and a sedative prescription based on fill date and days supply.
Drugs that are considered sedatives: benzodiazepines, barbiturates, hypnotics (e.g. zolpidem, zaleplon, zopiclone, eszopiclone), meprobamate, and carisoprodol.
Combining opioids with sedatives increases the risk of serious adverse events and death.
Chronic opioids
Defined as prescribing opioids for at least 90 days for the year in question (does not have to be consecutive days).
Chronic opioid therapy (COT) is associated with a significant increase in risk of mortality and serious adverse outcomes. Appropriate prescribing of COT requires a thorough evaluation with regular monitoring and documentation, such as screening for risk from comorbid conditions, checking the PMP database, assessing for clinically meaningful improvement in function (CMIF), administering random urine drug tests, and using results from screening to guide therapy. Continuing to prescribe opioids in the absence of CMIF or after the development of a severe adverse event is not considered proper and necessary care.
Non-specific pain
Pain for which it is not possible to identify a specific cause. Examples include low back pain, headaches, and fibromyalgia.
Who is included: All network providers with a valid DEA number who prescribed an opioid prescription within the year of interest for an injured worker with a workers’ compensation claim. To ensure stability of estimates and to target resources to providers who account for most opioid prescribing, analysis is limited to providers who prescribed opioids to at least 10 injured workers in the year in question.
How are providers compared: All providers are grouped into one of three categories: primary care/internal medicine (includes internal medicine subspecialties), surgeons (includes surgical specialties), and specialists (e.g. neurologists, physiatrists). We compare a provider’s opioid prescribing against his/her peer category as well as to all providers.
How are providers identified to receive a report: Once providers are identified for inclusion and categorized for subgroup comparison, group and overall means are calculated for each of the three indicators. The 90th percentile is calculated with respect to all providers. Providers who rank above the mean AND at or above the 90th percentile on at least one of the three indicators will receive an opioid prescribing report.
Metrics: The three measures evaluated are prescribing of: high-dose opioids, concurrent opioids and sedatives, and chronic opioids. These measures are associated with significant risk of severe adverse outcomes. Each measure is calculated as follows: the numerator is the number of injured workers that meets the definition of the measure, the denominator is the number of injured workers who received at least one opioid prescription during the year in question. Using high-dose opioids and provider Dr. Smith as an example, the numerator is the number of injured workers Dr. Smith prescribed >90 mg/day morphine equivalent dose for at least 28 days for the year and the denominator is the number of injured workers Dr. Smith prescribed at least one opioid prescription to for the year.
Data source: Prescription Monitoring Program and Department of Labor & Industries.
Results from analysis of 2018 data
For the year 2018, 1275 providers were included for analysis with 247 providers identified to receive an opioid prescribing report.
| Percentage of injured workers prescribed | Primary care/internists | Surgeons | Specialists | Overall |
|---|---|---|---|---|
| high-dose opioids | 2.6% | 0.2% | 15.8% | 2.5% |
| concurrent opioids and sedatives | 5.2% | 1.5% | 8.0% | 4.6% |
| chronic opioids | 10.0% | 1.1% | 38.4% | 9.6% |
Results from analysis of 2017 data
For the year 2017, 1449 providers were included for analysis with 294 providers identified to receive an opioid prescribing report.
| Percentage of injured workers prescribed | Primary care/internists | Surgeons | Specialists | Overall |
|---|---|---|---|---|
| high-dose opioids | 3.5% | 0.8% | 16.7% | 3.4% |
| concurrent opioids and sedatives | 6.9% | 2.3% | 8.4% | 5.7% |
| chronic opioids | 11.8% | 1.9% | 32.1% | 10.1% |
Results from analysis of 2016 data
For the year 2016, 1775 providers were included for analysis with 356 providers identified to receive an opioid prescribing report.
| Percentage of injured workers prescribed | Primary care/internists | Surgeons | Specialists | Overall |
|---|---|---|---|---|
| high-dose opioids | 4.2% | 1.0% | 16.0% | 3.9% |
| concurrent opioids and sedatives | 8.1% | 3.0% | 8.5% | 6.8% |
| chronic opioids | 12.5% | 2.2% | 30.4% | 10.7% |
Results from analysis of 2015 data
For the year 2015, 1077 providers were included for analysis with 200 providers identified to receive an opioid prescribing report.
| Percentage of injured workers prescribed | Primary care/internists | Surgeons | Specialists | Overall |
|---|---|---|---|---|
| high-dose opioids | 4.1% | 0.9% | 15.2% | 3.8% |
| concurrent opioids and sedatives | 7.5% | 3.8% | 11.7% | 6.7% |
| chronic opioids | 10.2% | 2.4% | 34.0% | 9.4% |
Percentages calculated based on X injured workers with prescriptions meeting each criterion over Y injured workers with opioid prescriptions that appear in the Prescription Monitoring Program, calculated separately for each provider, then averaged across the specified set of providers.
Clinical support
- University of Washington Medicine Pain and Opioid Consult Hotline for Clinicians
- UW TelePain
- Washington State University opioid education for health profession students and primary care providers
Guidelines
- L&I Guideline for Prescribing Opioids to Treat Pain in Injured Workers
- CDC Guideline for prescribing opioids for chronic pain
- Agency Medical Directors' Group Interagency Guideline on Prescribing Opioids for Pain