Distribution of Scripts by Age of Opioid Claim 100% 90% 80%

MAINE STATE LEGISLATURE

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Reproduced from scanned originals with text recognition applied (searchable text may contain some errors and/or omissions) STATE OF MAINE WORKERS 1 COMPENSATION BOARD OFFICE OF EXECtmVE DIREcroR/CHAIR 442 ClVIC CENTER DR:JVE, SU'ITE too 27STATE HOUSE STATION AUGUSTA, MAINE 04333-0027 PAtft. R. LEPAGE PAU1. H. STGH!NOLFl, EsQ GOVERNOR ExEcUTIVE DUlECTOR/CIWR January 12, 2017

Eric Brakey, Senate Chair Patricia Hymanson, House Chair Committee on Health and Human Services c/o Legislative Information Office I 00 State House Station Augusta, ME 04 3 3 3

Amy Volk, Senate Chair Ryan Fecteau, House Chair Committee on Labor, Commerce, Research and Economic Development c/o Legislative Information Office 100 State House Station Augusta, ME 04333

Dear Senator Brakey, Representative Ilymanson, Senator Volk_ and Representative Fecteau:

After the Legislature deliberated and passed LD 1646, An Act to Prevent Opiate Abuse by Strengthening the Controlled Substances Prescription },,foniforing Program, enacted as P.L. 2015, Chapter 488, this office was asked to study the use and effectiveness of opioids used in treating workplace injuries and the availability of alternative treatment. The stakeholders in workers ' compensati on were aware LD 1646 was having an impact on prescribers· practices and the exploration of alternatives before its effective date. In speaking with those in the stakeholder community. most believed a study in 2016 was too early. The areas you thought should be analyzed have been in transition because of the legislation. Data in our world matures very slowly. A study would be far more productive after the law takes effect to see how those in the medical commun1ty respond to the legislation in the context of workers' compensation obligations. ln lieu of a taskforce, I went to the National Commission on Compensation Insurance (NCCI) and asked for their help in identifying opioid and benzodiazepine use in Maine workers' compensation over the last five years. First, I met and had telephone conference calls '~'ith NCCI staffers. Raji Chada.revian, Manager & Associate Actuary, Susan Schulte, Department of Labor Focus Lead, and Law-a Backus Hall, CPCU, State Relations Executive. NCCI annually prepares a Medical Data Report for the state of Maine. Knowing they had avculable data, l sought their willingness to help the Workers' Compensation Board in providing you with a meaningful report on the use of opioids and benzodiazepines in our system. I am enclosmg a copy of a report prepared b) NCCI ~esearchers for your rev1cw and constderation. 1 have secw·ed authority from NCCI to share this report with you and your committee.

A national medical commentator on disabibty issues in the workplace bas referred to workers' compensation as a '·medically-driven legal system " 1 Because we deal with work i.njunes, it is

Jennifer Chnstian, MD

1lEL: 207-287-7086 ITY: 711 FAX: 207-287-7198 Toll Free: 888-801-9087 2

true there is a medical aspect to every claim. We all know opioid use has caused a medical crisis in the United States. The enclosed report is best summed up in the concluding remarks prepared by NCCI. We learn from the report opioids in the Maine workers' compensation system are in a mild decline. We Jearn further Maine has been paying about 30% less for opioids than rhe region? Finally, the report tells us those in Maine who take opioids and benzodiazepines together, on average, receive fewer than those in the regjon. /uJ. analysis of the report demonstrates there were 4,644 cases reviewed. These are claims where prescriptions were written. Of those, 1,891, or 41% received an opioid prescription. Two hundred and forty-nine, or 5% received only a benzodiazepine prescription and 172, or 3.7% received prescriptlons for both opioids and benzodiazepines. In 2015, those receiving opioids had, on average, five prescriptions per claim. Those being prescribed benzodiazcpines received three prescriptions, and when a claimant was receiving both opioid and benzodiazepine prescriptions, they received a total of 12. The chart appearing on page seven of the repott shows the usage percentage of opioids and benzodiazepines has declined slightly in the past year. The report tells us that of workers' compensation claimants who received at least one prescription in 20 15, two in five were prescribed an opioid, and one in 19 was prescribed a benzocliazepine.

One of the more telling aspects of lhis report is Maine, as compared to the region, has been below the average Ln opioid-paid claims. In 2015, we were 23% below the region. Part of the reason for this is opioids in Maine workers' compensation were, in 2015, approximately 15% less expensive than the region.

'VIlhen one analyzes the share of drug claims \:vith at least one opioid prescription, Maine was slightly below the region and, over the last five years, the prescription per claim percentage has fluctuated. We learn further prescription practices in workers' compensation demonstrate Maine is below the region and has been for the last four years.

One of the more telling insights is a chart on page 22 addressing utilization changes by claim age. Under the provisions of our Workers' Compensation Act, there are durationallim.its on incapacity benefits. That is, if an employee is mjured and incapacitated as a result of the injury. be is entitled to weekly indemnity benefits during the period of incapacity. As be recovers, however, the Act in some instances places a cap on the number of weeks benefits arc paid. There is no comparable !unit on medical care, including the provision of medication. As lonf as an injured worker continues to treat because of a work injury, medical benefits continue. As a result, workers' compensation cases have what is called in the insurance industry, a "long tail."' Charts on utilization changes by claim age demonstrate, in very gross tenns, years after the date of injury, the injured worker continues to receive opioids. Claims older than 16 years show an increase on a percentage basis ofthe use of opioids. The chart that shows utilization changes by claim age share uf dollars paid demonstrates claims greater than 1 1 years old are major cost drivers in Maine workers· compe11sation

In discussing the results oftlus analysis with rhe NCCI staff. it is clear opioids play an important role in the treatment of workers' compensation clatmants. It is not uncommon for an mjured worker to be in acute pam at the time of injury and receive an opioid prescn pt.Jon. It appears

2 For rL -pos~s of this report the region is defined as the New England stares except Massachuserts (Massachusetts 1s not an NCCI state). 3 There are a few technical reasons these benefits would cease. The most common JS when a claim settles.

l EL: 207-287-7086 TTY: 711 FAX 207 · 28i-719~ Toll Free: 888-801-9087 3

trends going forward show a reduction in the use of opioids in recent cases. Unlike the patient suffering from a non-work-related injury, workers' compensation, because it is so heavily . regulated, has controls from employers, insurance carriers, and their affiliates that are now more carefully monitoring phannaceutical use.

I hope this letter and the attached report are helpful to your committees. Now that the essential aspects of LD 1646 are in effect, the Board is better able to convene a group of stakeholders to address the impact of the legislation when compared to the established data and explore the use of alternate treatment modalities.

I am available if there are questions.

Very truly yours, ~!f,J;y Paul H. Sighinolfi, Esq. Executive Director/Chair

Enclosure

cc: Senator Benjamin Chipman Senator Roger Katz Representative Paul Chace Representative Dale Denno Representative Scott Hamann Representative Frances Head Representative Colleen Madigan Representative Richard Malaby Representative Jennifer Parker Representative Anne Perry Representative Deborah Sanderson Jill LaPlante, Committee Clerk Senator Sbeona Bellows Senator Brian Langley Representative Susan Austin Representative Dillon Bates Representative Donna Doore Representative James Handy Representative Lavvrence Lockman Representative .Anne-Marie Mastraccio Representative Joel Stetkls Representative 1\IG chael Sylvester Representative Karen Vachon Diane Steward, Committee Clerk

11EL: 207-287-7086 TTY· 7!1 FAX: 207-287~7198 Toil Free: 888-801-9087 ~Vlaine Opwowd anti BenzodiazepBne (Benzo) Report

This is a proprietary and co nfidential report prepa red by the National Council on Compensation lnsl.1rance, Inc. This report is provided for your internal use only and may not be copied, distributed, or otherwise · transferred to any third party without the prior written consent of NCCI .

• Maine combatting opioid abuse • Usage of opioids and benzos in Maine Comparison with the region o Concurrent use of opioids and benzos Development of opioid usage L 1 46 t e o ioid Epidemac

LD 1646, enacted in April of 2016, limits opioid scripts to a daily dose of 100mg of morphine.

CJ News reports suggest LD 1646 was signed into law by the governor after meeting with the widow of a man who was overprescribed opioids following a workplace injury.

"Approximately 75°/o of heroin addicts started with prescription opioid medications" - Office of Governor LePage. Source: http://www.lexology.co m/library/detail.aspx?g=S5d92e53-e4e5-49c6-8d18-ab372a861fc4

NCCI Proprietary and Confidenttal- Not For Distribution Methodology a d Data

Data Source: Prescription drug data from the NCCI Medical Data Call for Service Years 2011 to 2015 for Maine, Connecticut, New Hampshire, Rhode Island, and Vermont.

• Prescription drug data represents 4.1 °/o of overall workers compensation costs in Maine and excludes self insured .employers.

• When determining average prices per unit, an algorithm was used that compared derived units with reported units. If warranted, certain data elements were excluded from portions of the analysis. Usage of Opioids and Benzos in Maine

() Copyright 2(1 • 7 Natoonal Counrll un Compe nsation Insurance, Inc. All Roght> Rese rved. Curre t Usage of Opioids and diazepine in Maine

1) Number of Claimants 1,891 249 172 4,644 Percent of Claimants with at least one ... 41% 5% 4% 100%

2) Number of Scripts 8,779 766 2,021 26,986 Percent of Toto/Scripts 33% 3% 7%* 100%

3) Total Paid ($000) $1,250 $22 $288 $4,065 Percent of Total Rx Paid 31% 1% 7%* 100%

4) Scripts per Claim 5 3 12 6 (2)/(1) 5) Paid per Claim $661 $89 $1,672 $875 (3)/(1)

*Note: 7% of scripts and paid Rx dollars went to claimants who had both opioids and benzos during the year. Usage of Opionds and Benzodiazepines an Ma~ne §h:an·e of Paid Do~~ars SO% 45% 40% - 1%

"'C 35% 1% 1% ro a.. 30% X 0::: 25% ....,ro Benzo {!:. 20% '+- [) Opioid 0 QJ 15% '-ro J::. 10% V1 5% 0% 2011 2012 2013 2014 2015 Service Year Usage of Opioids and Benzodiazepines in Mai e Share of Scripts 50% 45% 40% V) ..., 4% . 3% 3% -~ 35% 3% .. 'u ~ 30% ...,n:s ~ 25% 't- Benzo o 20% cu '- • Opioid ~ 15% V') 10% 5%

0% +---~---L--~~--~~--~~--~~~~--~~~~-- 2011 2012 2013 2014 2015 Service Year CijJ]rrrent Usage of Opioids and Benzodgazepnnes in Maine

Claim Distribution - Service Year 2015

rn Opioids l Benzos

S!! Both tO Neither

EJ Of claimants wit h at least one script in 2015: w 2 in 5 were prescribed an opioid o 1/10 of t hese were also prescribed a benzo a 1 in 19 were prescribed a benzo Current x r g Usage in Maine Scrapt Counts

Avg. number of opioid 4.6 6.7 11.8 2.0 or benzo scri pts + + + +

Avg. number of non- 5.2 13.5 12.6 3.8 opioid and non-benzo - - - - scri pts Avg. number of scripts 9.8 20.2 24.4 5.8

• For Ma ine, claimants with at least 1 opioid script had about 10 scripts in 2015. • Approximately 1 of every 3 scripts was for an opioid or benzo.

NCCI Proprietary and Confidential· Not For Distribution e Curre t IRx Drug Usage in Maine Paid DoiDars

Avg. paid for opioids $662 $1,126 $1,687 $273 and benzos + + + +

Avg. paid for non- $898 $2,500 $2,559 $602 opioids and non-benzos = = = =

Avg. Paid $1,560 $3,626 $4,246 $875

• For claimants with an opioid script about 42°/o of drug dollars were for opioids. a For claimants with a benzo script about 31 °/o of drug dollars were for benzos. Comparison with the Region

Average Opioid Paid per Opioid Claim $1,000

$850 $800

$672 D 2011

$600 $539 $551 I . 12012 .------.1 • 2013 $400 2014 • 2015

$200

Maine Region

Note: The region contains states CT, NH, Rl, and VT. Cha ge Over T~me by erv·ce Year Maine vs. Region

$200 Average Paid per Opioid Script $180 $167 $160 $140 $124 El 2011 $120 $108 L 2012 $100 II 2013 $80 • 2014 $60 • 2015 $40 $20 $0 Maine Region Note: The region contains states CT, NH, Rl, and VT.

NCCI Proprietary and Confidential· Not For Distribution Cha ges Over Time by Service Year Average Paid per Script

$40 Average Paid per Benzo Scri pt

$35 $33

$30 $30 Gl 2011 $30 2012

II 2013 $25 2014 • 2015 $20

$15 Maine

NCCI Proprietary and Confidential- Not For Distribution \ -- -: - '. ,, _- --~- '1[4"~·.-."'f., ~~~~~~--~~ r ~ . . ,' ''~· ·-··.· r ~ .- ,•(.! ~.;:f·~' ' '~ ~- ~ ~-~· . ~ Cop~rjg ~~-29 !~-~*t lW~~ O!J -l\1 'O Co ~~~~·._..,_....;.~ ~· .: -. ~ . ~ Uti:i~ization C anges Maine vs. Region

70% Share of Drug Claims with at Least One Opioid Script

60% -

51% 49% 50% 46% .. I , I 42% 2011 40% 2012 • 2013 30% l\1 2014 20% • 2015

10%

0% Maine Region

Note: The region contains stat es CT, NH, Rl, and VT.

NCCI Proprietary and Confidential- Not For Distribution Utts~izati n Changes Maine vs. Regcon

7.0 Average Number of Opioid Scripts per Opioid Claim 6.0 5.4 5.3 5.3 5.4 5.3 5.0 5.0 U'l 5.0 .IJ a. 2011 ·-~ a u ....."' 4.0 2012 0 ~ m 2013 ~ 3.0 E 0 2014 ::::s z 2.0 • 2015

1.0

0.0 Maine Region

Note: The region contains states CT, NH, Rl, and VT. Comparisons Maine VSo Region

1) Share of claims with at least one opioid 41% 43% Share of Scripts for an opioid 33% 32%

2) Share of claims with at least one benzo 4% 5% and one opioid script Share of total opioid and benzo scripts received 21% 29% 3) Average opioid paid per opioid claim $662 $850

• In Maine, claimants receiving at least one benzo and one opioid receive proportionally less scripts, possibly lowering the risk of overdose. • In the past 4 years, t he average opioid paid per opioid cla im in Maine is approximately 30% below the regional average. Utiliz taon Changes Concurrent use o·f Opioids and Ben::zos

According to a report published by the British Medical Journal (BMJ) "benzodiazepines enhance the effects of opioid painkillers, which means this drug combination has a high potential for abuse."

• "The BMJ study found that, of 2,400 veterans in the study's population who died because of a drug overdose while taking opioid painkiller prescriptions, 49 percent had been concurrently prescribed benzodiazepines."

Source: http:/I a me rica na dd ictionce nters .org/ prescription-drugs/dangers-of- mixing/ Utg~izartion Changes ~Vdanne vsQ Reguon

Share of Opioid and Benzo Scripts Going to Claims that Had Both 35% Ill 31% 31% o6Ja. 'i: 30% u V') 0 ~ 25% 24% Q) .....---, 22% m £i 2011 -o n:sc: 20% t 1 2012 -o ·-0 II 2013 ·a. 15% .....0 m 2014 ~ 10% ' 2015 n:s ..c V') 5%

0% Maine Region Note: On average, for those w ho are prescribed both, those in Maine were prescribed proportionally fewer opioids and benzos relative to other drugs that were prescribed. Development of Opioid Usage

Distribution of Scripts by Age of Opioid Claim 100% 90% 80%

~ 70% ' . oloJ a. - .i:: 60% u 16+ V) 'Q SO% ~ 11-15 I 38% ·37% ~ 40% I' 41% 36%'; • 6-10 ..c V) 30% l··l 2-5 20% r3 1 year 1 10% indicates the accident year 0% 2011 2012 2013 2014 2015 Service Year ut· iza ion C cnnges by Claim Age

16,000 - Total Number of Opioid Scripts by Age of Opioid Claim 14,000 -

V) 12,000 - ..... Q. '6 10,000 - V') • 16+ 't- o 8,000 - 11-15 ' Q) .c • 6-10 E 6,000 5,562 4,849 :::l 4,115 1 I 2-5 z '3 448 4,000 - I I 3,121 • 1 year 1 2,000 indicates the accident year

2011 2012 2013 2014 2015 Service Year Uti ization C anges by Claim Age Share of Paid Dollars

Distribution of Paid by Age of Opioid Claim 100% 90% [i.. . 1 80% ,._«<) cu 70% 25% 0 c 60% • 16+ &. 50% 11-15 '+- 0 40% • 6-10 ,._Ql ~ 30% 2-5 "' 20% 31% 27% 21% I • 1 10% i20%j yea r 1 indicates the 0% -'~...__· -----..,.---.J..[ M L.l__,.-----1...... [ ~ J I 'VA!~ --, accident year 2011 2012 2013 2014 2015 Service Year C trncluding emarks

According to the script data the utilization of opioids in Maine's workers compensation system is on a mild decline. o The bulk of this decline is from claims that are within 2-10 years old. • Maine has been paying about 30°/o less for opioids than the region in Service Years 2011 to 2015. • Those who take opioid and benzos together, on average rece ive less opioids and benzos than those in the region . R ferences

• Smith, Elizabeth C. "Will The New Maine Opiate Control Law Impact the Workers." Will The New Maine Opiate Control Law Impact the Workers' Compensation System? - Lexology. Verrill Dana LLP, 19 Sept. 2016. Web. 16 Nov. 2016.

• "Dangers of Mixing Opiates & Benzos: Vicodin, Xanax, Oxycodone, Valium." American Addiction Centers. N.p., n.d. Web. 16 Nov. 2016 .

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