The Medical Board of California has established a Prescribing Task Force dedicated to producing revised Pain Management Guidelines, and their initial work has been released for public comment prior to final adoption. I am not sure what they hoped to accomplish, but it appears to be a damn fine effort at controlling workers' compensation costs. That is primarily because a dead claimant is far less expensive than a living one. This tentative plan appears that it will accomplish that goal.

First, I would draw your attention to pages 10 & 11, the section entitled “Dosing for Opioid Naïve Patients”.  In that section they advise that “Most pain can be managed effectively in most patients with dosages at or below 200mg a day of morphine or equivalent.” That is more than double what the Division of Workers' Compensation is proposing. The term “Opioid Naïve” essentially means “patients who are not chronically receiving opioid analgesics on a daily basis”. These patients are also known as “fresh meat” who will soon be “Opioid Tolerant”. Or dead. Whichever.

Now, compare that 200mg MED proposal to a study from Washington State's Agency Medical Directors Group (Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An educational aid to improve care and safety with opioid therapy), which states “Patients receiving 100mg or more per day MED had a 9-fold increase in overdose risk. Most overdoses were medically serious, and 12% were fatal.” That study says that in no event should dosages exceed 120mg per day.

Pullleeeease. Overdose, schmoverdose. Clearly the Medical Board of California considers that poppycock, and even indicates that in their proposed Pain Management Guidelines. On page A19 they directly say “Although there is no widely-agreed-upon dose of opioids that constitute an absolute “red flag” for prescriber concern that opioid therapy may not be working, doses above 100 mg daily of morphine or morphine equivalence have been suggested as worthy of clinician concern because the risk of overdose or adverse effects often rises with doses above this level. This suggestion is controversial, however.” (emphasis added)

Believe you me, I understand that discussing a nine fold increase in overdose risk and a 12% overdose fatality rate over 100mg is controversial. We all know that if something is good, then more MUST be better, right?

With the recommendation of up to a 200mg per day dosage of morphine or equivalent, the Medical Board of California has likely struck upon one of the most effective cost control efforts that state has seen since SB 863 made medical treatment delays a thing of the past. In an age when many are trying to figure out how to reduce opioid use, or even why opioids exist in workers' comp in the first place, California could be bucking the trend and ramping up usage. This of course, will save a tremendous amount of money. Dead people don't need indemnity payments. They don't need medical care. They don't need Independent Medical Reviews or Utilization Review. They don't whine about the crummy benefits, and they don't clog the disability rolls. They just lay there. And they just need a box.

And ironically, by killing those people now dependent on opioids, we are simultaneously reducing our overall prescription drug problem. It's a win-win-win if I ever heard of one. Well, except for the dead people. They don't really win, but their pain will finally be managed, and that is something.

The Institute for Clinical Evaluative Sciences in Toronto, Canada issued a study that showed “an average daily dose of 200 mg or more of morphine (or equivalent), was associated with a nearly 3-fold increase in the risk of opioid-related mortality”. Even the Ohio State Board of Pharmacy has reduced their Opioid guidelines to an 80 MED threshold in order “to curtail the prescription drug epidemic and rising overdose death rates from opiates and combinations therein.”

But those guys are just being controversial. The Medical Board of California is far more enlightened on this issue than most. It is a brilliant attempt to reduce our Opioid prescription dependency issues by eliminating those who use the drugs.

There is one thing you can say about it; 200mg per day in morphine equivalency for opioid naïve patients is truly a killer strategy for California.

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