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  • ACOEM Supports Objectives of Prescription Drug Abuse Prevention and Treatment Act of 2011

    July 18, 2011

    The Honorable John Rockefeller, IV
    United States Senate
    Washington, DC 20510

    Dear Senator Rockefeller:

    On behalf of the American College of Occupational and Environmental Medicine (ACOEM), thank you for your leadership in addressing the growing drug problem in America: the rapid increase in deaths and overdoses from prescription drug abuse. ACOEM is pleased to support the objectives of S. 507, the Prescription Drug Abuse Prevention and Treatment Act of 2011.

    ACOEM is the nation’s largest organization representing the voice of the nation’s physicians who practice occupational and environmental medicine (OEM). The specialty is devoted to prevention and management of occupational and environmental injury, illness, and disability, and the promotion of health and productivity of workers, their families, and communities.

    ACOEM and occupational physicians are leaders in addressing occupational issues associated with prescription drug abuse. For example, ACOEM is recognized by the U.S. Department of Transportation for providing continuing medical education for Medical Review Officers (MRO). An MRO is a person who is a licensed physician and who is responsible for receiving and reviewing laboratory results generated by an employer's drug testing program and evaluating medical explanations for certain drug test results.

    ACOEM publishes the Occupational Medicine Practice Guidelines to help providers provide effective treatment of occupational injuries and illnesses. They are intended to help improve or restore the health of those workers who incur occupationally related illnesses or injuries. The workers’ compensation system in each state provides a mechanism to ensure that medical care is provided to individuals when they suffer injuries at work. Most states provide unlimited care in an effort to cure and relieve the results of work-related injury or illness.

    The overuse of opioid therapy to treat chronic pain conditions is becoming epidemic in the workers’ compensation system. Recent studies have documented the growing reliance on prescription narcotics to treat injured workers. For example, an August 2009 study by the Washington State Division of Labor and Industry (DLI) estimated that the volume of opiate prescriptions in that state’s workers’ compensation program had increased 50 percent between 1999 and 2007, while a subsequent study by the National Council of Compensation Insurance (NCCI) estimated that narcotic medications accounted for 25 percent of all workers’ compensation drug costs nationwide and that the use of these drugs increases as claims age. 

    A 2011 study by the California Workers’ Compensation Institute found that nearly half of the Schedule II opioid prescriptions in California workers’ compensation are for minor back injury claims. It is estimated that 60 to 80% of the general population will experience an episode of low back pain (LBP) at some point during their lifetime. Low back disorders that may be work-related are the most frequent problems presented to occupational health and primary care physicians. These disorders are the most common cause of reported occupational complaints resulting in days absent from work and comprise 15 to 25% of all occupational injuries. In addition, low back disorders tend to be disproportionately expensive, accounting for 10 to 33% of all workers’ compensation costs. It is estimated nationally that occupationally related back pain has a direct cost of $10.8 billion annually. However, this estimate is overly conservative as it does not include the indirect cost to employers who must rehire and retrain replacement workers, loss of productivity and quality work, administrative costs, and losses to the patient and patient’s family (including productivity at home). Finally, it does not take into account those workers who do not even file for disability, but nonetheless suffer the effects of LBP.

    While opioid therapy may be appropriate in carefully selected cases, the medical evidence finds that such therapy is typically not useful in the sub-acute and chronic phases of treatment. As part of our commitment to addressing the overuse of opioid therapy, ACOEM is providing the ACOEM Guidelines for the Chronic Use of Opioids free to the medical community. The opioid guidelines were developed by an evidence-based, multidisciplinary expert panel in order to manage injured workers whose pain has not been controlled by more conservative means. This chapter is included with the 3rd edition of ACOEM’s Occupational Medicine Practice Guidelines.

    With this letter, we would like to offer the following suggestions and recommendations to improve S. 507.

    Provider Education: The occupational physician is required to remain on the front lines of pain management and maintain a primary comprehension of the type of pain medication and course of treatment that is warranted for treating work-related injuries. While a 16 credit hour requirement every three years for controlled substance licensure, as required in S. 507, may be overly burdensome, we agree that additional provider education of an undetermined amount is an important part of a strategy to address prescription drug abuse. ACOEM currently provides CME on pain management as part of the ongoing education effort on use of the Occupational Medicine Practice Guidelines. In the Third Edition of the ACOEM Guidelines, 1172 out of 2574 treatment recommendations are pain related. We request that section 4(a)(3)(B) of the bill be amended to include the American College of Occupational and Environmental Medicine as an accepted physician training organization. 

    Guidelines: S. 507 establishes the Controlled Substances Clinical Standards Commission. The responsibilities of the Commission include publishing in the Federal Register consensus guidelines for pain management with prescription opioid drugs. We respectfully request that the Commission be directed to include consideration of treatment guidelines for occupational injuries, including ACOEM’s Occupational Medicine Practice Guidelines. A growing body of scientific literature suggests that: 1) at higher levels of use, opioids can adversely impact an injured worker’s activity level and sense of self-efficacy; and 2) prolonged administration of narcotic pain medications may impede, rather than facilitate, an injured worker’s recovery from occupational back injuries. In California, physicians who want to participate in the medical network for the State Compensation Insurance Fund will be required to refrain from prescribing opioids for a period longer than 60 days without prior approval. This requirement was added in response to studies suggesting narcotic painkillers increase costs when they are not used according to treatment guidelines from organizations, such as ACOEM.

    Prescription monitoring: Many states have created prescription drug monitoring programs (PDMP), which use databases to track prescriptions of controlled substances. PDMPs are designed to prevent the misuse of prescription drugs that are prone to abuse—such as opioid painkillers and sedatives like benzodiazepines—by making doctors aware of the prescription histories of their patients. At least thirty-five states now have operational PDMPs. These range from programs with limited staffing and outreach ability to programs with large, well-staffed programs that make extensive use of the data they collect.

    Two recent CDC studies suggest that the state-specific differences among PDMPs might influence whether or not they are effective in reducing opioid misuse and overdose. According to CDC, these studies confirm that PDMPs are not a magic bullet for ending the prescription drug overdose epidemic. Additional studies are needed to identify what the other components of effective policies are. The choices states make in how they operate their PDMPs need to be rigorously evaluated, as these decisions may affect the programs’ effectiveness.  

    We agree that physicians should actively monitor the use and effects of chronic opioids on their patient. However, performing these services is a separate cognitive function which is typically not reimbursable. The Current Procedural Terminology (CPT) code set is maintained by the American Medical Association. The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. The CPT code set includes codes for evaluation and management, but currently there is not a code for monitoring use and effects of opioids. At least one state, Colorado, has adopted a state-specific code and reimbursement values for these services.

    We suggest that the legislation provide for the rigorous evaluation of PDMPs, including the benefit of payment systems to compensate for monitoring chronic opioid use. One option to consider is a pilot program within the Federal Employees Compensation Act (FECA) to reimburse providers for the evaluation and management of opioid and related drugs.

    We look forward to working with you on this important initiative. Please contact Patrick O’Connor, ACOEM’s Director of Government Affairs at 202/223-6222 or patoconnor@kentoconnor.com for questions or additional information.

    Sincerely,

    T. Warner Hudson, MD
    President