Panelists at the Workers Compensation Research Institute in Cambridge, Mass., in an April 25 webinar, discussed the institute’s new study, Longer-Term Use of Opioids in Workers’ Compensation.
Dongchun Yang, a WCRI economist, addressed the study’s major findings: doctors prescribe opioids more often in some states than in others, and fewer injured workers with longer-term use of opioids received recommended services for long-term opioid management. The study defines longer-term use of opioids as having the prescription filled within the first three months after injury; use of opioids continuing after six months post-injury; and three or more prescription refills during months 7-12.
WCRI’s study found that most injured workers who received pain medications received opioids, and that in at least 15 states, the percentage of musculoskeletal, nonsurgical injuries (more than seven days of lost time) with opioids prescribed approached or exceeded 75 percent.
“In most states, three in four injured workers who had pain medication received opioids. If you were in one of the states at the higher end, you would have [had] more than an 80 percent chance to get opioids,” said Yang. Even in states at the lower end, injured workers had more than a 50 percent chance of receiving opioids for a work-related injury, according to the study.
One in six workers in Louisiana and one in seven in New York experienced longer-term use of opioids. It also was prevalent in California, North Carolina, South Carolina, Pennsylvania and Texas. Some of the problems associated with longer-term opioid use are lost productivity and higher risk of opioid misuse, abuse and overdose, Yang stated.
Medical treatment guidelines include urine drug-testing, psychological and psychiatric evaluations and treatment, and active physical therapy. Yang noted that among injured workers with longer-term opioid use, few received monitoring services recommended by medical treatment guidelines for chronic opioid management. Moreover, the frequency of drug-testing, despite increases in recent years, has remained low.
“The opioid problem is big, and a big problem in workers’ comp,” concluded Yang, but also noted that public policy initiatives in recent years, within and outside of the workers’ compensation sphere, have targeted reducing use and misuse of these drugs.
University of Colorado Professor Kathryn Mueller, M.D., MPH, FACOEM, next addressed changing opioid practice. In 2010, Mueller noted, the cost of pain was $560-635 billion—a major driver in healthcare costs. She pointed to the three leading causes of injury death in the US between 1979 and 2007: motor vehicle traffic accidents, firearms, and poisoning. Poisoning was in third place until around 2003, but opioids are now the primary cause of death of these three.
“The majority of these drugs are prescription drugs. We are not dealing with street drugs as a major cause; we are dealing with opioid prescription drugs,” stated Mueller, characterizing it as a public health emergency, but also noting that there is no one-size-fits-all solution for the entire country.
Discussing Colorado’s and the ACOEM’s guidelines for managing cases, which Mueller stated follow all other guidelines, patients suffering from chronic pain should have active therapy, cognitive behavioral therapy focusing on coping behavior, pain self-management and other appropriate medical techniques. “If you’re not doing those, you shouldn’t be doing opioids,” said Mueller. “[Use of] opioids a very, very small part of pain therapy, and if there is a focus on that in your state, that’s an inappropriate medical focus.”
Mueller further noted that only 50 percent of patients tolerate opioid therapy and that group can only expect about a 30 percent reduction in pain. When opioids are used when a patient is not fully functional with the other therapies, an agreement for a trial is recommended, for functional goals and gains, but not pain relief. The patient agreement should include: a single prescribing practitioner, ongoing review for functional status and things like side effects, and checking for actual improvement and the functional goals. “We have to focus on function,” said Mueller.
Further, patients should understand from the beginning of treatment that they may be weaned from opioids, and the reasons that may happen; for instance, increased pain from opioid use, or noncompliance. It is absolutely necessary, under all guidelines, that psychological and addictive behavior screenings are conducted and that individuals with addiction issues are not prescribed opioids. Possible flags for opioid abuse include: a second prescription within 30 days of the first (50 percent of opioid prescriptions); opioids prescribed for minor soft tissue cases; smoking; early opioid use; and any prescription for long-acting or buccal opioids.
Mueller also noted that patients who receive this treatment should only have two opioids: one long-acting and one short-acting, and that sleep apnea, a common complication of opioid use, may be being covered under workers’ comp. It is also one of the reasons people die from opioid overdoses.