Patients suffering regularly may benefit from migraine prophylaxis (prevention), especially since using migraine abortive (medicines that stop the migraine once it has started) more than 3 days a week may cause an effect known as rebound headaches thus leading to the need for more and more abortive medication.  Additionally, many abortive medications contain acetaminophen, an analgesic which can cause serious liver damage if taken in large quantity and which is found in many prescription and over-the-counter medications.  Below are some examples of medications used to treat migraine headache:

1. Analgesics: Non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen and naproxen, opioid-analgesic combinations such as butalbital with acetaminophen and caffeine (Fioricet®), OTC preparations with acetaminophen, aspirin and caffeine (Excedrin®
2. Triptans such as sumatriptan (Imitrex®) which help with pain and nausea and are available in tablet or injectable forms.
3. Ergotamines  (Cafergot® which is ergotamine with caffeine), dihydroergotamine (D.H.E®)
4. Corticosteroids such as dexamethasone given intravenously

Some of the preventive medications listed by the updated guidelines (*see below) as effective in the prevention of migraine have the ability to treat other issues as well.  For example, the anti-epileptic medication Topiramate is suggested for use as a Level A drug (established as effective and should be offered for migraine prevention; there is anecdotal evidence suggesting this medication may also help in the management of nerve pain.  The beta-blockers propranolol and metoprolol (both also Level A) are primarily used in the treatment of high blood pressure as well as providing benefit in migraine prophylaxis.  Consideration could be given to one of the Level B choices (probably effective and should be considered for migraine prevention), Amitriptyline; this antidepressant may provide help with insomnia and is also known to provide benefit in the treatment of chronic pain.

The goal is to use the least amount of medication to manage the condition while improving the patient’s quality of life and increasing function.  Migraine prophylaxis is an appropriate measure which should be investigated for patients experiencing more frequent migraines.

*The complete updated guidelines were developed by and are accessible on either the American Headache Society (AHS) or American Academy of Neurology (AAN) websites.  The link to the guidelines at the AHS can be found here:  www.americanheadachesociety.org/assets/1/7/WNL203656.pdf  

Opioid analgesic sales rose from a national average of 96 mg/person in 1997 to 698 mg/person in 2007.  At the same time overdose deaths rose from 2,901 in 1999 to 11,499 in 2007 according to the National Vital Statistics System/DEA ARCOS system.    

In “The Disability Risk Identification Study Cohort”, published in SPINE (Volume 33, Number 2, pp 199–204) in 2008, Gary M. Franklin, MD, MPH, et. al., concluded:  “We have previously shown that about 1 of 3 workers receive an opioid prescription early after a low back injury, and a recent study suggested that such prescriptions may increase risk for subsequent disability.  Conclusion:  Prescription of opioids for more than 7 days for workers with acute back injuries is a risk factor for long-term disability.” Dr. Franklin now believes that opioids in workers’ compensation are likely contributing to a large proportion of the permanently unemployed/disabled in State, Federal and private disability programs.   A recent study by Ed Bernacki, from Johns Hopkins, on the Louisiana workers’ compensation system corroborates the dramatic increase in opioid doses with increasing disability duration.

The Washington Agency Medical Directors Group (AMDG) www.agencymeddirectors.wa.gov led by Dr. Gary Franklin and a broad group of clinical pain experts, systematically reviewed all deaths in the Washington workers’ compensation and Medicaid systems.  The findings were published in the first peer review paper describing deaths specifically related to prescribed opioids in the workers’ compensation system.  That study led to the development of Washington State’s Opioid Dosing Guidelines, along with an educational pilot that was implemented in April 2007.  This was the first guideline in the world to provide specific dosing guidance, with a yellow flag dose of 120 mg/day morphine equivalents. www.guideline.gov/content.aspx?id=23792&search=wa+opioids   

The Washington State Legislation went further to regulate opioid treatment, which was signed into law by Governor Gregoire on March 25, 2010, providing specific dosing guidance and guidance on physician consultations, assessments, and tracking the opioid treatment of chronic non-cancer pain, including:

• Opioid treatment agreements with patients
• Screen for prior or current substance abuse/misuse (alcohol, illicit drugs, heavy tobacco use)
• Screen for depression
• Prudent use of random urine drug screening (diversion, non-prescribed drugs)
• Do not use concomitant sedative-hypnotics or benzodiazepines
• Track pain and function to recognize tolerance
• Seek help if MED reaches 120 mg and pain and function have not substantially improved

The original Guideline was then updated in June 2010 in collaboration with actively practicing providers with extensive experience in the evaluation and treatment of patients with chronic pain. It is intended as a resource for primary care providers treating patients with chronic non-cancer pain.   The revised guidelines, available at www.agencymeddirectors.wa.gov/opioiddosing.asp, provide a set of open-source tools that are available to physicians, including:

• New data, including scientific evidence to support a 120mg MED dosing threshold
• Tools for calculating dosages of opioids during treatment and when tapering
• Validated screening tools for assessing substance abuse, mental health, and addiction
• Validated two-item scale for tracking function and pain
• Urine drug testing guidance and algorithm
• Information on access to mentoring and consultations, including reimbursement options
• New patient education materials and resources
• Guidance on coordinating with emergency departments to reduce opioid abuse
• New clinical tools and resources to help streamline clinical care

As a result of the Guidelines, a study was published in the American Journal of Industrial Medicine, “Bending the Prescription Opioid Dosing and Mortality Curves:  Impact of the Washington State Opioid Dosing Guideline”, 11-27-11 by:  Gary M. Franklin, MD, MPH, et. al.  The study assessed changes in opioid dosing patterns and opioid-related mortality in the Washington State workers’ compensation system, following implementation of a specific WA opioid dosing guideline.  The study concluded:  “The introduction in WA of an opioid dosing guideline appears to be associated temporally with a decline in the mean dose for long-acting opioids, percent of claimants receiving opioid doses 120 mg MED per day, and number of opioid related deaths among injured workers.  Am. J. Ind. Med. 2011 Wiley Periodicals.

In addition to guidance for prescribing physicians, insurance carriers and self-insured payers and their pharmacy benefit managers, third party administrators and managed care organizations need to play a role in opioid management in states where they provide services, including:

• Track high MED and prescribers
• Implement AMDG Opioid Dosing Guidelines
• Implement Prescription Monitoring Program
• Encourage/incent use of best practices (web-based MED calculator, use of state PMPs)
• DO NOT pay for office dispensed opioids
• ID high prescribers and offer assistance
• Incent community-based Rx alternatives (activity coaching and graded exercise early, opioid taper/multidisciplinary Rx later)

Gary M. Franklin, MD, MPH is a Research Professor, Departments of Environmental Health, Neurology, and Health Services, University of Washington as well as Medical Director at the Washington State Department of Labor and Industries.  Dr. Franklin heads the Washington Agency Medical Directors Group (AMDG) www.agencymeddirectors.wa.gov and is one of the nation’s leading advocates of prudent opioid management.

The Journal of the American Medical Association reported that extremely obese workers file twice as many workers’ compensation claims as healthy weight workers.

NCCI published a study on the relationship between obesity and the cost of workers’ compensation claims, concluding that medical costs for the same injury are three times higher among obese claimants in the first year, increasing to five times higher at 60 months. For the same injury, the range of medical treatment, the costs and the duration of the claim are consistently greater for obese employees.  Gallup-Healthways Well-Being Index based on data collected between Jan. 2 and Oct. 2, 2011 — Full-time workers in the U.S. who are overweight or obese and have other chronic health conditions miss an estimated 450 million additional days of work each year compared with healthy workers — resulting in an estimated cost of more than $153 billion in lost productivity annually.

Based on these studies it is clear that obesity is associated with a higher incidence of injury, higher costs and a longer duration of claims.

NCCI suggests that “insurers could be aware up front if obesity is likely to be an issue and try to improve the outcome for the injured worker and their family by keeping the claim from becoming a permanent injury and, in turn, reducing duration. Depending on the added costs, in terms of managing these claims, it may also reduce overall claims costs.”

Employers can and should do more to encourage healthy work and lifestyles, although that is ultimately the responsibility of each individual. When injuries occur among obese workers, physicians should be particularly attentive to the issues around extended recovery and include weight loss as part of a treatment plan.

• Claim frequency for workers’ compensation injuries increased by 3% in 2010, countering an average decline of 4.3% per year since 1990.
• Pharmacy accounts for 19% of workers’ comp medical expenses, the highest percent since NCCI started studying the issue.
• Per-claim drug costs grew 12% during 2009.  Increases were driven more by a rise in utilization than by increases in the price of prescription drugs.
• Drug costs for claims 4 to 9 years old are higher than in previous service years.
• Physician dispensed drugs continued to increase in most states during 2009, accounting for 28% of the dollar share of all prescriptions, up from 23% the prior year.   Physician dispensing accounted for half of all drug costs in Florida, 44% in Georgia, 35% in Maryland, and 32% in PA.   Increased physician dispensing is associated with increased drug costs per claim.
• OxyContin® climbed from the number 3 workers compensation drug in 2008 to number 1 in 2009 
• Hydrocodone-Acetaminophen dropped from the top workers compensation drug in 2008 to number 3 in 2009.

To view the complete report to go:   2011 NCCI Prescription Drug Research Brief

Q.  Gary:  Jonathan, as STRIMA President Elect and host of next year’s STRIMA conference I wanted to get your thoughts about how this year’s conference went and what your  plans are for hosting next year’s conference in Austin.

A.  Jonathan:  Thanks Gary.  Let me start out by thanking Pam Farmer for hosting this year’s conference in Lexington.  Kentucky is a beautiful setting, rich in history as the equine capital of the world, with rolling green hills, manicured acres of horse farms, beautiful trees and hand-built rock fences.

Q.  Gary:  In addition to the beautiful countryside, I really enjoyed the opportunity to chat with people in informal settings and hear about the priorities, programs, issues and opportunities from each of the state risk managers in the more formal Roundtable Sessions.

A.  Jonathan:  Yes, that was really a great forum for state managers to share their knowledge and experience.  Each of us is looking for ways to create efficiencies, to identify issues we haven’t looked at before, to analyze our risks and deploy our resources in a way that maximizes the effectiveness of our programs, given the resources available.  Having a good understanding of issues that might be headed your way and sharing strategies on how to prepare and respond to those issues is a real benefit from the conference.

We had a very productive roundtable in Lexington with very similar issues coming from the states.  The majority of us are impacted by budget shortfalls and costs that continue to escalate, while trying to develop and/or sustain programs that are designed to reduce risk and manage those costs.  You can’t take your eye off the ball or the losses are going to rob you of any savings that you would have gotten from the cuts.  As state risk managers, our challenge is to protect our state assets in a difficult financial climate.  

Q.  Gary:  There were also some very interesting presentations.

A.  Jonathan:  Yes there were, one in particular on controlling workers’ compensation costs, analyzing your loss trends, recognizing where the cost pressures are and how to respond to the drivers that are increasing losses.  It encompassed employer and injured worker issues, as well as a look at Third Party Administrators (TPA), to see how effective they are in controlling costs.  Another session focused on where we can spend our time and our attention to identify risk factors that impact our losses.

Q.  Gary:  How are the plans for next year’s conference in Austin shaping up?

A.  Jonathan:  Well, as next year’s host, I am exempt from the issues agenda, but we are planning a venue that everyone will really enjoy.  My goal as the conference host is to create an atmosphere where fellow members can comfortably step out from under their day-to-day pressures and look to each other to find the ideas, innovations and support that will to carry us through the challenges of the next year.  

Q.  Gary:  I know you don’t see it as a competition, but how are you going to top Lexington?  Remember the beautiful horses and Kentucky Bourbon?

A.  Jonathan:  Well, it will be tough to top Lexington, but Texas has its own natural beauty, although a bit harsher in appearance than the soft rolling green hills.  We’ve also got a lot of heritage and diversity, encompassing many different cultures.   I’m sure you have heard of Six Flags over Texas?  Every one of them has had an influence over this unique state.   We are also well known for our music, and although I don’t think we will be able to land Jerry Jeff Walker for an evening of entertainment, we will hear some of his songs, as well as others from Merle Haggard, the Texas Tornadoes, George Straight, Garth Brooks, Dwight Yoakam, Shake Russell, Robert Earl Keane and David Allen Coe, among others.  I’m really looking to give people the opportunity to experience Texas culture, Texas music, Texas’ quiescence, and just the spirit of the State of Texas.   

Q.  Gary:  And what about that Lone Star Beer?

A.  Jonathan:  We’ll be sure to save a couple of bottles in reserve for you.  I look forward to all members joining us in Austin next year!