Impacts of State-Level Opioid Review Programs on Injured Workers and Their Health Care Providers: A Qualitative Study in Washington and Ohio.

Policy Points Workers' compensation agencies have instituted opioid review policies to reduce unsafe prescribing. Providers reported more limited and cautious prescribing than in the past; both patients and providers reported collaborative pain-management relationships and satisfactory pain control for patients. Despite the fears articulated by pharmaceutical companies and patient advocates, opioid review programs have not generally resulted in unmanaged pain or reduced function in patients, anger or resistance from patients or providers, or damage to patient-provider relationships or clinical autonomy. Other insurance providers with broad physician networks may want to consider similar quality-improvement efforts to support safe opioid prescribing. CONTEXT: Unsafe prescribing practices have been among the central causes of improper reception of opioids, unsafe use, and overdose in the United States. Workers' compensation agencies in Washington and Ohio have implemented opioid review programs (ORPs)-a form of quality improvement based on utilization review-to curb unsafe prescribing. Evidence suggests that such regulations indeed reduce unsafe prescribing, but pharmaceutical companies and patient advocates have raised concerns about negative impacts that could also result. This study explores whether three core sets of problems have actually come to pass: (1) unmanaged pain or reduced function among patients, (2) anger or resistance to ORPs from patients or providers, and (3) damage to patient-provider relationships or clinical autonomy. METHODS: In-depth semistructured interviews were conducted with 48 patients (21 from Washington, 27 from Ohio) and 32 providers (18 from Washington, 14 from Ohio) who were purposively sampled to represent a range of injury and practice types. Thematic coding was conducted with codebooks developed using both inductive and deductive approaches. FINDINGS: The consequences of opioid regulations have been generally positive: providers report more limited prescribing and a focus on multimodal pain control; patients report satisfactory pain control and recovery alongside collaborative relationships with providers. Participants attribute these patterns to a broad environment of opioid caution; they do not generally perceive workers' compensation policies as distinctly impactful. Both patients and providers comment frequently on the difficult aspects of interacting with workers' compensation agencies; effects of these range from simple inconvenience to delays in care, unmanaged pain, and reduced potential for physical recovery. CONCLUSIONS: In general, the three types of feared negative impacts have not come to pass for either patients or providers. Although interacting with workers' compensation agencies involves difficulties typical of interacting with other insurers, opioid controls seem to have generally positive effects and are generally perceived of favorably.

Using the Functional Comorbidity Index with administrative workers' compensation data: Utility, validity, and caveats.

BACKGROUND: Chronic health conditions impact worker outcomes but are challenging to measure using administrative workers' compensation (WC) data. The Functional Comorbidity Index (FCI) was developed to predict functional outcomes in community-based adult populations, but has not been validated for WC settings. We assessed a WC-based FCI (additive index of 18 conditions) for identifying chronic conditions and predicting work outcomes. METHODS: WC data were linked to a prospective survey in Ohio (N = 512) and Washington (N = 2,839). Workers were interviewed 6 weeks and 6 months after work-related injury. Observed prevalence and concordance were calculated; survey data provided the reference standard for WC data. Predictive validity and utility for control of confounding were assessed using 6-month work-related outcomes. RESULTS: The WC-based FCI had high specificity but low sensitivity and was weakly associated with work-related outcomes. The survey-based FCI suggested more comorbidity in the Ohio sample (Ohio mean = 1.38; Washington mean = 1.14), whereas the WC-based FCI suggested more comorbidity in the Washington sample (Ohio mean = 0.10; Washington mean = 0.33). In the confounding assessment, adding the survey-based FCI to the base model moved the state effect estimates slightly toward null (<1% change). However, substituting the WC-based FCI moved the estimate away from null (8.95% change). CONCLUSIONS: The WC-based FCI may be useful for identifying specific subsets of workers with chronic conditions, but less useful for chronic condition prevalence. Using the WC-based FCI cross-state appeared to introduce substantial confounding. We strongly advise caution-including state-specific analyses with a reliable reference standard-before using a WC-based FCI in studies involving multiple states.

Identifying factors associated with physical therapy use versus non-use among injured workers with back pain in Washington State.

BACKGROUND: There is little information about predictors of physical therapy (PT) use among injured workers with back pain. The primary objective of this study is to investigate the associations between PT use and baseline factors not routinely captured in workers' compensation (WC) data. METHODS: We conducted a secondary analysis using the Washington State Workers' Compensation Disability Risk Identification Study Cohort, which combines self-reported surveys with claims data from the Washington State Department of Labor and Industries State Fund. Workers with an accepted or provisional WC claim for back injury between June 2002 and April 2004 were eligible. Baseline factors for PT use were selected from six domains (socio-demographic, pain and function, psychosocial, clinical, health behaviors, and employment-related). The outcome was a binary measure for PT use within 1 year of injury. Bivariate and multivariable logistic regression models were conducted to evaluate the associations between PT use and baseline factors. RESULTS: Among the 1370 eligible study participants, we identified 673 (49%) who received at least one PT service. Baseline factors from five of the six domains (all but health behaviors) were associated with PT use, including gender, income, pain and function measures, injury severity rating, catastrophizing, recovery expectations, fear avoidance, mental health score, body mass index, first provider seen for injury, previous injury, and several work-related factors. CONCLUSION: We identify baseline factors that are associated with PT use, which may be useful in addressing disparities in access to care for injured workers with back pain in a WC system.

Intensity of physical therapy services: Association with work and health outcomes in injured workers with back pain in Washington State.

BACKGROUND: Associations between the intensity of physical therapy (PT) treatments and health outcomes among individuals with back pain have been examined in the general population; however, few studies have explored these associations in injured workers. Our study objective was to examine whether intensity of PT treatments is positively associated with work and health outcomes in injured workers with back pain. METHODS: We conducted a secondary analysis of prospective data collected from the Washington State Workers' Compensation (WC) Disability Risk Identification Study Cohort (D-RISC). D-RISC combined survey results with WC data from the Washington State Department of Labor and Industries. Workers with a State Fund WC claim for back injuries between June 2002 and April 2004 and who received PT services within the first year of injury were eligible. Intensity of PT treatment was measured as the type and amount of PT services within 28 days from the first PT visit. Outcome measures included work disability and self-reported measures for working for pay, pain intensity, and functional status at 1-year follow-up. We conducted linear and logistic regression models to test associations. RESULTS: We identified 662 eligible workers. In adjusted models, although the intensity of PT treatment was not significantly associated with work disability at 1-year follow-up, it was associated with lower odds of working for pay, decreased pain intensity, and improved functional status. CONCLUSIONS: Our findings suggest that there may be small benefits from receiving active PT, manual therapy, and frequent PT treatments within 28 days of initiating PT care.

Development and maturation of the occupational health services research field in the United States over the past 25 years: Challenges and opportunities for the future.

Work is an important social determinant of health; unfortunately, work-related injuries remain prevalent, can have devastating impact on worker health, and can impose heavy economic burdens on workers and society. Occupational health services research (OHSR) underpins occupational health services policy and practice, focusing on health determinants, health services, healthcare delivery, and health systems affecting workers. The field of OHSR has undergone tremendous expansion in both definition and scope over the past 25 years. In this commentary, focusing on the US, we document the historical development and evolution of OHSR as a research field, describe current doctoral-level OHSR training, and discuss challenges and opportunities for the OHSR field. We also propose an updated definition for the OHSR field: Research and evaluation related to the determinants of worker health and well-being; to occupational injury and illness prevention and surveillance; to healthcare, health programs, and health policy affecting workers; and to the organization, access, quality, outcomes, and costs of occupational health services and related health systems. Researchers trained in OHSR are essential contributors to improvements in healthcare, health systems, and policy and programs to improve worker health and productivity, as well as equity and justice in job and employment conditions. We look forward to the continued growth of OHSR as a field and to the expansion of OHSR academic training opportunities.

Prescription opioid overdose and adverse effect hospitalisations among injured workers in eight states (2010-2014).

OBJECTIVE: High-risk opioid prescribing practices in workers' compensation (WC) settings are associated with excess opioid-related morbidity, longer work disability and higher costs. This study characterises the burden of prescription opioid-related hospitalisations among injured workers. METHODS: Hospital discharge data for eight states (Arizona, Colorado, Michigan, New Jersey, New York, South Carolina, Utah and Washington) were obtained from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. We calculated 5-year (2010-2014) average annual rates of prescription opioid overdose/adverse effect (AE) hospitalisations. Injured workers were identified using payer (WC) and external cause codes. RESULTS: State-level average annual prescription opioid overdose/AE hospitalisation rates ranged from 0.3 to 1.2 per 100 000 employed workers. Rates for workers aged ≥65 years old were two to six times the overall rates. Among those hospitalised with prescription opioid overdose/AEs, injured workers were more likely than other inpatients to have a low back disorder diagnosis, and less likely to have an opioid dependence/abuse or cancer diagnosis, or a fatal outcome. Averaged across states, WC was the primary expected payer for <1% of prescription opioid overdose/AE hospitalisations vs 6% of injury hospitalisations. CONCLUSIONS: Population-based estimates of prescription opioid morbidity are almost nonexistent for injured workers; this study begins to fill that gap. Rates for injured workers increased markedly with age but were low relative to inpatients overall. Research is needed to assess whether WC as payer adequately identifies work-related opioid morbidity for surveillance purposes, and to further quantify the burden of prescription opioid-related morbidity.

Lifetime exposure to ultraviolet radiation and the risk of multiple sclerosis in the US radiologic technologists cohort study.

BACKGROUND: Low exposure to ultraviolet radiation (UVR) from sunlight may be a risk factor for developing multiple sclerosis (MS). Possible pathways may be related to effects on immune system function or vitamin D insufficiency, as UVR plays a role in the production of the active form of vitamin D in the body. OBJECTIVE: This study examined whether lower levels of residential UVR exposure from sunlight were associated with increased MS risk in a cohort of radiologic technologists. METHODS: Participants in the third and fourth surveys of the US Radiologic Technologists (USRT) Cohort Study eligible (N = 39,801) for analysis provided complete residential histories and reported MS diagnoses. MS-specialized neurologists conducted medical record reviews and confirmed 148 cases. Residential locations throughout life were matched to satellite data from NASA's Total Ozone Mapping Spectrometer (TOMS) project to estimate UVR dose. RESULTS: Findings indicate that MS risk increased as average lifetime levels of UVR exposures in winter decreased. The effects were consistent across age groups <40 years. There was little indication that low exposures during summer or at older ages were related to MS risk. CONCLUSION: Our findings are consistent with the hypothesis that UVR exposure reduces MS risk and may ultimately suggest prevention strategies.

Brief report: Population-based reversal of the adverse impact of opioids on disability in Washington State workers' compensation.

BACKGROUND: Evidence has associated opioid use initiated early in a workers' compensation claim with subsequent disability. In 2013, the Washington State Department of Labor and Industries (DLI) implemented procedures based on new regulations that require improvement in pain and function to approve opioids beyond the acute pain period. METHODS: We measured opioid prescriptions between 6 and 12 weeks following injury, an indicator of persistent opioid use. Actuarial data for the association of any opioid use versus no opioid use with development of lost time payments are reported. RESULTS: Prior authorization with hard stops led to a sustained drop in persistent opioid use, from nearly 5% in 2013 to less than 1% in 2017. This reduction was also associated with reversal of the increased lost work time patterns seen from 1999 to 2010. CONCLUSIONS: Prior authorization targeted at preventing transition to chronic opioid use can prevent and reverse adverse time loss development that has occurred on a population basis concomitant with the opioid epidemic.

Innovations in Occupational Health Care Delivery Can Prevent Entry into Permanent Disability: 8-Year Follow-up of the Washington State Centers for Occupational Health and Education.

BACKGROUND: Long-term work disability is known to have an adverse effect on the nation's labor force participation rate. To reduce long-term work disability, the Washington State Department of Labor and Industries established a quality improvement initiative that created 2 pilot Centers of Occupational Health and Education (COHE). OBJECTIVES: To document the level of work disability in a sample of injured workers with musculoskeletal injuries and to examine (8-y) work disability outcomes associated with the COHE health care model. RESEARCH DESIGN: Prospective nonrandomized intervention study with nonequivalent comparison group using difference-in-difference regression models. SUBJECTS: Intervention group represents 18,790 workers with musculoskeletal injuries treated by COHE providers. Comparison group represents 20,992 workers with similar injuries treated within the COHE catchment area by non-COHE providers. MEASURES: Long-term disability outcomes include: (1) on disability 5 years after injury; (2) received a state pension for total permanent disability; (3) received total disability income support through the Social Security Disability Insurance program; or (4) a combined measure including any one of the 3 prior measures. RESULTS: COHE patients had a 30% reduction in the risk of experiencing long-term work disability (odds ratio=0.70, P=0.02). The disability rate (disability days per 1000 persons) over the 8-year follow-up for the intervention and comparison groups, respectively, was 49,476 disability days and 75,832 disability days. CONCLUSIONS: Preventing long-term work disability is possible by reorganizing the delivery of occupational health care to support effective secondary prevention in the first 3 months following injury. Such interventions may have promising beneficial effects on reversing the nation's progressively worsening labor force participation rate.

Impact of an Advanced Imaging Utilization Review Program on Downstream Health Care Utilization and Costs for Low Back Pain.

BACKGROUND: Early magnetic resonance imaging (MRI) for acute low back pain (LBP) has been associated with increased costs, greater health care utilization, and longer disability duration in workers' compensation claimants. OBJECTIVES: To assess the impact of a state policy implemented in June 2010 that required prospective utilization review (UR) for early MRI among workers' compensation claimants with LBP. RESEARCH DESIGN: Interrupted time series. SUBJECTS: In total, 76,119 Washington State workers' compensation claimants with LBP between 2006 and 2014. MEASURES: Proportion of workers receiving imaging per month (MRI, computed tomography, radiographs) and lumbosacral injections and surgery; mean total health care costs per worker; mean duration of disability per worker. Measures were aggregated monthly and attributed to injury month. RESULTS: After accounting for secular trends, decreases in early MRI [level change: -5.27 (95% confidence interval, -4.22 to -6.31); trend change: -0.06 (-0.01 to -0.12)], any MRI [-4.34 (-3.01 to -5.67); -0.10 (-0.04 to -0.17)], and injection [trend change: -0.12 (-0.06 to -0.18)] utilization were associated with the policy. Radiograph utilization increased in parallel [level change: 2.46 (1.24-3.67)]. In addition, the policy resulted in significant decreasing changes in mean costs per claim, mean disability duration, and proportion of workers who received disability benefits. The policy had no effect on computed tomography or surgery utilization. CONCLUSIONS: The UR policy had discernable effects on health care utilization, costs, and disability. Integrating evidence-based guidelines with UR can improve quality of care and patient outcomes, while reducing use of low-value health services.

Patterns of Opioid Use and Risk of Opioid Overdose Death Among Medicaid Patients.

BACKGROUND: The Centers for Disease Control and Prevention recognizes Medicaid as a high-risk population for fatal opioid overdose. Further research is needed to identify factors that put Medicaid patients at increased risk. OBJECTIVE: To determine whether patterns of opioid use are associated with risk of opioid-related mortality among opioid users. DESIGN: This is a retrospective cohort study. PATIENTS: In total, 150,821 noncancer pain patients aged 18-64 years with ≥1 opioid prescription, April 2006 to December 2010, Washington Medicaid. MEASURES: Average daily dose (morphine equivalents), opioid schedule/duration of action, sedative-hypnotic use. RESULTS: Compared with patients at 1-19 mg/d, risk of opioid overdose death significantly increased at 50-89 mg/d [adjusted hazard ratio (aHR), 2.3; 95% confidence interval (CI), 1.4-4.1], 90-119 mg/d (aHR, 4.0; 95% CI, 2.2-7.3), 120-199 mg/d (aHR, 3.8; 95% CI, 2.1-6.9), and ≥200 mg/d (aHR, 4.9; 95% CI, 2.9-8.1). Patients using long-acting plus short-acting Schedule II opioids had 4.7 times the risk of opioid overdose death than non-Schedule II opioids alone (aHR, 4.7; 95% CI, 3.3-6.9). Sedative-hypnotic use compared with nonuse was associated with 6.4 times the risk of opioid overdose death (aHR, 6.4; 95% CI, 5.0-8.4). Risk was particularly high for opioids combined with benzodiazepines and skeletal muscle relaxants (aHR, 12.6; 95% CI, 8.9-17.9). Even at opioid doses 1-19 mg/d, patients using sedative-hypnotics concurrently had 5.6 times the risk than patients without sedative-hypnotics (aHR, 5.6; 95% CI, 1.6-19.3). CONCLUSIONS: Our findings support Federal guideline-recommended dosing thresholds in opioid prescribing. Concurrent sedative-hypnotic use even at low opioid doses poses substantially greater risk of opioid overdose.

Opioid poisonings in Washington State Medicaid: trends, dosing, and guidelines.

BACKGROUND: Opioid poisonings have increased as use of prescription opioid medications have increased. To reduce these poisonings, guidelines for chronic opioid use have been implemented. However, if opioid poisonings occur in individuals who do not have high prescribed doses and who are not chronic opioid users, the current guidelines may need revision. OBJECTIVES: To examine changes in rates of methadone and other opioid poisonings after implementation of the WA State Opioid Guideline in 2007 and to examine the prescription history before poisonings. METHODS: The study sample consisted of individuals who had at least 1 paid claim for an opioid prescription in the Medicaid fee-for-service system between April 2006 and December 2010 and had an emergency department or inpatient hospital claim for an opioid poisoning. RESULTS: Methadone poisonings occurred at 10 times the rate of other prescription opioid poisonings and increased between 2006 and 2010. Rates of other prescription opioid poisonings appeared to level off after implementation of the WA opioid guideline in 2007. Among individuals with nonmethadone opioid poisonings, only 44% had chronic opioid use, 17% had prescribed doses in the week before the poisoning >120 mg/d morphine-equivalent dose (MED), 28% had doses <50 mg/d MED, and 48% had concurrent sedative prescriptions. CONCLUSIONS: It may be prudent to revise guidelines to address opioid poisonings occurring at relatively low prescribed doses and with acute and intermittent opioid use. Research is needed to establish the best strategies to prevent opioid poisonings.

Workers' compensation: poor quality health care and the growing disability problem in the United States.

The proportion of working age citizens permanently removed from the workforce has dramatically increased over the past 30 years, straining both Federal and State disability systems designed as a safety net to protect them. Almost one-third of these rapidly emerging disabilities are related to musculoskeletal disorders, and three of the top five diagnoses associated with the longest Years Lived with Disability are back, neck and other musculoskeletal disorders. The failure of Federal and state workers' compensation systems to provide effective health care to treat non-catastrophic injuries has been largely overlooked as a principal source of permanent disablement and corresponding reduced labor force participation. Innovations in workers' compensation health care delivery, and in use of evidence-based coverage methods such as prospective utilization review, are effective secondary prevention efforts that, if more widely adopted, could substantially prevent avoidable disability and provide more financial stability for disability safety net programs.

Nicotine from edible Solanaceae and risk of Parkinson disease.

OBJECTIVE: To test whether risk of Parkinson disease (PD) is associated with consumption of nicotine-containing edibles from the same botanical family as tobacco, Solanaceae, including peppers, tomatoes, and potatoes. METHODS: In a population-based study with 490 newly diagnosed idiopathic PD cases diagnosed during 1992-2008 at the University of Washington Neurology Clinic or Group Health Cooperative in western Washington State and 644 unrelated, neurologically normal controls, we examined whether PD was associated with self-reported typical frequency of consumption of peppers, tomatoes, tomato juice, and potatoes during adulthood, while adjusting for consumption of other vegetables, age, sex, race/ethnicity, tobacco use, and caffeine. RESULTS: PD was inversely associated with consumption of all edible Solanaceae combined (relative risk [RR] = 0.81, 95% confidence interval [CI] = 0.65-1.01 per time per day), but not consumption of all other vegetables combined (RR = 1.00, 95% CI = 0.92-1.10). The trend strengthened when we weighted edible Solanaceae by nicotine concentration (ptrend = 0.004). An inverse association was also evident for peppers specifically (ptrend = 0.005). The potentially protective effect of edible Solanaceae largely occurred in men and women who had never used tobacco or who had smoked cigarettes < 10 years. INTERPRETATION: Dietary nicotine or other constituents of tobacco and peppers may reduce PD risk. However, confirmation and extension of these findings are needed to strengthen causal inferences that could suggest possible dietary or pharmaceutical interventions for PD prevention.

Formulations of hormone therapy and risk of Parkinson's disease.

Hormone therapy (HT) is a class of medications widely prescribed to women in the Western world. Evidence from animal models and in vitro studies suggests that estrogen may protect against nigrostriatal system injury and increase dopamine synthesis, metabolism, and transport. Existing epidemiologic research indicates a possible reduced risk of Parkinson's disease (PD) associated with HT use. The objective of this study was to evaluate PD risk associated with specific HT formulations. Neurologist-confirmed cases and age-matched controls were identified from Group Health Cooperative (GHC) of Washington State. Final analysis included 137 female cases and 227 controls. Hormone therapy use was ascertained from the GHC pharmacy database, further classified as conjugated estrogens, esterified estrogens, and progestin. Ever use of HT formulation demonstrated a suggested elevated risk with esterified estrogen use (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.0-9.8), and no risk associated with conjugated estrogen use (OR, 0.6; 95% CI, 0.6-1.3). Restricting this analysis to prescriptions that included progestin further elevated the risk associated with esterified estrogen use (OR, 6.9; 95% CI, 2.1-22.9); again, no risk was associated with conjugated estrogen use (OR, 1.7; 95% CI, 0.6-5.0). The findings from this study suggest an increase in PD risk associated with esterified estrogen use combined with progestin, and no risk associated with conjugated estrogen with progestin. These findings could have important implications for choice of HT in clinical practice.

Opioid poisonings and opioid adverse effects in workers in Washington state.

OBJECTIVE: To examine trends in opioid poisonings and adverse effects in Washington (WA) State and nationally. METHODS: We calculated rates of opioid poisonings and adverse effects and examined opioid prescriptions in the WA workers' compensation system, 2004-2010. Using Health Care Cost and Utilization Project (HCUP), Nationwide Inpatient Sample (NIS) data, we also calculated national rates of opioid poisonings and adverse effects, 1993-2010. RESULTS: We identified 96 opioid poisonings and 312 opioid-related adverse effects in WA, 2004-2010. The rates did not change substantially over these years. Most poisonings and adverse effects occurred in cases without chronic opioid use and with prescribed doses <120 mg/day morphine-equivalent dose. Nationally, the rates of opioid poisonings and adverse effects increased significantly from 1993 to 2010. CONCLUSIONS: Many poisonings and adverse effects occurred in patients without high dose or long-term opioid therapy, suggesting that opioid dosing and duration guidelines may not be sufficient to reduce morbidity related to prescription opioid use.

Environmental tobacco smoke and Parkinson's disease.

BACKGROUND: Parkinson's disease is inversely associated with cigarette smoking, but its relation with passive smoking or environmental tobacco smoke exposure is rarely examined. METHODS: Within a case-control study, we assessed the association between Parkinson's disease and living or working with active smokers. Cases were newly diagnosed with idiopathic Parkinson's disease (n = 154) from western Washington State in 2002-2008. Age- and sex-matched controls (n = 173) were neurologically normal and unrelated to cases. RESULTS: Compared with never active or passive tobacco smokers, we observed reduced Parkinson's disease risks for ever passive only smokers (OR, 0.34; 95% CI, 0.16-0.73), similar to those for ever active smokers (OR, 0.35; 95% CI, 0.17-0.73). Among persons whose only tobacco smoke exposure was passive smoking at home, risk was inversely associated with years exposed. CONCLUSIONS: These observations parallel those well established for active smoking. However, it remains unresolved whether a true protective effect of tobacco smoke, generally detrimental to health, underlies these associations.

Bending the prescription opioid dosing and mortality curves: impact of the Washington State opioid dosing guideline.

BACKGROUND: Opioid use and dosing for patients with chronic non-cancer pain have dramatically increased over the past decade, resulting in a national epidemic of mortality associated with unintentional overdose, and increased risk of disability among injured workers. We assessed changes in opioid dosing patterns and opioid-related mortality in the Washington State (WA) workers' compensation system following implementation of a specific WA opioid dosing guideline in April, 2007. METHODS: Using detailed computerized billing data from WA workers' compensation, we report overall prevalence of opioid prescriptions, average morphine-equivalent dose (MED)/day, and proportion of workers on disability compensation receiving opioids and high-dose (≥120 mg/day MED) opioids over the past decade. We also report the trend of unintentional opioid deaths during the same time period. RESULTS: Compared to before 2007, there has been a substantial decline in both the MED/day of long-acting DEA Schedule II opioids (by 27%) and the proportion of workers on doses ≥120 md/day MED (by 35%). There was a 50% decrease from 2009 to 2010 in the number of deaths. CONCLUSIONS: 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.